Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association.

Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.

Development and Publication of Clinical Practice Parameters, Reviews, and Meta-analyses: A Report From the Society of Cardiovascular Anesthesiologists Presidential Task Force.

The Society of Cardiovascular Anesthesiologists (SCA) is committed to improving the quality, safety, and value that cardiothoracic anesthesiologists bring to patient care. To fulfill this mission, the SCA supports the creation of peer-reviewed manuscripts that establish standards, produce guidelines, critically analyze the literature, interpret preexisting guidelines, and allow experts to engage in consensus opinion. The aim of this report, commissioned by the SCA President, is to summarize the distinctions among these publications and describe a novel SCA-supported framework that provides guidance to SCA members for the creation of these publications. The ultimate goal is that through a standardized and transparent process, the SCA will facilitate up-to-date education and implementation of best practices by cardiovascular and thoracic anesthesiologists to improve patient safety, quality of care, and outcomes.

Selected 2023 Highlights in Congenital Cardiac Anesthesia.

This article reviews the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist published in 2023. After a search of the US National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2023. The authors of this article considered the following topics noteworthy to be included in this review: (1) advancements in percutaneous mechanical support in children with congenital heart disease, (2) children with pulmonary hypertension undergoing surgery for congenital heart disease, (3) dexmedetomidine in pediatric cardiac surgery, and (4) recommendations for pediatric heart surgery in the United States: Implications for pediatric cardiac anesthesia.

Selected 2022 Highlights in Congenital Cardiac Anesthesia.

This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist, and was published in 2022. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2022. The authors of this manuscript considered the following topics noteworthy to be included in this review-intensive care unit admission after congenital cardiac catheterization interventions, antifibrinolytics in pediatric cardiac surgery, the current status of the pediatric cardiac anesthesia workforce in the United States, and kidney injury and renal protection during congenital heart surgery.

Selected 2021 Highlights in Congenital Cardiac Anesthesia.

This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist and was published in 2021. After a search of the United States National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2021. The authors of this manuscript considered the following topics noteworthy to be included in this review: risk stratification in adult congenital heart disease surgery, physician burnout in pediatric cardiac anesthesia, transfusion practice in pediatric congenital heart surgery, and racial disparity and outcomes in pediatric patients with congenital heart disease.

Selected 2020 Highlights in Congenital Cardiac Anesthesia.

This article is a review of the highlights of pertinent literature published during the 12 months of 2020 that are of interest to the congenital cardiac anesthesiologist. After a search of the US National Library of Medicine's PubMed database, several topics emerged for which significant contributions were made in 2020. The authors of the present article considered the following topics noteworthy to be included in this review: pediatric cardiac care in the coronavirus disease 2019 era, the use of mechanical circulatory support in coronavirus disease 2019-related multisystem inflammatory syndrome in children, transfusion and coagulation management in children undergoing congenital heart surgery, and pulmonary vein stenosis.

New-onset intra-operative hyperthermia in a large surgical patient population: A retrospective observational study.

BACKGROUND: Intra-operative hypothermia has been extensively investigated. However, the incidence of intra-operative hyperthermia has not been investigated in detail. OBJECTIVE: The main objective of this study was to assess the incidence and risk factors of new-onset intra-operative hyperthermia in a large surgical patient population. DESIGN: Retrospective database review. SETTING: Tertiary-care teaching hospital. PATIENTS: Patients undergoing surgery with general anaesthesia between 1 January 2002 and 31 December 2017 were included. MAIN OUTCOME MEASURES: The primary outcome measurement was new-onset intra-operative hyperthermia (>37.5 °C). A logistic regression model was fitted to identify risk factors for intra-operative hyperthermia. RESULTS: A total of 103 648 patients were included in the final analyses. The incidence of new-onset hyperthermia in the overall patient cohort was 6.45%, reaching 20 to 30% after prolonged (>8 h) surgery, and was up to 26.5% in paediatric patients. The use of forced air active patient warming, larger amounts of fluid administration, longer surgery, younger age and smaller body size were all independently associated with intra-operative hyperthermia. The adoption of the Surgical Care Improvement Project (SCIP) temperature measures was associated with an increased incidence of intra-operative hyperthermia. CONCLUSION: Mild intra-operative hyperthermia is not uncommon particularly in longer procedures and small children.

The impact of mechanical oesophageal deviation on posterior wall pulmonary vein reconnection.

AIMS: During atrial fibrillation ablation, oesophageal heating typically prompts reduction or termination of radiofrequency energy delivery. We previously demonstrated oesophageal temperature rises are associated with posterior left atrial pulmonary vein reconnection (PVR) during redo procedures. In this study, we assessed whether mechanical oesophageal deviation (MED) during an index procedure minimizes posterior wall PVRs during redo procedures. METHODS AND RESULTS: Patients in whom we performed a first-ever procedure followed by a clinically driven redo procedure were divided based on both the use of MED for oesophageal protection and the ablation catheter employed (force or non-force sensing) in the first procedure. The PVR sites were compared between MED using a force-sensing catheter (MEDForce), or no MED with a non-force (ControlNoForce) or force (ControlForce) sensing catheter. Despite similar clinical characteristics, the MEDForce redo procedure rate (9.2%, 26/282 patients) was significantly less than the ControlNoForce (17.2%, 126/734 patients; P = 0.002) and ControlForce (17.5%, 20/114 patients; P = 0.024) groups. During the redo procedure, the posterior PVR rate with MEDForce (2%, 1/50 PV pairs) was significantly less than with either ControlNoForce (17.7%, 44/249 PV pairs; P = 0.004) or ControlForce (22.5%, 9/40 PV pairs; P = 0.003), or aggregate Controls (18.3%, 53/289 PV pairs; P = 0.006). However, the anterior PVR rate with MEDForce (8%, 4/50 PV pairs) was not significantly different than Controls (aggregate Controls-3.5%, 10/289 PV pairs, P = 0.136; ControlNoForce-2.4%, 6/249 PV pairs, P = 0.067; ControlForce-10%, 4/40 PV pairs, P = 1.0). CONCLUSION: Oesophageal deviation improves the durability of the posterior wall ablation lesion set during AF ablation.

Selected 2019 Highlights in Congenital Cardiac Anesthesia.

This article is a review of the highlights of pertinent literature published in 2019, which is of interest to the pediatric cardiac anesthesiologist. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2019. The authors of this manuscript considered the following topics noteworthy and were included in this review: advances in pediatric heart transplantation, blood management in pediatric cardiac surgery, the impact of nutrition on outcomes in congenital heart surgery, and the use of vasopressin in patients after Fontan palliation.

Selected 2018 Highlights in Congenital Cardiac Anesthesia.

THIS ARTICLE IS a review of the highlights of pertinent literature published during the 12 months of 2018 that is of interest to the congenital cardiac anesthesiologist. During a search of the US National Library of Medicine PubMed database, several topics that displayed significant contributions to the field in 2018 emerged. The authors of the present review consider the following topics noteworthy: the patient with high-risk congenital heart disease (CHD) presenting for noncardiac surgery, cardiopulmonary resuscitation in infants and children with CHD, dexmedetomidine use in pediatric patients, point-of-care lung ultrasound, and regional anesthesia in pediatric cardiac surgery.

Prognostic Value of Hyperlactatemia and Lactate Clearance After Mitral Valve Surgery.

OBJECTIVES: Blood lactate is frequently used to guide management in critically ill patients. In patients undergoing mitral valve surgery, an elevated lactate level is frequently observed; however, overall mortality is low. The authors hypothesized that hyperlactemia is not a useful predictor of poor outcomes in this patient population. The main aim of this study was to explore how blood lactate level and lactate clearance are associated with 30-day mortality and major adverse events in patients undergoing mitral valve surgery. DESIGN: This was a retrospective database review. Logistic regression analysis was performed to assess the associations of perioperative factors with blood lactate in the intensive care unit (ICU). SETTING: Tertiary-care teaching hospital. PARTICIPANTS: The study comprised 917 patients undergoing mitral valve surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The majority of patients (71.8%) had elevated blood lactate ≥2 mmol/L on ICU admission; however, within 24 hours, 85.1% of all patients had normal lactate values. Overall 30-day mortality was 2.29% (n = 21). The combination of lactate ≥7 mmol/L on ICU admission and a persistent elevated blood lactate level 24 hours after ICU admission provides an excellent prediction of 30-day mortality (C statistic = 0.85). However, even a significantly elevated lactate level on ICU admission was well-tolerated in the majority of patients as long as lactate values normalized within 24 hours. Male sex, longer cardiopulmonary bypass time, blood transfusion in the ICU, and an elevated blood lactate level on ICU admission and 12 hours after ICU admission all were independent risk factors of clearance failure. CONCLUSIONS: An elevated blood lactate level is common after mitral valve surgery and is well-tolerated in the majority of patients. Adding lactate clearance improved the predictive value of the blood lactate level.

Ventricular tachycardia ablation: a comprehensive review for anesthesiologists.

Percutaneous catheter ablation is being increasingly performed in patients with recurrent ventricular tachycardia (VT) unresponsive to medical treatment. Optimal management of patients requires careful consideration of the severity of the underlying cardiac disease, the anesthetic drug interactions, and the procedural technique during VT mapping and ablation. The goal is to choose an anesthetic technique that has the least effect on arrhythmogenicity, allowing reproducibility of the VT in the electrophysiology laboratory. Anesthetics can alter action potential and ventricular depolarization directly through their effects on ion channels and gap junctions, as well as indirectly via their effects on the autonomic nervous system. Furthermore, maintaining hemodynamic stability and monitoring for adequate end-organ perfusion are additional challenges. In this review, we provide a comprehensive update on the currently performed VT ablation procedures and their anesthetic considerations.

Mechanical esophageal displacement during catheter ablation for atrial fibrillation.

OBJECTIVE: To determine the feasibility and safety of esophageal displacement during atrial fibrillation (AF) ablation, to prevent thermal injury. BACKGROUND: Patients undergoing AF ablation are at risk of esophageal thermal injury, which ranges from superficial ulceration, to gastroparesis, to the rare but catastrophic atrioesophageal fistula. A common approach to avoid damage is luminal esophageal temperature (LET) monitoring; however, (1) temperature rises mandate interruptions in energy delivery that interrupt workflow and potentially decrease procedural efficacy, and (2) esophageal fistulas have been reported even with LET monitoring. METHODS: A cohort of 20 consecutive patients undergoing radiofrequency (RF) (16 patients) or laser balloon (4 patients) ablation of AF under general anesthesia. After barium instillation, the esophagus was deviated using an endotracheal stylet placed within a thoracic chest tube. LET monitoring was used during catheter ablation. Upper GI endoscopy was performed prior to discharge. RESULTS: At the pulmonary vein level, leftward deviation measured 2.8 ± 1.6 cm (range: 0.4-5.7) and rightward deviation 2.8 ± 1.8 cm (range: 0.5-4.9). The temperature rose to >38.5 °C in 3/20 (15%) patients. In these 3 patients, there was an average of 2 applications/patient that recorded temperatures >38.5 °C. No patient had a temperature rise > 40 °C. Endoscopy revealed no esophageal ulceration from thermal injury in 18/19 (95%) patients; the sole patient with a thermally mediated ulceration had an unusual esophageal diverticulum fully across the posterior left atrium. Twelve patients (63%) exhibited trauma related to instrumentation with no clinical sequelae. CONCLUSIONS: Mechanical esophageal deviation is feasible and allows for uninterrupted energy delivery along the posterior wall during catheter ablation of AF.