Remimazolam for anesthesia and sedation in cardiac surgery and for cardiac patients undergoing non-cardiac surgery: a systematic-narrative hybrid review.

INTRODUCTION: Remimazolam, an ultra-short-acting benzodiazepine recognized and approved as an anesthetic and sedative in multiple countries, offers a distinctive pharmacokinetic profile, boasting advantages such as rapid onset, short action duration, and rapid recovery. These attributes may contribute to enhanced hemodynamic stability and a diminished risk of respiratory depression compared to other sedatives. EVIDENCE ACQUISITION: We conducted the first comprehensive systematically structured narrative review to evaluate the role and potential application of remimazolam in cardiac surgery. Twenty-one studies published from 2021 to 2023 delved into remimazolam's application in open cardiac surgery, cardiac catheterization or electrophysiology laboratories, and high-risk cardiovascular patients undergoing non-cardiac surgery. EVIDENCE SYNTHESIS: Overall, remimazolam usage was apparently linked to potentially superior hemodynamic stability compared to other hypnotic drugs. However, findings regarding the reduction in postoperative delirium incidence with remimazolam and the doses of remimazolam for anesthesia induction and maintenance were inconsistent across the studies. CONCLUSIONS: Though remimazolam has demonstrated potential safety, efficacy, and ease-of-use for both anesthesia induction and maintenance in cardiac surgery patients and high-risk cardiovascular patients undergoing non-cardiac surgery, further research is imperative to delve into specific patient subgroups (e.g., the elderly or emergent procedures) so as to ascertain optimal dose ranges to suit diverse clinical scenarios.

Association of Impedance Aggregometry-Measured Platelet Aggregation With Thromboembolic Events in Patients Who Undergo Carotid Endarterectomy: A Pilot Study.

OBJECTIVES: The aim of the current study was to assess the relationship among thrombin receptor activator peptide 6 (TRAP test), adenosine-5'-diphosphate (ADP test), arachidonic acid (ASPI test), and stroke/transient ischemic attack (TIA), using the multiple electrode aggregometry (Multiplate) in patients undergoing carotid thromboendarterectomy (CEA). DESIGN: A retrospective study. SETTING: Vascular surgery operating rooms of a university hospital. PARTICIPANTS: One hundred thirty-one out of 474 patients undergoing CEA between November 2020 and October 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A preoperative blood sample of all enrolled patients was analyzed using the Multiplate analyzer. Receiver operating characteristics curves, were generated to test the ability of TRAP, ADP, and ASPI in discriminating perioperative thromboembolic stroke/TIA. A logistic LASSO regression model was used to identify factors independently associated with stroke/TIA. Eight patients experienced a perioperative stroke/TIA. Although all the platelet functional assays showed excellent predictive performance, an ADP value exceeding 72 U showed the highest specificity (87%) and sensitivity (68%) in discriminating patients who had a perioperative thromboembolic stroke/TIA, with a negative predictive value of 99% and a positive predictive value of 15%. After LASSO regression, an ADP >72 U and the need for a shunt during CEA were the only 2 variables independently associated with perioperative stroke/TIA. CONCLUSION: Because the ADP test was independently associated with perioperative stroke/TIA, the assessment of platelet reactivity using Multiplate may offer potential utility in monitoring patients undergoing CEA.

Anaesthetic management of paediatric patients undergoing electrophysiology study and ablation for supraventricular tachycardia: A focused narrative review.

Every year, 80,000-100,000 ablation procedures take place in the United States and approximately 1% of these involve paediatric patients. As the paediatric population undergoing catheter ablation to treat dysrhythmia is constantly growing, involvement of anaesthesiologists in the cardiac electrophysiology laboratory is simultaneously increasing. Compared with the adult population, paediatric patients need deeper sedation or general anaesthesia (GA) to guarantee motionlessness and preserve comfort. As a result, the anaesthesiologist working in this setting should keep in mind heart physiopathology as well as possible interactions between anaesthetic drugs and arrhythmia. In fact, drug-induced suppression of accessory pathways (APs) conduction capacity is a major concern for completing a successful electrophysiology study (EPS). Nevertheless, the literature on this topic is scarce and the optimal type of anaesthesia in EPS and ablation procedures in children is still controversial. Thus, the main goal of the present review is to collect the literature published so far on the effects on cardiac conduction tissue of the drugs commonly employed for sedation/GA in the cath lab for EPS and ablation procedures to treat supraventricular tachycardia in patients aged <18 years.

Management of Microvascular Bleeding after On-Pump Cardiac Surgery in a Patient with Perioperative Diagnosis of Impairment of Platelet Responses to Adenosine Diphosphate: A Case Report and a Literature Review.

BACKGROUND: Impairment of platelet responses to adenosine diphosphate (ADP) is typified by mild to severe bleeding diathesis, easy bruising, excessive mucosal and post-operative bleeding. Patients lack full platelet activation and aggregation in response to ADP. Following research of the literature in Scopus, PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, we report only 18 patients described to date with impaired platelet response to ADP, none of whom in the high bleeding-risk surgical setting or exploring potential therapeutic options. Data regarding population, putative genetic mutations, modes of inheritance, functional defects, and related clinical manifestations were retrieved from case series and case reports. CASE PRESENTATION: A 40-year-old woman was scheduled for on-pump cardiac surgery. Her past medical history included episodes of spontaneous mucocutaneous hemorrhages of the mild entity since childhood. Multiple electrode aggregometry (MEA, Multiplate® Roche Diagnostics, Rotkreuz, Switzerland) was used to evaluate platelet response to thrombin-activated peptide-6 (TRAP), arachidonic acid (ASPI), and ADP. An inadequate platelet aggregation induced using a high concentration of ADP with normal TRAP and ASPI tests was detected preoperatively. Therefore, intravenous desmopressin (DVVAP) 0.3 µg/kg body weight was administered to manage microvascular bleeding developed after weaning from cardiopulmonary bypass (CPB). CONCLUSIONS: Proper management of impaired platelet response to ADP requires a systematic assessment. The Multiplate analyzer is a valuable tool to promptly detect the disorder when a high clinical suspect is present and obtain insights during high bleeding-risk surgical procedures. DVVAP can be beneficial as first-line therapy in bleeding patients to improve platelet function.

Four-Factor Prothrombin Complex Concentrate in Left Ventricular Assist Device Implantation: Inverse Propensity Score-Weighted Analysis.

We compare the effect of intraoperative administration of four-factor prothrombin complex concentrates (PCCs) versus fresh frozen plasma (FFP) on major bleeding, transfusions, and complications. Out of 138 patients undergoing left ventricle assist device (LVAD) implantation, 32 received PCCs as first-line hemostatic agents and 102 FFP (standard group). The crude treatment estimates indicated that, compared with the standard group, the PCC group required more FFP units (odds ratio [OR]: 4.17, 95% confidence interval [CI]: 1.58-11; p = 0.004) intraoperatively, whereas a greater number of patients received FFP at 24 hours (OR: 3.01, 95% CI: 1.19-7.59; p = 0.021) and less packed red blood cells (RBC) at 48 hours (OR: 0.61, 95% CI: 0.01-1.21; p = 0.046). After the inverse probability of treatment weighting (IPTW) adjusted analyses, in the PCC group there was still a higher number of patients who required FFP (OR: 2.9, 95% CI: 1.02-8.25; p = 0.048) or RBC (OR: 6.23, 95% CI: 1.67-23.14; p = 0.007] at 24 hours and RBC at 48 hours (OR: 3.09, 95% CI: 0.89-10.76; p = 0.007). Adverse events and survival were similar before and after the ITPW adjustment. In conclusion, the PCCs, although relatively safe with respect to thrombotic events, were not associated with a reduction of major bleeding and blood product transfusions.

Dexmedetomidine versus remifentanil for sedation under monitored anesthetic care in complex endovascular aortic aneurysm repair: a single center experience with mid-term follow-up.

BACKGROUND: Sedation protocols in patients undergoing complex endovascular aortic aneurysm repair are not fully investigated. The aim of this study was to compare a dexmedetomidine (DEX) based sedation protocol with a remifentanil-based sedation protocol. METHODS: Seventy-nine consecutive patients undergoing complex endovascular aortic repair were enrolled and retrospectively analyzed. Forty-two received 0.03 mg/kg midazolam intravenous bolus with remifentanil (0.075-0.1 µg/kg/min for 10 minutes followed by continuous infusion 0.050-0.25 µg/kg/min) and 37 DEX (1 µg/kg over 10 minutes and continuous infusion 0.50-0.75 µg/kg/hour) to achieve an Observer Assessment of Alertness/Sedation Scale (OAAS) ≤4, a Richmond Agitation/Sedation Scale (RASS) ≤-2 and a Visual Analogic Scale (VAS) <4. The primary endpoint was patients' satisfaction. Secondary endpoints included assessment of sedation and pain, the incidence of perioperative hemodynamic or gas exchange imbalance, and 36 month-mortality. RESULTS: Remifentanil group showed a higher satisfaction rate than DEX (P<0.001). Patients on DEX were more sedated than remifentanil according to OAAS (3 [2-3] vs. 4 [3-4]; P=0.001) and RASS (-2[-3/-2] vs. -2[-2/-2]; P=0.001) with no difference in VAS (2 [1-3] vs. 2 [1-3]; P=0.41). DEX provides reliable sedation with lower patient's satisfaction. A higher number of patients were discharged from the recovery room on vasopressors in the DEX group compare with the remifentanil group (5 vs. 0; P=0.045, respectively). The two groups showed a non-significant difference in the survival rate at 36-month (DEX 67% vs. remifentanil 73%; (P=0.90). CONCLUSIONS: In this setting remifentanil provides reliable sedation with higher patient's satisfaction and less hemodynamic effect than DEX.

Opioid Free Anesthesia in Thoracic Surgery: A Systematic Review and Meta Analysis.

Introduction: Recent studies showed that balanced opioid-free anesthesia is feasible and desirable in several surgical settings. However, in thoracic surgery, scientific evidence is still lacking. Thus, we conducted the first systematic review and meta-analysis of opioid-free anesthesia in this field. Methods: The primary outcome was the occurrence of any complication. Secondary outcomes were the length of hospital stay, recovery room length of stay, postoperative pain at 24 and 48 h, and morphine equivalent consumption at 48 h. Results: Out of 375 potentially relevant articles, 6 studies (1 randomized controlled trial and 5 observational cohort studies) counting a total of 904 patients were included. Opioid-free anesthesia compared to opioid-based anesthesia, was associated with a lower rate of any complication (74 of 175 [42%] vs. 200 of 294 [68%]; RR = 0.76; 95% CI, 0.65−0.89; p < 0.001; I2 = 0%), lower 48 h morphine equivalent consumption (MD −14.5 [−29.17/−0.22]; p = 0.05; I2 = 95%) and lower pain at 48 h (MD −1.95 [−3.6/0.3]; p = 0.02, I = 98%). Conclusions: Opioid-free anesthesia in thoracic surgery is associated with lower postoperative complications, and less opioid demand with better postoperative analgesia at 48 h compared to opioid-based anesthesia.

Mitral Valve Systolic Anterior Motion in Robotic Thoracic Surgery as the Cause of Unexplained Hemodynamic Shock: From a Case Report to Recommendations.

Robotic major lung resection for lung cancer carries a risk for intraoperative hemodynamic instability. Systolic anterior motion (SAM) of the mitral valve is a rare and often misrecognized cause of intraoperative hemodynamic instability. If not promptly recognized, SAM leads to a complicated perioperative course. Here, we report for the first time a case of a patient with SAM with a severe degree of left ventricular outflow obstruction (LVOTO) undergoing robotic lung lobectomy and its challenging intraoperative management. A 70-year-old man undergoing robotic left upper lobectomy developed immediately after the induction of general anesthesia hemodynamic instability due to SAM-related LVOTO. The diagnosis was possible, thanks to the use of transesophageal echocardiography (TEE). The treatment strategies applied were preload optimization without fluid overload, ultra-short-acting beta-blockers, and vasopressors. Peripheral nerve blockades were preferred over epidural analgesia to avoid vasodilatation. The patient reported a good quality of recovery and no pain the day after surgery. The management of patients with higher risk of SAM and LVOTO development during robotic thoracic surgery requires a dedicated and skilled team together with high-impact treatment strategies driven by TEE. Since current guidelines do not recommend the use of TEE, even for patients with higher cardiac risk undergoing noncardiac surgery, the present case report may stimulate interest in future recommendations.

Intravenous amino acid therapy for kidney protection in cardiac surgery a protocol for a multi-centre randomized blinded placebo controlled clinical trial. The PROTECTION trial.

BACKGROUND: Postoperative acute kidney injury (AKI) is frequent in cardiac surgery patients. Its pathophysiology is complex and involves decreased renal perfusion. Preliminary clinical evidence in critically ill patients shows that amino acids infusion increases renal blood flow and may decrease the incidence and severity of AKI. We designed a study to evaluate the effectiveness of perioperative continuous infusion of amino acids in decreasing AKI. METHODS: This is a phase III, multi-center, randomized, double-blind, placebo-controlled trial. Adults undergoing cardiac surgery with cardiopulmonary bypass (CPB) are included. Patients are randomly assigned to receive either continuous infusion of a balanced mixture of amino acids in a dose of 2 g/kg ideal body weight/day or placebo (balanced crystalloid solution) from the operating room up to start of renal replacement therapy (RRT), or ICU discharge, or 72 h after the first dose. The primary outcome is the incidence of AKI during hospital stay defined by KDIGO (Kidney Disease: Improving Global Outcomes). Secondary outcomes include the need for, and duration of, RRT, mechanical ventilation; ICU and hospital length of stay; all-cause mortality at ICU, hospital discharge, 30, 90, and 180 days after randomization; quality of life at 180 days. Data will be analyzed in 3500 patients on an intention-to-treat basis. DISCUSSION: The trial is ongoing and currently recruiting. It will be one of the first randomized controlled studies to assess the relationship between amino acids use and kidney injury in cardiac surgery. If our hypothesis is confirmed, this practice could reduce morbidity in the studied population. STUDY REGISTRATION: This trial was registered on ClinicalTrials.gov with the trial identification NCT03709264 in October 2018.

Association Between Type of Anaesthesia and Clinical Outcome in Patients Undergoing Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms by Fenestrated and Branched Endografts.

OBJECTIVE: Although endovascular repair of thoraco-abdominal aortic aneurysm (TAAA) is the treatment of choice in the high risk population that is ineligible for an open surgical approach, little is known about the association between the type of anaesthesia and complications. This study compared the short term clinical outcomes of patients undergoing the visceral step of TAAA with fenestrated endograft aortic repair (FEVAR) and branched endograft aortic repair (BEVAR) under general anaesthesia (GA) with sedation with monitored care anaesthesia (MAC). METHODS: This single centre, retrospective, observational study recruited 124 consecutive patients undergoing elective F/BEVAR from 2014 - 2021. The primary endpoint was the short term complication rate according to the type of anaesthesia. Secondary endpoints included: need for inotropes or vasopressors for hypotension, time spent in the operating room, and admission to the intensive care unit. Propensity score matching was generated to account for the between group imbalance in the pre-operative covariables. RESULTS: After propensity score matching, 42 patients under GA were matched with 42 under MAC. The two groups showed no difference in cardiac and non-cardiac complications. Among the secondary outcomes, a higher number of patients in the GA group required inotropes or vasopressors compared with MAC (33% vs. 9%; p = .031). Although GA and MAC showed the same 30 day technical success (81% vs. 83%; p = .078), non-significant lower rates of major adverse events (10% vs. 12%; p = .72), one year re-intervention (14% vs. 21%; p = .39), and one year target vessel instability (10% vs. 21%; p = .39) were observed in the GA group. Overall, the in hospital mortality rate was 4%, with no difference between GA and MAC (2% vs. 5%; p = 1.0). CONCLUSION: The type of anaesthesia seemed to have no effect on procedure success, peri-operative morbidity, or mortality in patients undergoing F/BEVAR.

Trigger and Target for Fibrinogen Supplementation Using Thromboelastometry (ROTEM) in Patients Undergoing Open Thoraco-Abdominal Aortic Aneurysm Repair.

OBJECTIVE: To determine the relationship between the value of fibrinogen assessed by the FIBTEM clot amplitude at 10 minutes (A10 FIBTEM) measured on admission to the intensive care unit (ICU) and the amount of drainage output at 24 hours, to investigate whether the A10 FIBTEM predicts severe bleeding (SB), and to define A10 FIBTEM thresholds to prevent (trigger) and treat (target) severe bleeding by fibrinogen supplementation. METHODS: In a single centre, retrospective observational study, 166 patients underwent elective open thoraco-abdominal aortic aneurysm (TAAA) repair between March 2016 and January 2019. Exclusion criteria were emergency, congenital, or acquired coagulopathy, or administration of P2Y12 inhibitor antiplatelet agents in the five days before surgery. All patients were managed intra-operatively and post-operatively according to a rotational thromboelastometry driven transfusion protocol. The principal endpoint was a composite outcome, which included bleeding, large volume transfusion, and re-operation. RESULTS: FIBTEM clot amplitude after 10 minutes measured on ICU admission and post-operative bleeding at 24 hours showed an inverse linear relationship (R2 = .03; p = .026). Performance of A10 FIBTEM in predicting SB evaluated by Receiving Operating Curve analysis showed an area under the curve of 0.63 (95% CI 0.56 - 0.70; p = .026) with a best cutoff of 9 mm. An A10 FIBTEM of 3 mm was the cutoff associated with a positive predictive value of 50%, while an A10 FIBTEM of 9 mm showed a negative predictive value of 92%. On multivariable analysis, an A10 FIBTEM ≤ 3 mm remained independently associated with SB. CONCLUSION: The present investigation shows for the first time in a population undergoing open TAAA repair that an A10 FIBTEM ≤ 3mm on ICU admission is associated with post-operative severe bleeding. Trigger and target values for fibrinogen supplementation, based on A10 FIBTEM, have been provided. The transferability and reliability of these cutoff values require further study.

Tranexamic acid in open aortic aneurysm surgery: a randomised clinical trial.

BACKGROUND: Bleeding and transfusions affect mortality in aortic surgery. Although tranexamic acid significantly reduced bleeding in multiple settings, its role in major vascular surgery was never studied. The aim of this study was to determine if tranexamic acid reduces blood loss in open abdominal aortic aneurysm (AAA) surgery. METHODS: A total of 100 patients undergoing elective open AAA repair were randomised to receive tranexamic acid (a loading dose of 500 mg and a continuous infusion of 250 mg h-1) or placebo. The primary outcome was intraoperative blood loss, and the secondary outcomes were the number of patients receiving red blood cells, occurrence of thromboembolic events, and mortality. Data were analysed using the intention-to-treat principle. RESULTS: Fifty patients were randomised into each group. Median (inter-quartile range) intraoperative blood loss was 400 (300-1050) ml in the tranexamic acid group vs 500 (360-1000) ml in the placebo group (P=0.44). Transfusion rate was seven/50 (14%) in the tranexamic group vs 12/50 (24%) in the placebo group (P=0.20). No thrombosis was recorded. In a post hoc analysis, postoperative blood loss was reduced in the tranexamic group both at 4 h (60 [40-80] ml vs 100 [60-140] ml, P<0.001) and 24 h (180 [120-275] vs 275 [190-395] ml, P=0.003) after surgery. At 1 yr, three patients were dead, all in the placebo group (P=0.24) and all after 28 days. CONCLUSIONS: Tranexamic acid did not reduce intraoperative blood loss or blood transfusions in open AAA repair, although it may reduce postoperative blood loss without increasing adverse effects. CLINICAL TRIAL REGISTRATION: NCT02335359.

Editor's Choice - A Rotational Thromboelastometry Driven Transfusion Strategy Reduces Allogenic Blood Transfusion During Open Thoraco-abdominal Aortic Aneurysm Repair: A Propensity Score Matched Study.

OBJECTIVE: Open repair of thoraco-abdominal aortic aneurysm (TAAA) is a challenging procedure, associated with high rates of peri-operative bleeding and blood product transfusions. A large intra-operative volume transfusion has been associated with higher in hospital mortality and prolonged mechanical ventilation. A propensity score matched study was carried out to assess whether the introduction of a rotational thromboelastometry (ROTEM) based transfusion strategy reduces allogenic blood transfusion and affects morbidity in patients undergoing open TAAA repair. METHODS: All patients undergoing open TAAA repair at the San Raffaele Scientific Institute between 2009 and 2017 were included. Until 2016, a protocol based on estimated blood loss and conventional coagulation tests was used. After March 2016 a ROTEM guided transfusion protocol was developed and adopted. To account for selection bias, propensity score matching was performed. RESULTS: Five hundred and forty-seven consecutive patients were included. After propensity score matching, 77 patients in the ROTEM algorithm group were successfully matched with 77 patients in the standard algorithm group. Patients managed with ROTEM received fewer red blood cells units (3.5 [range 0-11] vs. 4 [range 0-17]; p = .026) and a lower volume of fresh frozen plasma (286 ± 496 vs. 2,050 ± 1,120; p < .001). In addition, fewer patients received fresh frozen plasma (35% vs. 97%; p < .001). Patients in the ROTEM group showed a significant decrease in the occurrence of pulmonary complications (44% vs. 83%; p = .01). Cost analysis showed a relevant reduction of per-patient expense after the introduction of ROTEM (€834 ± €577 vs. €1,285 ± €851; p < .001) CONCLUSION: A ROTEM guided transfusion strategy significantly limited the quantity of transfused blood products during open TAAA repair, improving clinical outcomes while reducing costs, allowing for better resource distribution in a setting where blood loss is relevant.

Epidural Analgesia in Open Thoraco-abdominal Aortic Aneurysm Repair.

OBJECTIVE: Epidural analgesia improves pain control and outcomes of abdominal aortic aneurysm procedures, while the effect of thoracic epidural analgesia on thoraco-abdominal aortic aneurysm (TAAA) repair is unknown. The aim of the study was to evaluate thoracic epidural analgesia effects in patients undergoing open TAAA repair in terms of pain control and clinically relevant outcomes. METHODS: This was a retrospective study of a prospectively collected database. Patients undergoing open TAAA repair between January 2009 and December 2016. RESULTS: Four hundred and fifty-nine consecutive patients were included. Thoracic epidural analgesia was used in 409 (89%) of cases. On multivariable analysis, patients who received thoracic epidural analgesia experienced reduced post-operative pain (odds ratio [OR] 0.003, 95% confidence interval [CI] 0.0007-0.009; p < .001), a lower rate of acute kidney injury (AKI; OR 0.39, 95% CI 0.21-0.71 [p = .002]), atrial fibrillation (OR 0.47, 95% CI 0.23-0.95; p = .04), acute myocardial infarction (AMI; OR 0.189, 95% CI 0.05-0.64; p = .008), and paraplegia (OR 0.31, 95% CI 0.157-0.615; p = .001) compared with the conventional analgesia (CA) group. After propensity score matching, 43 patients in the CA group were compared with 43 in thoracic epidural analgesia group. On case match analysis thoracic epidural analgesia showed a significant reduction in post-operative pain (p < .001) and no differences in the incidence of AKI, atrial fibrillation, AMI, and paraplegia. In the thoracic epidural analgesia group there were no epidural haematomas. CONCLUSION: Thoracic epidural analgesia was effective in reducing post-operative pain with no effect on major post-operative complications. The use of thoracic epidural analgesia, if not contraindicated, might be considered in clinical practice, even in patients undergoing open TAAA repair. Whether a better post-operative management enhances patient's recovery in this setting remains to be tested.

Periprocedural and perioperatory management of patients with tricuspid valve disease.

Tricuspid regurgitation (TR) is a common valvular lesion which may affect morbidity and mortality. It can be related to an intrinsic abnormality of the tricuspid valve leaflets (organic) or secondary to annular dilatation (functional). Often organic and functional TR coexist in the same patient. A long-standing TR is associated with ascites, congestive hepatopathy, peripheral edema, renal failure, and abdominal fullness which significantly affect the outcome. In particular, the perioperative course may be complicated due to both the presence of comorbidities and the development of a severe postoperative right ventricle (RV) dysfunction. In fact, the TR may conceal a preoperative RV dysfunction due to a backflow in in the right atrium, which becomes overt only after the tricuspid valve (TV) repair/replacement (afterload mismatch). In light of this, an appropriate medical treatment before surgery may improve the performance of the RV, maximizing the result of the elective surgical therapy. The perioperative optimization should reduce the right atrial and ventricle overload, decrease the pulmonary vascular resistances, improve RV contractility and treat aggressively the arrhythmias. In doing so, the following rules should be considered: careful fluid administration, ß1-agonists favored over α-agonists to treat hemodynamic instability, and maintenance of a normal-to-elevated heart rate. Since the TV repair/replacement needs mechanical ventilation in both open and percutaneous surgery, a careful volume and pharmacological management should be adopted to counteract the detrimental effect of the mechanical ventilation on the top of an already dysfunctional RV. In fact, in the context of RV failure the cardiac output is strictly dependent on the preload and the increase of the intrathoracic pressure, reducing the venous return, may lead to acute heart failure. The intraoperative administration of volume and vasoactive drugs, titrated on the basis of the transesophageal echocardiography, permit to support the RV intraoperatively. Paracorporeal mechanical hemodynamic support should be always available as "bail out" in the event of intractable RV failure. In conclusion the patients undergoing TV surgery are complex and only a detailed anesthesiologic and surgical workup may decrease the perioperative mortality and morbidity.