The Year in Thoracic Anesthesia: Selected Highlights from 2022.

This article reviews research highlights in the field of thoracic anesthesia. The highlights of this year included new developments in the preoperative assessment and prehabilitation of patients requiring thoracic surgery, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic and postoperative management of these patients, including protective OLV ventilation, the use of opioid-sparing techniques and regional anesthesia, and outcomes using enhanced recovery after surgery, as well as the use of expanding indications for extracorporeal membrane oxygenation, specialized anesthetic techniques for airway surgery, and nonintubated video-assisted thoracic surgery.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023.

This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.

Infective Endocarditis-Update for the Perioperative Clinician.

Infective endocarditis is a common pathology routinely encountered by perioperative physicians. There has been a need for a comprehensive review of this important topic. In this expert review, the authors discuss in detail the incidence, etiology, definition, microbiology, and trends of infective endocarditis. The authors discuss the clinical and imaging criteria for diagnosing infective endocarditis and the perioperative considerations for the same. Other imaging modalities to evaluate infective endocarditis also are discussed. Furthermore, the authors describe in detail the clinical risk scores that are used for determining clinical prognostic criteria and how they are tied to the current societal guidelines. Knowledge about native and prosthetic valve endocarditis, with emphasis on the timing of surgical intervention-focused surgical approaches and analysis of current outcomes, are critical to managing such patients, especially high-risk patients like those with heart failure, patients with intravenous drug abuse, and with internal pacemakers and defibrillators in situ. And lastly, with the advancement of percutaneous transcatheter valves becoming a norm for the management of various valvular pathologies, the authors discuss an in-depth review of transcatheter valve endocarditis with a focus on its incidence, the timing of surgical interventions, outcome data, and management of high-risk patients.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2022.

This special article is the 15th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief Dr. Kaplan and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialties of cardiothoracic and vascular anesthesiology. The major themes selected for 2022 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights, in the specialties for 2022, begin with an update on COVID-19 therapies, with a focus on the temporal updates in a wide range of therapies, progressing from medical to the use of extracorporeal membrane oxygenation and, ultimately, with lung transplantation in this high-risk group. The second major theme is focused on medical cardiology, with the authors discussing new insights into the life cycle of coronary disease, heart failure treatments, and outcomes related to novel statin therapy. The third theme is focused on mechanical circulatory support, with discussions focusing on both right-sided and left-sided temporary support outcomes and the optimal timing of deployment. The fourth and final theme is an update on cardiac surgery, with a discussion of the diverse aspects of concomitant valvular surgery and the optimal approach to procedural treatment for coronary artery disease. The themes selected for this 15th special article are only a few of the diverse advances in the specialties during 2022. These highlights will inform the reader of key updates on a variety of topics, leading to the improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Perioperative Right Ventricular Dysfunction: Analysis of Outcomes.

Right ventricular dysfunction (RVD) is a well-known prognostic factor for adverse outcomes in cardiovascular medicine. The right ventricle (RV) in medically managed heart failure patients and in surgical patients perioperatively generally is overshadowed by left ventricular disease. However, with advancement of various diagnostic tools and better understanding of its functional anatomy, the role of the RV is emerging in many clinical conditions. The failure of one ventricle has significant effect on the function of the other ventricle and it is predominantly due to ventricular interdependence.1 The etiology of RVD is multifactorial and irrespective of etiology. RVD has been associated with significant increases in morbidity and mortality in various clinical scenarios.2,3 The primary objective of this comprehensive review is to analyze various etiology-related outcomes of RVD in the perioperative population.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part I - Lung Transplantation.

This special article focuses on the highlights in cardiothoracic transplantation literature in the year 2020. Part I encompasses the recent literature on lung transplantation, including the advances in preoperative assessment and optimization, donor management, including the use of ex-vivo lung perfusion, recipient management, including those who have been infected with coronavirus disease 2019, updates on the perioperative management, including the use of extracorporeal membrane oxygenation, and long-term outcomes.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2021.

This special article is the fourteenth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2021 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2021 begin with an update on structural heart disease, with a focus on updates in arrhythmia and aortic valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and procedural management. The third major theme is focused on the perioperative management of patients with COVID-19, with the authors highlighting literature discussing the impact of the disease on the right ventricle and thromboembolic events. The fourth and final theme is an update in heart failure, with discussion of diverse aspects of this area. The themes selected for this fourteenth special article are only a few of the diverse advances in the specialty during 2021. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2020.

THIS SPECIAL article is the 13th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology.1 The major themes selected for 2020 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2020 begin with an update on valvular disease, with a focus on updates in management of aortic and mitral valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and surgical management. The third major theme is focused on the perioperative management of patients with coronavirus disease 2019 (COVID-19), with the authors highlighting literature discussing medical, surgical, and anesthetic considerations for their cardiac care. The fourth major theme is an update in heart failure, with discussion of medical, psychosocial, and procedural aspects of this complicated disease process. The fifth and final theme focuses on the latest analyses regarding survival in heart transplantation. The themes selected for this 13th special article are only a few of the diverse advances in the specialty during 2020. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA.

Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500 mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.

Anesthetic management of lung transplantation: Results from a multicenter, cross-sectional survey by the society for advancement of transplant anesthesia.

BACKGROUND: Current protocols for the perioperative care of lung transplant (LTX) recipients lack rigorous evidence and are often empiric, based upon institutional preferences. We surveyed LTX anesthesiologists to determine the most common practices. METHODS: We developed a survey of 40 questions regarding perioperative care of LTX recipients using Qualtrics software. The survey was sent out to members of the Society of Cardiovascular Anesthesiologists performing LTX at geographically diverse sites to facilitate data collection for as many practices as possible. RESULTS: The responses were center-weighed (127 responses, 85% from academic settings). The clamshell approach was commonly used (70%). Cardiopulmonary bypass was preferred by 56%, ex vivo lung perfusion utilized by 43%, and 49.4% indicated they use lungs from donation after circulatory determination of death. Most (69%) used oximetric pulmonary artery catheters, 60% used tissue oximetry, and 89.3% utilized transesophageal echocardiography. Inhaled nitric oxide was preferred by 48%, restrictive fluid management by 48%, and systemic analgesia advocated by 49% of participants. Inspired oxygen concentration <30% was applied to the new lung on reperfusion by 28% of the respondents. CONCLUSION: Variations in healthcare delivery and utilization for LTX recipients indicate gaps in knowledge and potential opportunities to improve the quality of care.

Analysis of Conduction Abnormalities and Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement.

Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as the recommended approach for patients with high and intermediate risk for surgical aortic valve replacement. Even though initial trials demonstrated a higher incidence of conduction abnormalities (CAs), such as left bundle branch block, atrial fibrillation, and permanent pacemaker implantation with TAVR, the incidence of CAs has not decreased. With an increasing number of patients expected to undergo TAVR in the coming decades, even those at low risk for surgical aortic valve replacement, it is important to review the incidence, course, risk factors, mortality, and rehospitalization associated with CAs and permanent pacemaker implantation after TAVR. The newer-generation valves have demonstrated an improved safety profile, but have failed to demonstrate a clinically significant reduction in the incidence of CAs.

Loop Diuretics-Analysis of Efficacy Data for the Perioperative Clinician.

HEART FAILURE (HF) is one of the most common causes of hospitalization in the United States. Loop diuretics (LD) are the mainstay of treatment in the management of acute and chronic HF. Although they generally are effective in relieving symptoms and reducing congestion, LD have not been shown to significantly affect morbidity and mortality. The initial decongestion strategy for management of HF is likely to be an LD, with evidence suggesting that an initial "high-dose" strategy either by twice-daily bolus injection or by continuous infusion is likely to be more successful than an initial lower dose in respect to relief of symptoms but at the expense of increased worsening of renal function. This review focuses on the current state of evidence of different strategies related to the use of LD in the treatment of congestive symptoms in critically ill patients and presents a summary of the body of evidence regarding dosages, timing, and different diuretic agents.

The Year in Cardiothoracic Transplantation Anesthesia: Selected Highlights from 2019.

The highlights in cardiothoracic transplantation focus on the recent research pertaining to heart and lung transplantation, including expansion of the donor pool, the optimization of donors and recipients, the use of mechanical support, the perioperative and long-term outcomes in these patient populations, and the use of transthoracic echocardiography to diagnose rejection.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019.

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients.

Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point-of-care (POC) coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, have increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has only modestly declined over the last decade, remaining at ≥50% in high-risk patients. Given these limitations, and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists (SCA) has formed the Blood Conservation in Cardiac Surgery Working Group to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.

Analysis of Neurologic Complications After Surgical Versus Transcatheter Aortic Valve Replacement.

Ove the last decade, transcatheter aortic valve replacement (TAVR) has emerged as the recommended approach over surgical aortic valve replacement (SAVR) for many patients with aortic stenosis. While initial trials demonstrated a higher incidence of stroke with TAVR compared to SAVR, the incidence of stroke appears to have improved over time. With the increasing number of patients expected to undergo TAVR in the coming decades, it is important to review the incidence and etiology of stroke after SAVR and TAVR. Alterations in surgical technique for SAVR, and embolic protections devices for TAVR, have failed to demonstrate a clinically significant reduction in the incidence of post-procedural stroke. However, the definitions and assessment methods used for assessing stroke and neurological events varies among studies.

Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients.

Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point of care coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, has increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has declined only modestly over the last decade, remaining at 50% or greater in high-risk patients. Given these limitations and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists has formed the Blood Conservation in Cardiac Surgery Working Group in order to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.

Effect of remifentanil on the recovery profile after head and neck surgeries: A prospective study.

BACKGROUND AND AIMS: Development of opioid tolerance in the perioperative period due to remifentanil remains controversial. We evaluated occurrence of opioid tolerance and other adverse effects due to remifentanil in patients undergoing head and neck surgery. MATERIAL AND METHODS: We recruited adult participants with ASA status I to III who received general anesthesia for approximately 2 h for elective head and neck procedures. Remifentanil infusion was used in one group and intermittent boluses of morphine or fentanyl were administered in another group. Postoperative pain was treated with intermittent boluses of morphine and fentanyl in post-anaesthesia care unit (PACU) to achieve a numerical rating scale score of 3. Opioid requirement was assessed as an indicator of opioid tolerance. Patients were also evaluated for time to discharge from PACU. RESULTS: We studied 222 adults aged between 21 and 80 years. One hundred and eleven patients received a combination of remifentanil infusion and morphine boluses, and another 111 patients received only fentanyl and/or morphine boluses intraoperatively. Fifty-one patients in the remifentanil group and 25 in the fentanyl/morphine group required opioids in the PACU. Opioid requirement were significantly more (mean ± SD, 44.98 ± 59.7 Vs 20.23 ± 46.66 mcg.kg-1; P = 0.001) and required longer time to discharge from PACU in the remifentanil group compared to the fentanyl/morphine group (Mean ± SD, 88.6 ± 39.5 min Vs 73.1 ± 38.4 min; P < 0.001). No difference in the incidence of adverse effects in two groups was noted. CONCLUSION: At clinically relevant doses, intraoperative remifentanil infusion appears to increase opioid consumption in the immediate postoperative period. This can result in delayed discharge from PACU for patients undergoing elective head and neck procedures.