Off-Pump Coronary Artery Bypass Grafting: Closing the Communication Gap Across the Ether Screen.

Cardiopulmonary bypass (CPB) has been one of the most important additions to the field of heart surgery in the past century. However, significant morbidity associated with CPB has led to the increasing implementation of off-pump coronary artery bypass (OPCAB). The use of OPCAB has broadened surgical revascularization for patient populations at high risk for undergoing CPB, including the very elderly and patients with impending end-organ failure. Intraoperative hemodynamic instability requires expeditious correction of hypotension with various medical and surgical techniques that require the close attention and skill of both the anesthesia and surgical teams. Technical skill at performing and interpreting transesophageal echocardiography is essential to help differentiate regional wall motion abnormalities from coronary ischemia and external compression from manipulation of the heart, which require different management strategies to resolve hemodynamic collapse. Flawless communication between the anesthesiologist and surgeons, with frequent intraoperative adjustments, is paramount for the completion of successful OPCAB.

Open Surgical Access for Transfemoral TAVR Should Not Be a Contraindication for Conscious Sedation.

OBJECTIVES: The use of monitored anesthesia care (MAC) for transcatheter aortic valve replacement (TAVR) is gaining favor in the United States, although general anesthesia (GA) continues to be common for these procedures. Open surgical cutdown for transfemoral TAVR has been a relative contraindication for TAVR with MAC at most centers. The objective of this study was to review the authors' results of transfemoral TAVR performed in patients with open surgical cutdown with the use of MAC. DESIGN: Retrospective study design from a prospectively recorded database. SETTING: Tertiary academic (teaching) hospital. PARTICIPANTS: Two hundred eighty-two patients undergoing transfemoral TAVR with open surgical cutdown under MAC from 2015 to 2017. INTERVENTIONS: Transfemoral TAVR under MAC with surgical cutdown for femoral vascular access. MEASUREMENTS AND MAIN RESULTS: The study cohort consisted of 282 patients with severe aortic stenosis (mean area 0.65 [± 0.16] cm2, mean gradient of 48.9 [±13.3] mmHg, and mean age of 82.7 [± 7.31] years). Eleven (3.9%) patients required conversion to GA. First postoperative pain score (0-10) was 2.9 and highest postoperative pain score was 4.6. Major and minor vascular complications occurred in 2 (0.7%) and 6 (2.1%) patients, respectively. Twenty-nine (10.3%) patients were readmitted within 30 days, and 6 (2.1%) patients had in-hospital mortality. CONCLUSIONS: Open surgical cutdown for transfemoral TAVR can be performed safely using MAC and ilioinguinal block with low rates of conversion to general anesthesia and acceptable postoperative outcomes and pain scores.