An argument for routine ultrasound screening of the thoracic aorta in the cardiac surgery population.

Stroke and neurological injury are among the most devastating and disabling complications associated with cardiac surgery. Transesophageal echocardiography and epiaortic ultrasound allow for sensitive, point-of-care diagnosis of thoracic aortic disease, which is especially common in patients with heart disease. Unlike other operative procedures, the manipulation of the ascending aorta is routine in cardiac surgery and often unavoidable. Dislodgement and embolization from the ascending and aortic arch atheromas have been clearly associated with manipulation during cardiac surgery. Epiaortic ultrasound and transesophageal echocardiography screening are more accurate and more accessible to the operative team than any other available modality to diagnose atherosclerosis of the aorta. The goal of this review is to review the rationale and scientific evidence that suggests that the routine use of ultrasound guidance in cardiac surgery may improve postoperative outcomes in this patient population.

Operative strategies to reduce cerebral embolic events during on- and off-pump coronary artery bypass surgery: A stratified, prospective randomized trial.

OBJECTIVE: To determine the impact of different aortic clamping strategies on the incidence of cerebral embolic events during coronary artery bypass grafting (CABG). METHODS: Between 2012 and 2015, 142 patients with low-grade aortic disease (epiaortic ultrasound grade I/II) undergoing primary isolated CABG were studied. Those undergoing off-pump CABG were randomized to a partial clamp (n = 36) or clampless facilitating device (CFD; n = 36) strategy. Those undergoing on-pump CABG were randomized to a single-clamp (n = 34) or double-clamp (n = 36) strategy. Transcranial Doppler ultrasonography (TCD) was performed to identify high-intensity transient signals (HITS) in the middle cerebral arteries during periods of aortic manipulation. Neurocognitive testing was performed at baseline and 30-days postoperatively. The primary endpoint was total number of HITS detected by TCD. Groups were compared using the Mann-Whitney U test. RESULTS: In the off-pump group, the median number of total HITS were higher in the CFD subgroup (30.0; interquartile range [IQR], 22-43) compared with the partial clamp subgroup (7.0; IQR, 0-16; P < .0001). In the CFD subgroup, the median number of total HITS was significantly lower for patients with 1 CFD compared with patients with >1 CFD (12.5 [IQR, 4-19] vs 36.0 [IQR, 25-47]; P = .001). In the on-pump group, the median number of total HITS was 10.0 (IQR, 3-17) in the single-clamp group, compared with 16.0 (IQR, 4-49) in the double-clamp group (P = .10). There were no differences in neurocognitive outcomes across the groups. CONCLUSIONS: For patients with low-grade aortic disease, the use of CFDs was associated with an increased rate of cerebral embolic events compared with partial clamping during off-pump CABG. A single-clamp strategy during on-pump CABG did not significantly reduce embolic events compared with a double-clamp strategy.

Avoiding aortic clamping during coronary artery bypass grafting reduces postoperative stroke.

OBJECTIVE: The purpose of this study was to determine whether the incidence of postoperative stroke could be reduced by eliminating aortic clamping during coronary artery bypass grafting. METHODS: From 2002 to 2013, 12,079 patients underwent primary, isolated coronary artery bypass grafting at a single US academic institution. Aortic manipulation was completely avoided by using in situ internal thoracic arteries for inflow in 1552 patients (12.9%) (no-touch), a clampless facilitating device for proximal anastomoses in 1548 patients (12.8%), and aortic clamping in 8979 patients (74.3%). These strategies were assessed in a logistic regression model controlling for relevant variables. RESULTS: The overall incidence of postoperative stroke was 1.4% (n = 165), with an unadjusted incidence of 0.6% (n = 10) in the no-touch group, 1.2% (n = 18) in the clampless facilitating device group, and 1.5% (n = 137) in the clamp group (P < .01 for no-touch vs clamp). The ratio of observed to expected stroke rate increased as the degree of aortic manipulation increased, from 0.48 in the no-touch group, to 0.61 in the clampless facilitating device group, and to 0.95 in the clamp group. Aortic clamping was independently associated with an increase in postoperative stroke compared with a no-touch technique (adjusted odds ratio, 2.50; P < .01). When separated by cardiopulmonary bypass use, both the off-pump partial clamp and the on-pump crossclamp techniques increased the risk of postoperative stroke compared with no-touch (adjusted odds ratio, 2.52, P < .01; and adjusted odds ratio, 4.25, P < .001, respectively). CONCLUSIONS: A no-aortic touch technique has the lowest risk for postoperative stroke for patients undergoing coronary artery bypass grafting. Clamping the aorta during coronary artery bypass grafting increases the risk of postoperative stroke, regardless of the severity of aortic disease.

A review of cardiac transplantation.

Perioperative anesthetic management for cardiac transplantation is reviewed. Recent developments in adult cardiac transplantation are noted. This review includes demographics and historical results, recipient and donor selection and evaluation, mechanical circulatory support and heart transplantation techniques, and patient management immediately postimplantation.

Training in perioperative echocardiography.

PURPOSE OF REVIEW: Echocardiography has been used perioperatively as an important diagnostic tool since the 1980s. Introduction of this new technique has been beneficial to our practice, but has also introduced questions and issues related to methods of teaching, requirements for demonstration of competence and testing and certification processes as evidence of satisfactory completion of necessary learning parameters. This article will review the issues presented to date, how they have been addressed, and what options could be arriving in the future. RECENT FINDINGS: The introduction of Adult Cardiothoracic Anesthesiology fellowship accreditation by the American College of Graduate Medical Education provides a venue for completion of the guidelines for advanced echocardiographer status. The option of obtaining certification without formal training will remain for anyone who completes core residency training by 30 June, 2008. The written testing process is advancing to development of a recertification examination. There continue to be difficulties with learning and certification outside a training program. Recent evidence in the literature shows that formal cardiology training programs do not have the same correlation between experience and test success as past anesthesia data show. Like many other specialties, perioperative echocardiography provides time-limited certifications for 10 years from the time the examination is taken, meaning the original test group will recertify next year. SUMMARY: Perioperative echocardiography has rapidly become an integral part of anesthetic practice. The training and certification process has been formalized. There are still issues related to difficulty of training individuals outside core residency programs.