Acid citrate dextrose formula A versus unfractionated heparin for anticoagulation of salvaged red blood cells in cardiac surgery

Red blood cell salvage plays an important role in reducing the use of allogeneic blood transfusion during cardiac surgery. While there is consensus as to the benefit of employing cell salvage systems, there are no clear recommendations on the anticoagulant used for salvaged blood. In eight patients undergoing elective cardiac surgery at our university hospital's cardiovascular center, the authors describe hemodynamic effects of salvaged autologous blood transfusion when either unfractionated heparin or acid citrate dextrose formula A was used as the anticoagulant. Mean arterial pressure, heart rate, central venous pressure and acid-base status of the autologous red blood cell concentrate were compared between patients receiving autologous blood anticoagulated with acid citrate dextrose formula A versus unfractionated heparin. A clinically relevant decrease in mean arterial pressure (median change, - 19 mmHg [min -29; max -1] and marked acidosis [group median <6.30 [<6.30; 6.49] was observed in group acid citrate dextrose formula A. Acid citrate dextrose formula A anticoagulant for autologous red blood cell salvage has the potential to cause major adverse hemodynamic events during free-flowing re-transfusion of autologous red blood cell concentrate. Acute ionized hypocalcemia and acidemia may ensue from residual citrate in the supernatant of red blood cell concentrate reconstituted in unbuffered saline.

Risk and Timing of Noncardiac Surgery After Transcatheter Aortic Valve Implantation

IMPORTANCE

Noncardiac surgery after transcatheter aortic valve implantation (TAVI) is a clinical challenge with concerns about safety and optimal management.

OBJECTIVES

To evaluate perioperative risk of adverse events associated with noncardiac surgery after TAVI by timing of surgery, type of surgery, and TAVI valve performance.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data from a prospective TAVI registry of patients at the tertiary care University Hospital in Bern, Switzerland. All patients undergoing noncardiac surgery after TAVI were identified. Data were analyzed from November through December 2021.

EXPOSURES

Timing, clinical urgency, and risk category of noncardiac surgery were assessed among patients who had undergone TAVI and subsequent noncardiac surgery.

MAIN OUTCOMES AND MEASURES

A composite of death, stroke, myocardial infarction, and major or life-threatening bleeding within 30 days after noncardiac surgery.

RESULTS

Among 2238 patients undergoing TAVI between 2013 and 2020, 300 patients (mean [SD] age, 81.8 [6.6] years; 144 [48.0%] women) underwent elective (160 patients) or urgent (140 patients) noncardiac surgery after TAVI and were included in the analysis. Of these individuals, 63 patients (21.0%) had noncardiac surgery within 30 days of TAVI. Procedures were categorized into low-risk (21 patients), intermediate-risk (190 patients), and high-risk (89 patients) surgery. Composite end points occurred within 30 days of surgery among 58 patients (Kaplan-Meier estimate, 19.7%; 95% CI, 15.6%-24.7%). There were no significant differences in baseline demographics between patients with the 30-day composite end point and 242 patients without this end point, including mean (SD) age (81.3 [7.1] years vs 81.9 [6.5] years; P = .28) and sex (25 [43.1%] women vs 119 [49.2%] women; P = .37). Timing (ie, ≤30 days from TAVI to noncardiac surgery), urgency, and risk category of surgery were not associated with increased risk of the end point. Moderate or severe prosthesis-patient mismatch (adjusted hazard ratio [aHR], 2.33; 95% CI, 1.37-3.95; P = .002) and moderate or severe paravalvular regurgitation (aHR, 3.61; 95% CI 1.25-10.41; P = .02) were independently associated with increased risk of the end point.

CONCLUSIONS AND RELEVANCE

These findings suggest that noncardiac surgery may be performed early after successful TAVI. Suboptimal device performance, such as prosthesis-patient mismatch and paravalvular regurgitation, was associated with increased risk of adverse outcomes after noncardiac surgery.

The impact of on-site cardiac rhythm on mortality in patients supported with extracorporeal cardiopulmonary resuscitation: A retrospective cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used in patients with out-of-hospital or in-hospital cardiac arrest in whom conventional cardiopulmonary resuscitation remains unsuccessful. The aim of this study was to analyze the impact of initial cardiac rhythm-detected on-site of the cardiac arrest-on mortality.

METHODS

We performed a retrospective cohort study of patients who received ECPR in our tertiary care cardiac arrest center. Patients were divided into three groups depending on their cardiac rhythm: shockable rhythm, pulseless electrical activity, and asystole. The primary endpoint was mortality within the first 7 days after ECPR deployment. Secondary endpoints were mortality within 28 days and the impact of pre-ECPR potassium, serum lactate, pH, and pCO₂ on mortality. The association of the initial cardiac rhythm and the location of arrhythmia detection (patient monitored in hospital [category: monitored], not monitored but hospitalized [in-hospital], not monitored, not hospitalized [out-of hospital]) with the primary and secondary outcome was examined by means of univariable and multivariable logistic regression.

RESULTS

Sixty-five patients could be included in the final analysis. Thirty-two patients (49.2%, 95%CI 36.6%-61.9%) died within the first 7 days. In terms of 7-day-mortality patients differed in the initial cardiac rhythm (p = 0.040) and with respect to the location of arrhythmia detection (p = 0.002). Shockable cardiac rhythm (crude OR 0.21; 95%CI 0.03-0.98) and pulseless electrical activity (0.13; 0.02-0.61) as the initial rhythm on-site showed better odds for survival compared to asystole. However, this association did neither persist in adjusted analysis nor pairwise comparison.

DISCUSSION

The study could not demonstrate a better outcome with shockable rhythm after ECPR. More homogeneous and adequately powered cohorts are needed to better understand the impact of cardiac rhythm on patient outcomes after ECPR.

Perfusion management during cardiopulmonary bypass in a patient with high cardiac output due to arteriovenous malformations

We present a case of a 37-year-old woman diagnosed with Parkes-Weber syndrome characterized by high-flow arterio-venous malformations of the pelvic region with an estimated cardiac output of 7.2-8.5 l/min. Due to concomitant Marfan syndrome, the patient also presented an aortic root aneurysm needing surgical treatment under cardiopulmonary bypass. Concerns arose regarding the ability to maintain sufficient perfusion pressure during cardiopulmonary bypass due to the arterio-venous malformations. To address this, an intravascular balloon occlusion at the level of the aortic bifurcation was placed in order to limit arterial inflow into the arterio-venous malformations and achieve optimal perfusion pressure during cardiopulmonary bypass. The patient did not experience any complications and recovered completely after surgery.

Dexmedetomidine versus Propofol for Operator-Directed Nurse-Administered Procedural Sedation during Catheter Ablation of Atrial Fibrillation: a Randomized Controlled Study

BACKGROUND

Operator-directed nurse-administered (ODNA) sedation with propofol is the preferred sedation technique for catheter ablation of atrial fibrillation (AF) in many centers.

OBJECTIVE

We aimed to investigate whether Dexmedetomidine, an α2-adrenergic receptor agonist, is superior to propofol.

METHODS

We randomized 160 consecutive patients undergoing first AF ablation to ODNA sedation by dexmedetomidine (DEX group) versus propofol (PRO group), according to a standardized protocol. Patients were unaware of treatment allocation. The primary endpoint was a composite of inefficient sedation, termination/change of sedation protocol or procedure abortion, hypercapnia (transcutaneous CO2 >55 mmHg), hypoxemia (SpO₂ <90%) or intubation, prolonged hypotension (systolic blood pressure <80 mmHg), and sustained bradycardia necessitating cardiac pacing. Secondary endpoints were the components of the primary endpoint and patient satisfaction with procedural sedation, as assessed by a standardized questionnaire the day following ablation.

RESULTS

The primary endpoint occurred in 15 DEX group and 25 PRO group patients (19% vs. 31%; p=0.068). Hypercapnia was significantly more frequent in PRO group patients (29% vs. 10%; p=0.003). There was no significant difference among the other components of the primary endpoint, no procedure was aborted. Patient satisfaction was significantly better in PRO group patients (visual analog scale 0-100; median 100 in PRO group vs. median 93 in DEX group; p<0.001).

CONCLUSION

Efficacy of ODNA sedation with dexmedetomidine was not different to propofol. Hypercapnia occurs less frequent with dexmedetomidine, but patient satisfaction is better with propofol sedation. In selected patients, dexmedetomidine may be used as an alternative to propofol for ODNA sedation during AF ablation. (ClinicalTrials.gov number NCT03844841).

Early-experience with a novel suture device for sternal closure in pediatric cardiac surgery

BACKGROUND

Sternal closure by absorbable suture material is an established method for chest closure in pediatric cardiac surgery. However, the formation of granuloma around knotted suture material is frequently observed and has potential for prolonged wound healing and infection, particularly in newborns and infants. This retrospective study analyses the suitability and reliability of a novel absorbable, self-locking, multi-anchor knotless suture with antibacterial technology for sternal closure in pediatric cardiac surgery.

METHODS

The applied material (STRATAFIX^TMSymmetric PDS Plus, Ethicon) presents a poly-dioxanon PDS suture with a self-locking, multi anchor design, which enables a sternal closure in a continuous knotless suture technique. All children undergoing knotless closure after standard median sternotomy were examined for the occurrence of sternal wound infection or sternal instability by applying the screening criteria of the Centers for Disease Control and Prevention at hospital discharge, at 30 and 60 days.

RESULTS

In 130 cases, the new knotless sternal closure was used. Patients` mean age was 19.0±31.9 months (range: 0 to 142 months), mean bodyweight 7.8±6.6 kg (range: 2.4 to 35 kg). Delayed sternal closure occurred in 23 cases with a mean closure time after 2.9±2.6 days. One superficial incisional sternal site infection but no cases of deep sternal site infection or sternal instability were observed.

CONCLUSIONS

The application of the absorbable, knotless suture technique provides excellent results regarding the rate of sternal wound infection and improved healing after median sternotomy in pediatric patients.

Study design for a randomized crossover study investigating myocardial strain analysis in patients with coronary artery disease at hyperoxia and normoxemia prior to coronary artery bypass graft surgery (StrECHO-O2)

BACKGROUND

Supplemental oxygen (O₂) is used routinely during anesthesia. In the treatment of acute myocardial infarction, it has been established that hyperoxia is to be avoided, whereas information on benefit and risk of hyperoxia in patients with stable coronary artery disease (CAD) remain scarce, especially in the setting of general anesthesia. This study will compare the immediate effects of normoxemia and hyperoxia on cardiac function, with a primary focus on changes in peak longitudinal left-ventricular strain, in anesthetized stable chronic CAD patients using peri-operative transesophageal echocardiography (TEE).

METHODS

A single-center randomized cross-over clinical trial will be conducted, enrolling 106 patients undergoing elective coronary artery bypass graft surgery. After the induction of anesthesia and prior to the start of surgery, cardiac function will be assessed by 2D and 3D TEE. Images will be acquired at two different oxygen states for each patient in randomized order. The fraction of inspired oxygen (F_IO₂) will be titrated to a normoxemic state (oxygen saturation of 95-98%) and adjusted to a hyperoxic state (F_IO₂ = 0.8). TEE images will be analyzed in a blinded manner for standard cardiac function and strain parameters.

CONCLUSION

By using myocardial strain assessed by TEE, early and subtle signs of biventricular systolic and diastolic dysfunction can be promptly measured intraoperatively prior to the onset of severe signs of ischemia. The results may help anesthesiologists to better understand the effects of F_IO₂ on cardiac function and potentially tailor oxygen therapy to patients with CAD undergoing general anesthesia.

Cerebral microemboli during extracorporeal life support: a single-centre cohort study

OBJECTIVES

The aim of this study was to investigate the load and composition of cerebral microemboli in adult patients undergoing venoarterial extracorporeal life support (ECLS).

METHODS

Adult ECLS patients were investigated for the presence of cerebral microemboli and compared to critically ill, pressure-controlled ventilated controls and healthy volunteers. Cerebral microemboli were detected in both middle cerebral arteries for 30 min using transcranial Doppler ultrasound. Neurological outcome (ischaemic stroke, global brain ischaemia, intracerebral haemorrhage, seizure, metabolic encephalopathy, sensorimotor sequelae and neuropsychiatric disorders) was additionally evaluated.

RESULTS

Twenty ECLS patients (cannulations: 15 femoro-femoral, 4 femoro-subclavian, 1 femoro-aortic), 20 critically ill controls and 20 healthy volunteers were analysed. ECLS patients had statistically significantly more cerebral microemboli than critically ill controls {123 (43-547) [median (interquartile range)] vs 35 (16-74), difference: 88 [95% confidence interval (CI) 19-320], P = 0.023} and healthy volunteers [11 (5-12), difference: 112 (95% CI 45-351), P < 0.0001]. In ECLS patients, 96.5% (7346/7613) of cerebral microemboli were of gaseous composition, while solid cerebral microemboli [1 (0-5)] were detected in 12 out of 20 patients. ECLS patients had more neurological complications than critically ill controls (12/20 vs 3/20, P = 0.003). In ECLS patients, a high microembolic rate (>100/30 min) tended to be associated with neurological complications including ischaemic stroke, neuropsychiatric disorders, sensorimotor sequelae and non-convulsive status epilepticus (odds ratio 4.5, 95% CI 0.46-66.62; P = 0.559).

CONCLUSIONS

Our results indicate that adult ECLS patients are continuously exposed to many gaseous and, frequently, to few solid cerebral microemboli. Prolonged cerebral microemboli formation may contribute to neurological morbidity related to ECLS treatment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02020759, https://clinicaltrials.gov/ct2/show/NCT02020759?term=erdoes&rank=1.

Challenges in the Cardiothoracic and Vascular Anesthesia Fellowship Program Since the Coronavirus Disease 2019 (COVID-19) Pandemic: An Electronic Survey on Potential Solutions

Objective

The authors explored the current practice of fellowship training in cardiothoracic and vascular anesthesia and surveyed the acceptability of potential solutions to mitigate the interrupted fellowship training during the severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) pandemic.

Design

A prospective electronic questionnaire-based survey.

Setting

The survey was initiated by the Education Committee of the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC).

Participants

The study comprised EACTAIC fellows, EACTAIC, and non-EACTAIC subscribers to the EACTAIC newsletter and EACTAIC followers on different social media platforms.

Interventions

After obtaining the consent of participants, the authors assessed the perioperative management of COVID-19 patients, infrastructural aspects of the workplace, local routines for preoperative testing, the perceived availability of personal protective equipment (PPE), and the impact of COVID-19 on fellowship training. In addition, participants rated suggested solutions by the investigators to cope with the interruption of fellowship training, using a traffic light signal scale.

Measurements and Main Results

The authors collected 193 responses from 54 countries. Of the respondents, 82.4% reported cancelling or postponing elective cases during the first wave, 89.7% had provided care for COVID-19 patients, 75.1% reported staff in their center being reassigned to work in the intensive care unit (ICU), and 45% perceived a shortage of PPE at their centers. Most respondents reported the termination of local educational activities (79.6%) and fellowship assessments (51.5%) because of the pandemic (although 84% of them reported having time to participate in online teaching), and 83% reported a definitive psychological impact. More than 90% of the respondents chose green and/or yellow traffic lights to rate the importance of the suggested solutions to cope with the interrupted fellowship training during the pandemic.

Conclusions

The COVID-19 pandemic led to the cancellation of elective cases, the deployment of anesthesiologists to ICUs, the involvement of anesthesiologists in perioperative care for COVID-19 patients, and the interruption of educational activities and trainees’ assessments. There is some consensus on the suggested solutions for mitigation of the interruption in fellowship training.

European Association of Cardiothoracic Anesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum: First Edition

Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

Resolution of severe secondary mitral valve regurgitation following aortic valve replacement in infective endocarditis

We present the case of a patient with infective endocarditis anesthetized for replacement of severely regurgitant aortic valve. Intraoperative transesophageal echocardiography revealed a new diagnosis of severe secondary mitral regurgitation. After aortic valve replacement and tricuspid valve repair, severe mitral regurgitation resolved rapidly without any intervention. In multivalvular disease, instant spontaneous resolution of secondary mitral regurgitation is possible after surgical correction of an aortic regurgitation causing left ventricular volume overload.

Bradycardia in a newborn with accidental severe hypothermia: treat or don't touch? A case report

Background

Hypothermia significantly affects mortality and morbidity of newborns. Literature about severe accidental hypothermia in neonates is limited. We report a case of a neonate suffering from severe accidental hypothermia. An understanding of the physiology of neonatal thermoregulation and hypothermia is important to decide on treatment.

Case presentation

A low-birth-weight newborn was found with severe accidental hypothermia (rectal temperature 25.7 °C) due to prolonged exposure to low ambient temperature. The newborn presented bradycardic, bradypnoeic, lethargic, pale and cold. Bradycardia, bradypnea and impaired consciousness were interpreted in the context of the measured body temperature. Therefore, no reanimation or intubation was initiated. The newborn was closely monitored and successfully treated only with active and passive rewarming.

Conclusion

Clinical parameters such as heart frequency, blood pressure, respiration and consciousness must be interpreted in light of the measured body temperature. Medical treatment should be adapted to the clinical presentation. External rewarming can be a safe and effective measure in neonatal patients.

European Association of Cardiothoracic and Vascular Anesthesiology and Intensive Care Fellowship Program: The Graduates' Experience

OBJECTIVES

In 2009, the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) established a fellowship program to train highly qualified specialists in the field of cardiac anesthesia. For the further development of the program, a survey among graduates was distributed to get information about the individual motivation and career perspectives of fellows.

DESIGN

Online survey among graduates of the EACTAIC cardiothoracic and vascular anesthesia (CTVA) fellowship program.

SETTING

Twenty-four-item online survey after personal invitation from the EACTAIC office PARTICIPANTS: Forty-nine graduates.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The survey had a response rate of 77%. On average, graduates joined the EACTAIC fellowship program four years after completing their residency program. Participants felt well-prepared by the program regarding their clinical and nonclinical skills. The majority participated in research activities during the fellowship and continued to work in the field of CTVA. Ninety-two percent of the respondents found a job opportunity within a reasonable time after completing the training.

CONCLUSIONS

Among the respondents, the survey showed a high satisfactory rate with the received training and good job opportunities after completing the fellowship. Further research should investigate the question of beneficial effects on research activities after completing the fellowship.

Checking the integrity of eyes in prone position: A novel application of video laryngoscopes

Perioperative visual loss is a rare but severe complication after surgery in prone position. One of several mechanisms is direct ophthalmic compression. This can be avoided through optimal positioning and padding of the head, but position and integrity of the eyes need to be checked at regular intervals. We describe the use of a conventional video laryngoscope during vascular surgery in prone position as a simple solution for intermittent monitoring of external integrity of the eyes and size of the pupils. This requires no additional material and allows documentation of the findings. Our method might reduce complications and improve patient outcome.

The use of minimal invasive extracorporeal circulation for rewarming after accidental hypothermia and circulatory arrest

BACKGROUND

Extracorporeal cardiopulmonary resuscitation has become a recommended treatment option for patients with severe hypothermia with cardiac arrest. Minimal invasive extracorporeal circulation (MiECC) may offer advantages over the current standard extracorporeal membrane oxygenation (ECMO).

METHODS

Retrospective cohort analysis of hospital database for patients with accidental hypothermia and extracorporeal rewarming with MiECC admitted between 2010 and 2019.

RESULTS

Overall, six of 17 patients survived to hospital discharge. Eleven patients suffered accidental hypothermia in an alpine and six in an urban setting. Sixteen patients arrived at the hospital under ongoing cardiopulmonary resuscitation (CPR). CPR time was 90 minutes (0-150). Four patients survived from an alpine setting and two from an urban setting with CPR duration of 90 minutes (0-150) and 85 minutes (25-100), respectively. Asphyctic patients tended to have lower survival (one of seven patients). Two patients of six with major trauma survived.

CONCLUSION

MiECC for extracorporeal rewarming from severe accidental hypothermia is a feasible alternative to ECMO, with comparable survival rates.