Cardiac Anesthesiologists Research Articles

CASE SERIES OF PREGNANCY-ASSOCIATED MYOCARDIAL INFARCTION: AN EPIDEMIC IN WAITING

Acute myocardial infarction during pregnancy or postpartum period is a rare but life-threatening condition associated with poor maternal and fetal outcome. Although atherosclerotic coronary artery disease is the most common etiology in general population, the causation is more diverse in pregnancy and this may have therapeutic implications. Early diagnosis and timely management with collaboration among Maternal-fetal medicine specialist, interventional cardiologist, cardiac anaesthetist, intensivist and neonatologist is essential to prevent maternal cardiac deaths. We present a case series of two patients with postpartum and antepartum acute MI, respectively and their diagnosis, management and outcomes in a tertiary care center.

Perioperative outcomes in children with congenital heart disease when cared for by a Congenital Cardiac Anesthesiologist during Noncardiac Surgery

Background: Congenital cardiac anesthesiologists are a limited resource, but their expertise may be beneficial to children with Congenital Heart Disease (CHD) undergoing procedures outside of the cardiac operating room. Our objective was to evaluate the incidence of adverse events in patients with CHD during noncardiac surgery when their perioperative care was coordinated and executed by a congenital cardiac anesthesiologist.Methods: We conducted a retrospective cohort study at a tertiary care health system. Children with CHD were assigned one of three American College of Surgeons National Surgery Quality Improvement Program functional severity classifications (minor, major, or severe). Perioperative care was performed by a congenital cardiac anesthesiologist. Outcomes such as perioperative cardiac arrest, postoperative intubation, and survival data were compared to those reported in the literature.Results: 131 patients with CHD underwent 171 noncardiac surgical procedures. Congenital cardiac anesthesiologists primarily cared for children with major (45%) or severe (45%) CHD undergoing noncardiac surgery. An intraoperative cardiac arrest occurred in a single patient (0.6%; 95% CI 0.0–3.2) with severe CHD. Patients with severe CHD accounted for most (66.7%) of the 3.5% (CI 1.3–7.5) of patients who required postoperative reintubation. The 30-day and overall mortality rates for patients with severe CHD remained high at 13.6% (95% CI 5.2–27.4) and 18.2% (95% CI 6.8–29.6) respectively.Conclusions: Perioperative risk stratification, planning and care of pediatric patients with major or severe CHD by a dedicated team of congenital cardiac anesthesiologists is associated with a low rate of perioperative complications.

Barriers and facilitators to implementing evidence based bleeding management in Australian Cardiac Surgery Units: a qualitative interview study analysed with the theoretical domains framework and COM-B model

BackgroundBleeding during cardiac surgery is a common complication that often requires the transfusion of blood products. The combination of bleeding and blood product transfusion incrementally increases adverse outcomes including infection and mortality. Following bleeding management guideline recommendations could assist with minimising risk but adherence is not high, and the cause for lack of adherence is not well understood. This study aimed to identify barriers and facilitators to practicing and implementing evidenced-based intra-operative, bleeding management in Australian cardiac surgery units.MethodsWe used a qualitative descriptive design to conduct semi-structured interviews with Australian cardiac surgeons, anaesthetists and perfusionists. The Theoretical Domains Framework (TDF) was utilised to guide interviews and thematically analyse the data. Categorised data were then linked with the three key domains of the COM-B model (capability, opportunity, motivation - behaviour) to explore and understand behaviour.ResultsSeventeen interviews were completed. Nine of the 14 TDF domains emerged as significant. Analysis revealed key themes to improving capability included, standardisation, monitoring, auditing and feedback of data and cross discipline training. Opportunity for change was improved with interpersonal and interdepartmental collaboration through shared goals, and more efficient and supportive processes allowing clinicians to navigate unfamiliar business and financial models of health care. Results suggest as individuals, clinicians had the motivation to make change and healthcare organisations have an obligation and a responsibility to partner with clinicians to support change and improve goal directed best practice.ConclusionUsing a theory-based approach it was possible to identify factors which may be positively or negatively influence clinicians ability to implement best practice bleeding management in Australian cardiac surgical units.

Maternal Outcome among Women Having Cardiac Disease at Tertiary Care Hospital

Aim: To determine the maternal outcome among women presented with cardiac disease at tertiary care hospital. Study design: Prospective study. Place and duration of study: Department of Obstetrics & Gynaecology, Liaquat University of Medical and Health Science Jamshoro from 1st April 2019 to 31st March 2020. Methodology: Fifty-seven women after 24 weeks of alive pregnancy and having cardiac diseases were included. The subjects were seen in the Gynaecology OPD every two weeks till 34-36 weeks, as per institutional protocols and after that every week by obstetrician. Cardiologists saw subjects in each trimester and delivery schedule were developed and medications were adapted with collaboration. The anaesthetic scheme of the subject was also reviewed with the cardiac anaesthetist. All the maternal outcome data was recorded. Results: Most of the patients 89.5% had age group of 25-32 years. Multiparous women were commonest 43.3% and 53.7% patients underwent normal vaginal delivery. 35.8% patients had congenital heart disease, 32.8% had cardiomyopathy and 16.4% had Rheumatic heart disease. According to the maternal outcome anemia was most common among 85.1%, pre-eclampsia 41.8%, pulmonary edema 35.8%, IUGR 20.9%, birth asphyxia 26.9%, preterm 38.8% and maternal mortality 14.9%. Abruption placenta and preterm birth were significantly associated with congenital heart disease and cardiomyopathy p=0.047 and p=0.002 respectively. Pulmonary edema was higher among patients of cardiomyopathy (p=0.027). Birth asphyxia was higher among patients of rheumatic heart disease. While anemia, IUGR and maternal mortality were equally found among cardiac diseases, p-values were quit insignificant. Conclusion: Cardiac disease showed adverse maternal outcome during pregnancy with mortality rate of 14.9%. Keywords: Pregnancy cardiac disease, Maternal outcome, Mortality rate

Year in Review 2020: Noteworthy Literature in Cardiothoracic Anesthesiology.

The year 2020 was marred by the emergence of a deadly pandemic that disrupted every aspect of life. Despite the disruption, notable research accomplishments in the practice of cardiothoracic anesthesiology occurred in 2020 with an emphasis on optimizing care, improving outcomes, and expanding what is possible for patients undergoing cardiac surgery. This year's edition of Noteworthy Literature Review will focus on specific themes in cardiac anesthesiology that include preoperative anemia, predictors of acute kidney injury following cardiac surgery, pain management modalities, anticoagulation strategies after transcatheter aortic valve replacement, mechanical circulatory support, and future directions in research.

How Do We Use Dashboards to Enhance Quality in Cardiac Anesthesia?

The use of clinical dashboards has expanded significantly in healthcare in recent years in a variety of settings. The ability to analyze data related to quality metrics in one screen is highly desirable for cardiac anesthesiologists, as they have considerable influence on important clinical outcomes. Building a robust quality program within cardiac anesthesia relies on consistent access and review of quality outcome measures, process measures, and operational measures through a clinical dashboard. Signals and trends in these measures may be compared to other cardiac surgical programs to analyze gaps and areas for quality improvement efforts. In this article, the authors describe how they designed a clinical cardiac anesthesia dashboard for quality efforts at their institution.

Perioperative Management of Cardiac Implantable Electronic Devices: A Single-Center Report of 469 Interrogations

ObjectiveAnesthesiologists increasingly are involved in the perioperative management of cardiac implantable electronic devices (CIEDs). The variety of devices available and the ongoing advancements in technology, programming capabilities, and responses to conventional management (eg, magnet application) complicate the management of these devices. As an aid to this clinical challenge, this manuscript reviews 469 interrogations performed by a single cardiac anesthesiologist during a 4.5-year period to derive useful information with which to guide anesthesiologists who have chosen to pursue training in this area of perioperative care. DesignRetrospective review of prospectively collected data. SettingSingle institution, quaternary care hospital. ParticipantsPatients with CIEDs presenting for surgery; the quality assurance (QA) reports of 469 interrogations performed between May 2015 and September 2019 were reviewed. InterventionsNo intervention. Measurement and Main ResultsThe distributions of surgical procedures, device types, device manufacturers, pacing modes, rate-response sensors, special functions, and performed interventions were reviewed and analyzed. The QA reports were evaluated to identify information or experiences that demonstrated important lessons for anesthesiologists engaging in perioperative CIED management. ConclusionsThis database review provides general guidance for anesthesiologists managing CIEDs in the perioperative period. Concepts germane to the operating room are emphasized.

Dexmedetomidine, Delirium, and Adverse Outcomes: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database

BackgroundWe tested the hypothesis that dexmedetomidine was associated with a reduced incidence of postoperative delirium (POD) and adverse outcomes in cardiac surgery patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database including the Adult Cardiac Anesthesiology subsection. MethodsWe identified 55,905 patients in The Society of Thoracic Surgeons Adult Cardiac Surgery Database who underwent cardiac surgery between July 2014 and December 2018. Using propensity score–weighted regression analysis, we analyzed the effect of intraoperative dexmedetomidine on the primary (POD) and secondary outcomes (highest pain score on day 3 and at discharge, stroke, prolonged ventilation, postoperative intubation/reintubation, additional postoperative hours ventilated, renal failure, atrial fibrillation, and 30-day mortality). In separate propensity score–weighted analyses, we examined the effect of postoperative dexmedetomidine on the highest postoperative pain score at discharge and 30-day mortality. ResultsThe rate of intraoperative dexmedetomidine use was 25.5% (n = 13,963), and its administration was associated with increased odds for POD (odds ratio, 1.85; 95% confidence interval [CI], 1.60-2.13), a small higher average pain score on day 3 (mean difference, 0.08; 95% CI, 0.02-0.14), increased odds for postoperative intubation/reintubation (odds ratio, 1.29; 95% CI, 1.12-1.48), and a small lower average pain score at discharge (mean difference, –0.31; 95% CI, –0.21 to–0.41). Postoperative dexmedetomidine was associated with a small higher average pain score at discharge (mean difference, 0.27; 95% CI, 0.21-0.34) and higher odds for 30-day mortality (odds ratio, 1.25, 95% CI, 1.07-1.46). ConclusionsIn this registry of cardiac surgical patients dexmedetomidine administration was associated with POD and adverse outcomes.

Prevalence of burnout and its relationship to health status and social support in more than 1000 subspecialty anesthesiologists

BackgroundPhysician burnout may be at ‘epidemic’ proportions due to factors associated with modern healthcare practice and technology. Practice attributes vary appreciably among subspecialists. Understanding burnout incidence and its associated factors...

Combined Liver Kidney Transplant in Adult Patient With Alagille Syndrome and Pulmonary Hypertension

In this article, we describe a case of a 33-year-old female with Alagille syndrome complicated by bilateral branch pulmonary artery stenosis resulting in moderate pulmonary hypertension, end-stage liver disease complicated by portal hypertension, and chronic renal disease who presented for combined liver-kidney transplant. Alagille syndrome is an autosomal dominant disease affecting the liver, heart, and kidneys. Multidisciplinary preoperative evaluation was performed with a team consisting of a congenital heart disease cardiologist, a cardiac anesthesiologist, a nephrologist, and a transplant surgeon. We describe Alagille syndrome and our intraoperative management. To our knowledge, this is the first description of a combined liver-kidney transplant in an adult patient with Alagille syndrome.

Thorny and fruitful path of Tomsk cardiac surgery and anesthesiology

The article presents a brief historical sketch on the development of cardiovascular surgery in Tomsk. The main achievements and clinical and research activities of the Department of Cardiovascular Surgery at Cardiology Research Institute are presented. The article is intended for cardiologists, internal medicine specialists, cardiac surgeons, and anesthesiologists.

Perioperative care of heart transplant recipients undergoing non-cardiac surgery.

The life expectancy of patients with end-stage heart disease undergoing Orthotopic Heart Transplantation (OHT) has increased significantly in the recent decades since its original introduction into the medical practice in 1967. Substantial advances in post-operative intensive care, surgical prophylaxis, and anti-rejection drugs have clearly impacted survivability after OHT, therefore the volume of patients presenting for non-cardiac surgical procedures is expected to continue to escalate in the upcoming years. There are a number of caveats associated with this upsurge of post-OHT patients requiring non-cardiac surgery, including presenting to healthcare facilities without the resources and technology necessary to manage potential perioperative complications or that may not be familiar with the care of these patients, facilities in which a cardiac anesthesiologist is not available, patients presenting for emergency procedures and so forth. The perioperative care of patients after OHT introduces several challenges to the anesthesiologist including preoperative risk assessments different to the general population and intraoperative management of a denervated organ with altered response to medications and drug-drug interactions. The present review aims to synopsize current data of patients presenting for non-cardiac surgery after OHT, surgical aspects of the transplant that may impact perioperative care, physiology of the transplanted heart as well as anesthetic considerations.

Validated tool for quality assessment of anesthesia services by cardiac surgeons.

Background and Aim:The role of the cardiac anaesthesiologists extends beyond mere patient wellbeing to diagnostic input and active participation in decision making during cardiac surgery. The quality of service provision should therefore be judged not only by patient satisfaction but also by the satisfaction of cardiac surgeons. Unfortunately, quantification of cardiac surgeon satisfaction remains a challenge due to the absence of a reliable and validated tool. We therefore attempted to develop a robust, validated, pilot psychometric questionnaire, to measure satisfaction of cardiac surgeons' to cardiac anesthesia services.Methods:The questionnaire was developed with the help of senior cardiac anesthesiologist, cardiac surgeon and statistician with database search in PubMed and the Cochrane Library. The questionnaire was tested for content validity, comprehensibility, and identification of new items. This generated the second version of the questionnaire with nine socio-demographic and professional questions, 46 Likert type questions, an abridged Marlowe Crowne Social Desirability scale and one open ended question. This questionnaire was e-mailed to 100 cardiac surgeons requesting them to participate via a web-based survey application.Results:Content validity of the responses was tested by Aiken's content validity coefficient (V). Internal consistency was tested with Chronbach's alpha. Fifty-two cardiac surgeons participated in the survey. Twelve Likert type questions were deleted due to low V values. Excellent Chronbach's alpha (0.94) was obtained in the remaining 34 items.Conclusions:We have developed a questionnaire that includes 34 variables and allows quantifying surgeon satisfaction in a reliable fashion and is validated for the purpose.

Selected 2020 Highlights in Congenital Cardiac Anesthesia

This article is a review of the highlights of pertinent literature published during the 12 months of 2020 that are of interest to the congenital cardiac anesthesiologist. After a search of the US National Library of Medicine's PubMed database, several topics emerged for which significant contributions were made in 2020. The authors of the present article considered the following topics noteworthy to be included in this review: pediatric cardiac care in the coronavirus disease 2019 era, the use of mechanical circulatory support in coronavirus disease 2019-related multisystem inflammatory syndrome in children, transfusion and coagulation management in children undergoing congenital heart surgery, and pulmonary vein stenosis.

A Short Course on the Teachings of Paul Barash.

A Short Course on the Teachings of Paul Barash.

An analytical study of Comparison between Ketamine - Dexmedetomidine versus Ketamine - Propofol for Sedation in Children Undergoing Minor Cardiac Procedures in a Cardiac Catheterization Laboratory

Background: The management of children with heart diseases has been a major challenge for cardiac anesthetists. The anesthetic technique to be used should be easy, safer and provide cardiac stability throughout the operation. So cardiac interventionist prefer deep sedation with the patient breathing spontaneously and painlessly in the room. Propofol, Ketamine along with other combinations drugs have been used worldwide by cardiac anesthetists to achieve these goals. We carried out this study to evaluate the combination drugs for pediatric cardiac surgeries which are Ketamine – Dexmedetomidine (KD) and Ketamine – Propofol (KP). Methodology: This study was conducted in the Department of Cardiology. A total number of 80 cases were selected, 40 from each comparative groups of Ketamine – Dexmedetomidine (KD) and Ketamine – Propofol (KP). Patient data was categorized into age, sex, procedure done and recovery time, analgesic boluses required and hemodynamic parameters during the surgery. Results: Mean age in KD group was 5.24 ± 1.25 years and in KP group was 4.95 ± 1.86 years. There were 24 males (60%) and 16 females (40%) in KD group and 22 males (55%) and 18 females (45%) in KP group. Most common procedures done in both the groups was ASD for device closure done in 12 patients (30%) in KD group and 13 patients (32.5%) in KP group. There was significant difference between the mean recovery time and number of ketamine boluses consumption in both the groups. (p<0.05) Heart rate was significantly lower in KD group at 5, 10, 15 and 20 min post induction when compared to KP group. No statistically significance was found in difference between the Mean Respiratory rate and MAP. Conclusion: Our study concludes that the use of KD combination is relatively safe, practical alternative, we did not find any hemodynamic or respiratory effects during the cardiac procedures but there was some delayed recovery.

Recommendations for developing clinical care protocols during pandemics: From theory and practice.

In 2019, a novel coronavirus called the severe acute respiratory syndrome coronavirus 2 led to the outbreak of the coronavirus disease 2019, which was deemed a pandemic by the World Health Organization in March 2020. Owing to the accelerated rate of mortality and utilization of hospital resources, health care systems had to adapt to these major changes. This affected patient care across all disciplines and specifically within the perioperative services. In this review, we discuss the strategies and pitfalls of how perioperative services in a large academic medical center responded to the initial onset of a pandemic, adjustments made to airway management and anesthesia specialty services – including critical care medicine, obstetric anesthesiology, and cardiac anesthesiology - and strategies for reopening surgical caseload during the pandemic.

Professor Rehana Yaseen

After a long and courageous battle against her disease Prof. Rehana Yaseen breathed her last on 19th December, 2020 at AKUH Karachi. She was diagnosed as suffering from leukemia about a year ago. Despite her disease and treatment she continued to work as Senior Cardiac Anesthetist till her death in PNS Shifa Karachi. She joined PNS Shifa in April, 2017 and helped establish Cardiac Surgery there.

Single-center experience of 105-minimalistc transfemoral transcatheter aortic valve replacement and its outcome

IntroductionTranscatheter aortic valve replacement (TAVR) increases worldwide, and indications expand from high-risk aortic stenosis patients to low-risk aortic stenosis. Studies have shown that minimalistic TAVR done under conscious sedation is safe and effective. We report single-operator, the single-center outcome of 105 minimalist transfemoral, conscious sedation TAVR patients, analyzed retrospectively. MethodsAll patients underwent TAVR in cardiac catheterization lab via percutaneous transfemoral, conscious sedation approach. A dedicated cardiac anesthetist team delivered the conscious sedation with a standard protocol described in the main text. The outcomes were analyzed as per VARC-2 criteria and compared with the latest low-risk TAVR trials. ResultsA total of 105 patients underwent transcatheter aortic valve replacement between July 2016 to February 2020. The mean age of the population was 73 years, and the mean STS score was 3.99 ± 2.59. All patients underwent a percutaneous transfemoral approach. Self-expanding valve was used in 40% of cases and balloon-expandable valve in 60% (Sapien3™ in 31% and MyVal™ in 29%) of cases. One patient required conversion to surgical aortic valve replacement. The success rate was 99 percent. The outcomes were: all-cause mortality: 0.9%, stroke rate 1.9%, New pacemaker rate 5.7%, 87.6% had no paravalvular leak. The mild and moderate paravalvular leak was seen in 2.8% and 1.9%, respectively. The mean gradient decreased from 47.5 mmHg to 9 mmHg. The average ICU stay was 26.4 h, and the average hospital stay was 5.4 days. Our outcomes are comparable with the latest published low-risk trial. ConclusionMinimalist, conscious sedation, transfemoral transcatheter aortic valve replacement when done following a standard protocol is safe and effective.

Valvular Heart Disease in Pregnancy.

Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical decompensation in high-risk women. Women with VHD considering pregnancy should undergo preconception counseling with a high-risk obstetrician and cardiologist to review the maternal, fetal, and obstetric risks of pregnancy and delivery. Vaginal delivery is recommended for most women with VHD. Given the complexity of managing VHD during pregnancy, women should be managed by a multidisciplinary Pregnancy Heart Team during pregnancy, consisting of a high-risk obstetrician, cardiologist, and cardiac anesthesiologist.