Outcome analysis of synchronous carotid endarterectomy and cardiac surgery. Comparison of two anesthetic techniques after propensity score-matching.

BACKGROUND: The aim of this study was to investigate the outcome of patients undergoing synchronous carotid endarterectomy and coronary and/or other cardiac surgery. The impact of anesthesia on the outcome was examined. METHODS: A retrospective single-center observational study was performed, to investigate the outcome of 127 consecutive adult patients submitted to synchronous surgery from 2011 to 2019. Cooperative patient general anesthesia for carotid endarterectomy followed by standard general anesthesia for cardiac surgery and standard general anesthesia for the whole surgery were compared after a propensity score analysis. RESULTS: Primary outcomes were 30-day mortality (3.1%), incidence of stroke (3.1%), and myocardial infarction (0.8%). Agitation upon awakening, postoperative cardiac troponin I release, the increase of serum creatinine, the occurrence of acute kidney injury and the need for continuous renal replacement therapy were the secondary outcomes. A binary logistic regression revealed that cardiopulmonary bypass use, standard general anesthesia for the whole surgery and the European risk score II, were the strongest predictors of any severe postoperative complications. After propensity score matching, general anesthesia for the whole surgery was significantly correlated with the occurrence of any severe postoperative complication (P=0.038). CONCLUSIONS: Synchronous surgery was performed with acceptable mortality and complication rate even in combination with other than isolated coronary surgery. Cooperative patient general anesthesia during carotid endarterectomy, was not inferior to general anesthesia in this setting.

Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine.

BACKGROUND: This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association. METHODS: GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations. RESULTS: The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]). CONCLUSIONS: This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

Anesthetic management of carotid endarterectomy: an update from Italian guidelines.

BACKGROUND AND AIMS: In order to systematically review the latest evidence on anesthesia, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure management for carotid endarterectomy. The present review is based on a single chapter of the Italian Health Institute Guidelines for diagnosis and treatment of extracranial carotid stenosis and stroke prevention. METHODS AND RESULTS: A systematic article review focused on the previously cited topics published between January 2016 and October 2020 has been performed; we looked for both primary and secondary studies in the extensive archive of Medline/PubMed and Cochrane library databases. We selected 14 systematic reviews and meta-analyses, 13 randomized controlled trials, 8 observational studies, and 1 narrative review. Based on this analysis, syntheses of the available evidence were shared and recommendations were indicated complying with the GRADE-SIGN version methodology. CONCLUSIONS: From this up-to-date analysis, it has emerged that any type of anesthesia and neurological monitoring method is related to a better outcome after carotid endarterectomy. In addition, insufficient evidence was found to justify reversal or no-reversal of heparin at the end of surgery. Furthermore, despite a low evidence level, a suggestion for blood pressure monitoring in the postoperative period was formulated.

Rotational thromboelastometry for diagnosis of fibrinolysis induced by urokinase in an in-vitro model.

Fibrinolysis can be abnormally activated in several critical care settings but it's often misdiagnosed by standard laboratory tests. Although rotational thromboelastometry can assess the whole coagulative process, its ability to detect fibrinolysis has been questioned. Aim of this study was to investigate the ability of thromboelastometry in detecting induced fibrinolysis in an in-vitro model. Whole blood samples were taken from 18 healthy volunteers. Each sample was split and added with increasing urokinase concentrations till to reach 0, 50, 75 and 100 IU/ml. Thromboelastometry tests, extem and aptem, were performed on the obtained samples. If significant lysis at 50 IU/ml was recorded, also 10, 25 and 35 IU/ml drug concentrations were tested. No lytic effects were detected in 10 IU/ml samples. Lysis variables were the most sensitive in detecting fibrinolysis even at 25 IU/ml (P < 0.05). Clot firmness parameters were also affected by urokinase, but only at the two highest drug concentrations (P < 0.05). Extem/aptem ratio enhanced the sensitivity of these parameters only if lysis was more marked. Analysing groups of different lysis severity, the time to achieve maximum clot firmness could anticipate an ongoing fulminant or intermediate lysis with 100% sensitivity and 100% specificity (P < 0.05) when lower than 1341.5 s. Rotational thromboelastometry could detect fibrinolysis when it was induced in vitro by 25 IU/ml urokinase or more. Apart from the parameters specific for lysis, time to achieve maximum clot firmness appeared as the earliest indicator of fibrinolysis with high sensitivity and specificity especially if a more intense lysis was going on.

Systematic Application of Rapid Sequence Intubation With Remifentanil During COVID-19 Pandemic.

In this letter, the authors wonder about the need to apply some of the precautions that have been repeatedly suggested during the recent COVID-19 (coronavirus disease 19) pandemic not only to suspected or documented cases of infection but also to all the new cases entering the hospital. In this regard, orotracheal intubation has been universally recognized as a maneuver with a high risk of viral transmission. On the other hand, rapid sequence induction, which represents the gold standard for limiting the risk of transmission for health care professionals, implies side effects that can be potentially harmful for patients with impaired hemodynamics. In this regard, the authors report a particular type of rapid induction that they are performing in a systematic way during the recent pandemic in cardiac surgery patients. This is performed after the patient reaches a deep analgesic plan, thanks to the unique characteristics of the opioid remifentanil. This type of induction, already tested in vasculopathic patients who underwent carotid surgery, is characterized by great hemodynamic stability and is very advantageous, in the writer's experience, when rapid sequence induction has to be systematically applied to cardiovascular patients, especially if you only want to protect operators.

Overweight and aging increase the risk of atrial fibrillation after cardiac surgery independently of left atrial size and left ventricular ejection fraction.

BACKGROUND: Body mass index (BMI), age, left atrium (LA) dimension and left ventricular ejection fraction (LVEF) have been linked to post-operative atrial fibrillation (POAF) after cardiac surgery. The aim of this study was to better define the role of these risk factors. METHODS: This retrospective cohort study evaluated 249 patients (without prior atrial dysrhythmia) undergoing cardiac or aortic surgery. Prior to surgery, the following data were collected: age, BMI, LA diameter, LA area, LVEF, thyroid stimulating hormone (TSH), creatinine and the presence of arterial hypertension (AH) and diabetes. Intraoperative data such as operation time, total clamp time, cardiopulmonary bypass time, and presence of pericardial/pleural effusion were also collected. Only patients without pre- and post-surgery prophylactic anti-arrhythmic therapy were included. RESULTS: Patients with (N = 127, 51%) and without POAF (N = 122, 49%) were compared. No difference was observed for sex, LA diameter, LA area, LVEF, TSH, diabetes and use of ACE inhibitors or statins prior to intervention. Moreover, no difference was observed in terms of operation time, total clamp time, cardiopulmonary bypass time, and presence of pericardial/pleural effusion. However, patients with POAF were older (70.6 ± 10.7 vs. 60.4 ± 16.4 years, p = 0.001), had higher BMI (26.8 ± 4.5 vs. 24.9 ± 3.6 kg/m2, p = 0.001), higher baseline creatinine (1.06 ± 0.91 vs. 0.88 ± 0.32 mg/dL, p = 0.038) and a higher frequency of arterial hypertension (73.2% vs. 50%, p = 0.001) and Bentall procedure (24.4% vs. 9.8%, p = 0.023). Multivariate analysis showed that the only independent predictors of POAF were age (OR = 1.05, 95%CI 1.02-1.07, p = 0.001) and BMI (OR = 1.11 95%CI 1.03-1.2,p = 0.006). CONCLUSIONS: These findings suggest that advanced age and a higher BMI are strong risk factors for POAF in patients without previous AF even in the presence of comparable LA dimensions and LVEF.

Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol.

BACKGROUND: Integration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound (FoCUS) can impact decision-making, assist in the diagnosis of reversible etiologies and help guiding resuscitation of patients with cardiac arrest. OBJECTIVE: To evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing resusTEE after a course with clinical training in the cardiac surgery theatre. METHODS: Ten EPs without previous TEE experience underwent a resusTEE course, based on a 2-h workshop and an 8-h hands-on training. The training was performed in a cardiac surgery theatre tutored by cardiovascular anesthesiologists. The six taught views were mid-esophageal four-chamber (ME4CH), mid-esophageal long axis (MELAX), mid-esophageal two-chamber (ME2CH), mid-esophageal bicaval view (MEbicaval), transgastric short axis (TGSAX) and aorta view (AOview). The EPs were evaluated by a cardiovascular anesthesiologist at the end of the course as well as after 12 weeks according to a standardized evaluation method. Once the course was completed, resusTEE exams, performed by EPs in Emergency Department (ED), were monitored for a 12-week period. RESULTS: The average assessment of the ten EPs by the tutors was higher than 4 points out of 5, both at the end of the course and after 12 weeks. Probe insertion, acquisition and interpretation of the different views scored on average more than 4 points out of 5 except for TGSAX that showed worsening after 12 weeks. Trainees performed twelve resusTEE exams in ED in patients with out-of-hospital cardiac arrest (OHCA) over 12 weeks after the course. EPs used only four out of six taught views in clinical practice, in the following order of frequency: ME4CH, AOview, MEbicaval and MELAX. CONCLUSIONS: EPs, after a course with clinical training in the cardiac surgery theatre, can successfully acquire and maintain the skills needed to perform resusTEE. However, among the six views learned in the course, EPs used only four of them (ME4CH, MEbicaval, MELAX and AOview).

Rotational Thromboelastometry-Guided Hemostatic Therapy for Management of Cerebrospinal Fluid Catheter in Patients Undergoing Endovascular Aortic Repair.

OBJECTIVE: Central neuraxial techniques are typically avoided in patients with underlying coagulopathy or abnormal coagulation tests. Vertebral canal hematoma is a rare but devastating complication of those procedures. Although the sensitivity and specificity of standard laboratory tests in predicting this event are rather poor or unknown, these tests are commonly used to allow or advise against the insertion of an epidural or spinal catheter. Furthermore, the role of viscoelastic point-of-care tests, which are widely used to monitor coagulation in the perioperative setting, is unexplored. CASE REPORT: We report a patient presenting for endovascular repair of a dissecting thoracoabdominal aortic aneurysm, in which we placed a subarachnoid catheter for continuous cerebrospinal fluid drainage because of the high risk of spinal cord ischemia associated with the procedure. Unfortunately, the patient presented with an overt consumption coagulopathy that would have advised against performing any central neuraxial technique. Bedside monitoring, diagnosis, and goal-directed hemostatic therapy guided by thromboelastometry documented improved coagulation both at the time of insertion and removal of the subarachnoid device. No catheter-related complications occurred. CONCLUSIONS: Thromboelastometry proved useful to guide hemostatic therapy before subarachnoid catheter placement and extraction in a patient with severe coagulopathy when standard coagulation tests were of less benefit.

Anatomic characteristics of bileaflet mitral valve prolapse--Barlow disease--in patients undergoing mitral valve repair.

OBJECTIVE: Barlow disease is a still challenging pathology for the surgeon. Aim of the present study is to report anatomic abnormalities of mitral valve in patients undergoing mitral valve repair. METHODS: Between January 1st, 2007, and December 31st, 2010, 85 consecutive patients (54 men and 31 women, mean age 59 +/- 14 years--range: 28-85 years) with the features of a Barlow mitral valve disease underwent mitral repair Forty seven percent of patients were in New York Heart Association functional class III or IV. Preoperative transesophageal echocardiography was compared with anatomical findings at the moment of surgery. RESULTS: Transthoracic echocardiography diagnosis of Barlow disease according to the criteria described by Carpentier was confirmed at anatomical inspection. Annular calcifications were found in 28 patients while 7 patients presented single or multiple clefts. A flail posterior mitral leaflet was detected in 32 subjects, while a flail anterior leaflet in 8. Elongation of chordae tendineae was demonstrated in 45 patients and chordal rupture in 31. All patients showed at trans esophageal echocardiography the typical features of Barlow disease. Seventy-seven (90.6%) patients had severe mitral valve regurgitation, in the remaining 9.4% it was moderate to severe. Transesophageal echocardiography failed to identify clefts in 2/7 and chordal rupture in 4/31. CONCLUSIONS: bileaflet prolapse > 2 mm, billowing valve with excess tissue and thickened leaflets > or = 3 mm, and severe annular dilatation, are characteristics of Barlow disease, however the identification of the associated and complex abnormalities of mitral valve is necessary to obtain optimal valve repair.

Spinal cord injury after ascending aorta and aortic arch replacement combined with antegrade stent grafting: role of postoperative cerebrospinal fluid drainage.

Ascending aorta and aortic arch replacement combined with antegrade stent grafting of the descending thoracic aorta represents an emerging hybrid surgical approach for complex and extensive thoracic aortic disease. We present a case of a patient at low risk for spinal cord ischemia who underwent hybrid thoracic aortic surgery (aortic arch replacement and E-vita prosthesis implantation) and developed a spinal cord injury (SCI) after the intervention. Treatment aimed at increasing spinal cord perfusion pressure with the aid of cerebrospinal fluid (CSF) drainage was effective in recovering neuromuscular function.

Dynamic response of liquid-filled catheter systems for measurement of blood pressure: precision of measurements and reliability of the Pressure Recording Analytical Method with different disposable systems.

PURPOSE: We aimed to compare the effects of a blood pressure transducer system specifically manufactured to limit underdamping artifacts with those of a standard system on hemodynamic parameter estimation and accuracy. MATERIALS AND METHODS: Forty-three consecutive patients undergoing vascular surgery at the University of Florence, Italy, were included. Arterial blood pressure signal was simultaneously registered with 2 MostCare monitors, connected to the artery either by a standard transducer or a specific transducer manufactured to avoid underdamping artifacts (Resonance Over-Shoot Eliminator [R.O.S.E.]; Becton Dickinson, Becton Drive, NJ). Patients were divided into 2 groups: absence (C group) or presence (R group) of underdamping/resonance artifacts of blood pressure signal. Systolic blood pressure, cardiac index, maximal pressure/time ratio (dP/dt(MAX)), and cardiac cycle efficiency were recorded every 30 seconds for 30 minutes. A total of 2675 measurements were performed with 34.9% incidence of underdamping/resonance artifacts. RESULTS: All hemodynamic parameters showed clinically acceptable differences in the C group; in contrast, the results differed greatly in the R group between standard and R.O.S.E. transducer (systolic blood pressure bias, 16.7 mm Hg; cardiac index bias, 0.24 L min(-1) m(-2); dP/dt(MAX) bias, 0.92 mm Hg/ms; cardiac cycle efficiency bias, 0.018 units). CONCLUSIONS: Underdamping/resonance artifacts frequently affect blood pressure measurement in operating rooms and intensive care units and cause severe overestimation of systolic blood pressure and incorrect estimation of hemodynamic parameters when the pulse contour method is used.

Anesthesia for carotid endarterectomy: the third option. Patient cooperation during general anesthesia.

BACKGROUND: Carotid endarterectomy is typically performed using either regional or general anesthesia techniques, which exhibit several differences, especially regarding the intraoperative neurological monitoring of patients. In this study, we introduce a technique of general anesthesia (cooperative patient general anesthesia), which allows neurological monitoring of the awake patient during surgery. METHODS: We prospectively enrolled 181 consecutive adult patients scheduled for carotid endarterectomy. Patients were anesthetized with a total i.v. anesthesia technique. During carotid clamping, anesthesia was reduced and maintained only with high-dose remifentanil, such that the patient was able to respond to verbal statements and neurological monitoring could be performed. The technique is described in detail. Patient neurological and cardiac outcomes were investigated. Patient and surgeon satisfaction with the technique were also evaluated. RESULTS: General anesthesia with a cooperative patient was achieved in 179 patients. No postoperative neurological events were observed. Two (1.1%) nonfatal myocardial infarctions occurred in the early postoperative period in two patients. Eighty-one percent of patients described the operation duration as brief, whereas 19.3% accurately perceived the time they were conscious. Both patients and surgeons were highly satisfied with the technique. CONCLUSIONS: In our series, cooperative patient general anesthesia proved to be a safe and satisfactory anesthetic technique for both the patient and surgeon. The technique was characterized by hemodynamic stability, excellent control of ventilatory pattern, continuous neurological monitoring, and immediate and safe conversion to general anesthesia whenever required. Further studies are needed to highlight the advantages of this technique compared with standard general and local anesthesia.

Cardiac output by arterial pulse contour: reliability under hemodynamic derangements.

Pulse contour methods (PCM) for the measurements of cardiac output (CO) are gaining popularity in intensive care settings but their reliability during hemodynamic instability has been questioned. Pressure-recording-analytical-method (PRAM) is a newly developed uncalibrated hemodynamic monitor and its capability in measuring CO during hemodynamic instability is still under investigation. Dobutamine (2.5 and 5 microg/kg/min), vasoconstriction (arginine-vasopressin 4, 8 and 16 IU/h), hemorrhage (-10%, -20%, -35%, and -50% of the theoretical volemia), and volume resuscitation were induced in eight swine. CO by means of thermodilution (CO(ThD)), transesophageal echocardiography (CO(TEE)) and PRAM (CO(PRAM)) were contemporarily registered. R(2), bias, and percentage error were used to compare the methods. Comparison between CO(PRAM) and CO(ThD) resulted in: r(2)=0.87; bias=-0.006 l/min; precision=+/-0.87 l/min; percentage error=22.8%. Comparison between CO(PRAM) and CO(TEE) resulted in: r(2)=0.85; bias=-0.007 l/min; precision=+/-0.86 l/min; percentage error=22%. Sub-group analysis revealed disagreement between methods only during the last two steps of hemorrhage: CO(PRAM) vs. CO(ThD): r(2)=0.67, bias=-0.37 l/min, precision=+/-1.04 l/min, limits of agreement=-1.39+0.66 l/min, and percentage error=45%; CO(PRAM) vs. CO(TEE): r(2)=0.38, bias=0.4 l/min, precision=+/-1.42 l/min, limits of agreement=-0.99+1.79 l/min, and percentage error=62%. PRAM resulted to be accurate in measuring CO during hemodynamic stability, tachycardia, and vasoconstriction. When volemia was reduced by >35%, disagreement between methods was observed.