Fluid Management in Cardiac Surgery: Results of a Survey in European Cardiac Anesthesia Departments.

OBJECTIVE: To evaluate the current practice of perioperative fluid management in cardiac surgery patients. DESIGN: Multiple choice survey with 26 questions about existing practice of perioperative fluid management in cardiac surgery patients. SETTING: Online survey. PARTICIPANTS: Representatives of anesthesia departments in European cardiac surgical centers. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The study comprised 106 respondents from 18 European countries who mainly worked in teaching hospitals (66%). In 73% of institutions, patients were admitted to a cardiac surgery intensive care unit (ICU) postoperatively. Perfusionists were responsible for the cardiopulmonary bypass priming solution, whereas anesthesiologists were responsible for intraoperative and postoperative fluid management. For cardiopulmonary bypass priming, balanced crystalloids were used in 51.5% of the centers, whereas in 36%, a combination of crystalloid with either synthetic colloid or albumin was administered. Intraoperatively, balanced crystalloids were used by 74% of centers, followed by a combination of crystalloids with synthetic colloids (15%) and other combinations (11%). No colloids were used by 32% of respondents. When colloids were used, gelatin was preferred, compared with hydroxyethyl starches and albumin (60% v 24% v 16%, respectively). Seventy-three percent of respondents, also involved in ICU treatment, did not change their fluid strategy in the ICU compared with their intraoperative strategy. Thirty-two percent of those who changed their strategy either added (32%) or decreased (29%) synthetic colloids or added (32%) or decreased (7%) natural colloids. CONCLUSIONS: Perioperative fluid management in cardiac surgery patients may have changed in the last few years in European centers. Balanced crystalloids now seem to be the preferred solutions, followed by synthetic colloids (mainly gelatins) and albumin.

Echocardiographic Guidance of Intentional Leaflet Laceration prior to Transcatheter Aortic Valve Replacement: A Structured Approach to the Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction Procedure.

Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is a recently developed technique to reduce the risk of ostial coronary obstruction during transcatheter aortic valve replacement. Intraprocedural fluoroscopy and transesophageal echocardiography imaging are used complimentarily to guide the procedure. So far, no structured echocardiographic imaging protocol has been described for this intervention. Based on an experience of more than 50 BASILICA procedures at two different institutions, we present a step-by-step approach for transesophageal echocardiography guidance during BASILICA and highlight anatomical and procedural characteristics from an echocardiographic perspective.

Systematic use of intentional leaflet laceration to prevent TAVI-induced coronary obstruction: feasibility and early clinical outcomes of the BASILICA technique.

AIMS: The aim of this study was to evaluate the feasibility, efficacy and safety of the bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) technique during transcatheter aortic valve implantation (TAVI) in an initial cohort at a single European centre. METHODS AND RESULTS: Between August 2018 and March 2020, BASILICA was attempted in 23 leaflets in 21 consecutive patients undergoing TAVI (age 78±6 years, 52% female). The index procedure was performed for 21 degenerated bioprosthetic leaflets (90%, 9.2±2.6 years after implantation) and two native leaflets (10%). BASILICA was performed for a single leaflet in 19 (90%) patients and for both leaflets in two (10%) patients. The median total procedure time was 82 (interquartile range [IQR] 70-131) minutes, and BASILICA time (sheath-in to laceration) was 45 (IQR 35-67) minutes. A cerebral embolic protection device was used in 20 (95%) patients. BASILICA was feasible in all but one patient (95%) and resulted in effective prevention of coronary obstruction in 19 patients (90%). One patient developed a non-flow-limiting ostial lesion after BASILICA and TAVI, and was treated by additional coronary stenting. No mortality or stroke was observed up to 30 days. CONCLUSIONS: The feasibility, efficacy and safety of BASILICA in this early single-centre experience were consistent with the initial proof-of-concept reports. Further validation by ongoing multicentre registries remains warranted.