Cardiothoracic Anesthesia Research Articles

Further Retractions of Dr. Joachim Boldt in the Journal of Cardiothoracic and Vascular Anesthesia

Further Retractions of Dr. Joachim Boldt in the Journal of Cardiothoracic and Vascular Anesthesia

A comment on the clinical experience of cardiothoracic anaesthesia trainees in a tertiary Australian hospital.

A comment on the clinical experience of cardiothoracic anaesthesia trainees in a tertiary Australian hospital.

Time critical diagnoses and transfers of patients with acute type A aortic dissection in the UK: national audit of current practice*

SummaryBackgroundType A aortic dissection repair is one of the most common emergency cardiac surgical procedures undertaken in the UK and has a high mortality. Early diagnosis and prompt surgery by an expert cardiac surgical team is crucial. Little is known about the patient's journey from first symptoms until surgery.MethodsThe Association for Cardiothoracic Anaesthesia and Critical Care undertook a prospective national audit of the management of type A aortic dissection in the UK.ResultsThe details of 334 patients with type A aortic dissection were reported by 28 UK cardiac centres over 12 months. Median (IQR [range]) time from onset of symptoms until arrival in an emergency department was 2.3 (1.4–4.7 [0.1–491.6]) h. Median (IQR [range]) time between arrival in the emergency department and the start of surgery was 9.5 (6.1–18.2 [0.8–363.5]) h. Delays in diagnosis and transfers were reported in 158 (47.3%) patients. Fifty‐two patients (15.6%) had an initial misdiagnosis. The condition of 56 patients (16.8%) deteriorated clinically before arrival in the operating theatre. A medical doctor accompanied 50 patients (15.0%) during transfer. Sixty‐four patients (19.2%) died in hospital with 41 (12.3%) dying within the first 5 days after surgery.ConclusionsThis audit provides a snapshot of current practice for patients with type A aortic dissection in the UK. Our findings show the acuity, clinical severity and vulnerability of patients with type A aortic dissection, and the deficits in the process of diagnosis and the quality of transfer. This audit demonstrates the need for the implementation of comprehensive, regionally governed, interdisciplinary medical management for every patient with type A aortic dissection.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2024

This special article is the seventeeth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology.1 The major themes selected for 2024 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2024 begin with an update on perioperative rehabilitation and enhanced recovery (ERACS) in in cardiothoracic surgery, with a focus on novel methods to best assess our patients in the preoperative period and the impact of implementing enhanced recovery care models on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into anemia, transfusions, and CABG outcomes with a focus on gender disparities. The third theme is focused on cardiothoracic transplantation, with discussions focusing on techniques related to lung transplantation including MCS. The fourth theme is focused on mechanical circulatory support, with discussions exploring advancements in left ventricular assist devices (LVADs) highlight the evolving landscape of mechanical circulatory support and discussion of anticoagulation practices. The fifth, and final theme is an update on medical cardiology, with focus on outcomes of transcatheter management of regurgitant pathology, device management in heart failure, and new techniques in catheter ablation. The themes selected for this article are only a few of the diverse advances in the specialty during 2024. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Bibliometric and knowledge map analysis of one lung ventilation.

One lung ventilation (OLV) is an essential method of lung isolation to protect the ventilated lung from soiling by the contralateral lung and obtain optimal surgical exposure in thoracic surgery. This study aims to examine the trends and developments in OLV research from 1982 to 2024 through bibliometric analysis. The literature on OLV was systematically searched in the Web of Science Core Collection database for this study. VOSviewer and CiteSpace were utilized to perform comprehensive bibliometric and visual analyses of global publication/trends, countries/institutions, authors/co-cited authors, journals/co-cited journals, co-cited references, and keywords in the field of OLV. A total of 1,682 articles and reviews on OLV research were identified, which showed an overall growing trend from 1982 to 2024. The United States was the leader in this field, accounting for the largest number of publications (n=299). Among all institutions, Yonsei University had the largest number of publications (n=23), but National Taiwan University Hospital had the highest number of cited publications (n=876). The papers related to OLV were mainly published in Journal of Cardiothoracic and Vascular Anesthesia (n=147) and the most productive author was Cheng YJ (n=15). After keywords analysis, "infants", "dexmedetomidine", "inflammation", and "airway management" were newly emergent research hotspots. Through bibliometric and visualization methods, we undertook a comprehensive analysis in the field of OLV. The United States maintained a top position in this field, the emerging hotspots of OLV changed from basic research to clinical research and the further innovation of OLV management. This study provides new ideas for scholars in their future works.

An Update on Guidelines to Prevent and Manage Atrial Fibrillation After Cardiac Surgery and a Survey of Practice in the UK

ObjectivesPostoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and affects around 30% of patients. Variable guidelines from multiple organisations exist for the prevention of POAF after cardiac surgery. We conducted a survey of UK practice was conducted to define “usual care” for a platform trial of interventions to prevent POAF after cardiac surgery. To provide context for the survey, we reviewed all current guidelines for the prevention and management of AF after cardiac surgery. DesignOnline survey and literature review SettingSurvey: All 35 UK National Health Service Cardiac Surgery Centres. Literature Review: Guidelines from specialist societies and other guideline making organisations from the UK, Europe and North America. ParticipantsEstablished link network of researchers. Measurements and Main ResultsReview: Five relevant guidelines were identified. All guidelines recommend β-blockade for prevention of AF after cardiac surgery. Treatment of AF is recommended using either rate or rhythm control. Cardioversion is recommended only for the haemodynamically unstable patient. Patients who remain in AF for over 48 hours should be considered for anticoagulation. Patients should be followed up within 60 days to review the need for anti-arrhythmic and anticoagulant therapy. Survey: 31/35 (89%) of centres responded. 11 of 31 (35.5%) centres followed local guidance for prevention of POAF, 4 (13%) centres followed Society of Cardiovascular Anesthesiologists / European Association of Cardiothoracic Anaesthesia guidelines, 4 (13%) followed UK National Institute of Health and Care Excellence guidance and 4 followed “other” guidance. 8 of 31 (26%) followed no guidelines to prevent POAF. 28 of 31 (90%) centres did not risk-stratify their patients for POAF. Most centres (23/31, 74%) do not have a care-package in place to prevent POAF, but 14 of 31 (45%) try in some way to prevent AF in patients presenting in sinus rhythm. The most common interventions to prevent POAF are β-blocker use post-operatively (23/31, 74%), use of magnesium (20/31, 64.5%) and maintaining a serum K+ ≥4.5mmol/L (26/31, 84%). ConclusionsGuidance to prevent AF after cardiac surgery clusters around the use of β-blockade. Although patients in the UK do not appear to be risk-assessed for POAF, the main interventions used to prevent it are similar; β-blockade and maintenance of serum K+ and Mg2+ levels.

Educational perspectives in cardiothoracic anesthesia in the United States using a survey of educators and learners.

Cardiothoracic anesthesiology training presents learners with unique challenges, procedural skills, and the management of high-intensity critical scenarios. An effective relationship between educator and learner can serve as the backbone for effective learning, which is crucial for the development of budding anesthesiologists. Strengthening this educational alliance between teachers and trainees involves understanding the educational values educators and learners find most important to their learning experiences. This study aimed to identify the key educational values related to cardiothoracic anesthesia for both learners and educators. By identifying these values in separate cohorts (learners and educators), the importance of various educational values can be examined and compared between the trainees and teachers. Two separate surveys (one for learners and one for teachers) were adapted from the Pratt and Collins Teaching Perspectives Inventory to establish the importance of various educational values related to cardiothoracic anesthesia. Surveys were sent to 165 Accreditation Council for Graduate Medical Education-accredited anesthesiology residency training programs in the United States to trainees (residents and cardiothoracic anesthesiology fellows) and educators (board-certified cardiothoracic anesthesiologists). Analysis of survey results from 19 educators and 57 learners revealed no statistical differences across the two groups, except Q15: "Let trainee perform critical technical steps" (P value = 0.02). While learners and educators in cardiothoracic anesthesia hold similar values regarding cardiac anesthesia education, they differ in the degree to which critical technical steps should be performed by learners.

Preoperative right ventricular strain as an early predictor of perioperative cardiac failure in patients undergoing mitral surgery: An exploratory study.

This study's primary purpose was to demonstrate the correlation of preoperative right ventricular free-wall longitudinal strain (RVFWLS) and pre-/postsurgical variation in strain (delta strain) with the clinical and echocardiographic diagnosis of right ventricular dysfunction. Its secondary purpose was to determine the correlation of RVFWLS and delta strain with length of stay (LOS) in the intensive care unit (ICU), ventilation days, trend of natriuretic peptide test. (NT-proBNP) and lactate in the first 48 h, incidence of acute renal failure, and 28-day mortality. Prospective observational study. Cardio-thoracic and Vascular Anaesthesia Department and ICU of the University Hospital Integrated Trust of Verona. Patients scheduled for mitral surgery. None. All clinical and transoesophageal echocardiographic (TEE) parameters were collected at baseline, before surgery (T1) and at admission in the ICU postsurgery (T2). During the postoperative period, the clinical and echocardiographic diagnoses of right, left, or biventricular dysfunction were evaluated. TEE parameters were evaluated by a cardiologist offline. The patients were divided into two subgroups according to the development of any type of ventricular dysfunction. No statistically significant differences emerged between the two groups. According to a logistic regression model, a T1-RVFWLS value of -15% appeared to predict biventricular dysfunction (sensitivity: 100%; specificity: 91.3%). No correlation between T1- or T2-RVFWLS and creatinine, hours of ventilation or ICU LOS was found. Our study introduces a new parameter that could be used in perioperative evaluations to identify patients at risk of postoperative biventricular dysfunction.

The role of anesthesiology in modern cardiac surgery: overview of key techniques and issues

Anesthesiology plays a key role in modern cardiac surgery, ensuring the safe conduct of surgical interventions on the heart and blood vessels. The paper provides an overview of the main techniques and problems in the field of anesthesiology in cardiac surgery. The first section is devoted to the basic methods of anesthesiological provision of cardiac surgery. He describes the various types of anesthesia used in cardiac surgery, including general anesthesia, epidural and spinal anesthesia, as well as combined methods. The advantages and disadvantages of each of them are considered, as well as the specifics of their application, depending on the type of operation and the patient’s condition. The second section examines the key problems faced by anesthesiologists in cardiac surgery. This includes managing hemodynamic parameters during surgery, monitoring heart and respiratory function, ensuring adequate analgesia, and preventing possible complications such as myocardial ischemia, arrhythmias, hypothermia, and thromboembolic events. Special attention is paid to solving problems related to patients with concomitant diseases such as hypertension, diabetes mellitus, chronic obstructive pulmonary disease, etc. The article discusses the features of the use of cardiothoracic anesthesia in cardiac surgery, as well as emerging problems and prospects in this area. An overview of the use of anesthesia in the field of cardiac surgery is presented, both current challenges and problems in this area are highlighted. The current state of anesthesia in cardiac surgery is analyzed and a number of problems faced by anesthesiologists during cardiac surgery, including problems of cardiothoracic anesthesia, are highlighted. This includes difficulties with controlling the depth of anesthesia, ensuring safety while maintaining artificial circulation, managing fluid balance, and monitoring cardiac function during surgery. The article reveals the relevance and importance of the work of anesthesiologists in cardiac surgery and the problems they face, as well as reveals the prospects for the development of anesthesia in cardiac surgery. This work will help anesthesiologists and cardiac surgeons better understand the specifics of anesthesiological care in cardiac surgery and effectively solve emerging problems, ensuring maximum safety and comfort for patients.

The Year in Graduate Medical Education: Selected Highlights from 2023

This special article is the third in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia that highlights significant literature from the world of graduate medical education that was published over the past year. Some of the major themes that will be addressed in this review include the potential uses and pitfalls of artificial intelligence in graduate medical education, trainee well-being and the rise of unionized house staff, the effect of gender and race/ethnicity on residency application and attrition rates, and the adoption of novel technologies in medical simulation and education. The authors would like to thank the editorial board for again allowing us to draw attention to some of the more interesting work published in the field of graduate medical education during 2023. We hope that the readers find these highlights thought-provoking and informative as we all strive to successfully educate the next generation of anesthesiologists.

The Year in Perioperative Echocardiography: Selected Highlights from 2023

This article is the eighth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

Intraoperative and Intraprocedural Use of 3-Dimensional Transesophageal Echocardiography: An International European Association of Cardiothoracic Anesthesia and Intensive Care Survey of Cardiac Surgical Centers

ObjectiveTo assess the intraoperative use of three-dimensional transesophageal echocardiography (3D TEE) in cardiac surgical centers, we created a survey aimed at evaluating the availability of equipment, the use of 3D TEE for specific surgical and interventional procedures and single image modalities. Finally, we asked to identify the perceived impact on patient's management and current limitations to its routine use. DesignMultiple-choice 25-questions online survey submitted to the members of the European Association of Cardiothoracic Anesthesia and Intensive Care (EACTAIC) on December 6th, 2021 and closed on January 31st, 2022. SettingOnline survey. ParticipantsRegistered EACTAIC members in 2021. InterventionsNone. Measurements and Main ResultsA total of 239 respondents from 44 different countries took part in the survey (27% of total 903 EACTAIC members). Most respondents (59%) were TEE certified by National Board of Echocardiography (NBE), European Association of Cardiovascular Imaging (EACVI/EACTAIC) or had a national certificate. Sixty-eight percent of respondents had no formal 3D TEE training. Eight percent of respondents had no 3D machines. While 40% had one for each operating room, 33% had only one for the entire operating room block. 3D TEE was performed most frequently in more than 67% of cases for mitral valve (MV) surgery and in more than 54% of cases for mitral- and tricuspid clips, aortic valve- (AV), tricuspid valve- (TV) and aortic surgery. ConclusionCurrent guidelines suggest integrating 3D TEE in all comprehensive examinations. Our survey reports that intraoperative 3D TEE was used in the majority of mitral valve surgery and only half of other valve surgeries and transcatheter procedures. Its use may be explained by the availability of 3D machines, trained personnel and limited time to perform TEE in the operating room. Educational initiatives for training in 3D TEE may further increase its routine use.

Simulation-based Training for Anaesthesiology Residents: A Boon

Training in anaesthesiology necessitates exposure to diverse clinical situations, demanding quick thinking, decision-making, and intervention. Achieving expertise in this field traditionally requires years of clinical practice and exposure to various scenarios. Simulation-Based Medical Education (SBME) revolutionises anaesthesiology training by providing a controlled environment where trainees can acquire knowledge, refine clinical skills, and develop clinical and non clinical competencies. This approach includes training in soft skills, critical analysis of clinical scenarios, and receiving constructive feedback from qualified instructors. In alignment with industries like aviation and the military, various countries have incorporated SBME into medical curricula. The present scoping review explores the benefits, limitations, and diverse applications of SBME for anaesthesiology trainees. The historical progression of SBME, from basic procedural models to advanced simulations and virtual reality, underscores its transformative impact on medical education. Standards and accreditation for simulation laboratories ensure quality maintenance in training programs. SBME in anaesthesiology focuses on technical skill development and cultivating crucial non technical skills essential for patient safety. The review emphasises the need for a comprehensive curriculum, qualified instructors, reliable equipment, and ethical considerations to establish standards for simulation in anaesthesia. The versatility of simulation types, including low-fidelity task trainers, high-fidelity mannequins, and virtual simulations, enhances training opportunities. Anaesthesia simulation encompasses a spectrum of scenarios, from cardiothoracic anaesthesia to airway management, addressing technical and soft skills. While SBME offers advantages such as enhanced teamwork, regulated skill development, and exposure to rare situations, drawbacks include costs, ethical concerns, and replicating real-world complexity. Ongoing research is crucial to assess the effectiveness of SBME and its impact on patient outcomes. The evolving significance of SBME in anaesthesiology suggests its continued promise for breakthroughs in medical education.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023

This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantationstrategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on bothtemporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes ofinvasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.

A role for ultra-high resolution three-dimensional printed human heart models.

Echocardiography is essential for diagnosing and assessing the severity of perioperative structural and functional heart disease. Yet, educational opportunities to better understand echocardiography-based cardiac anatomy remain limited by the two-dimensional display, lack of anatomic details, variability of heart models, and costs and global access of training. We performed micro computed tomography of human heart specimens not suitable for orthotopic transplantation. We created high-resolution computational 3D models of different human hearts, sliced them in the different recommended American Society of Echocardiography views, and 3D printed them using different materials. We scanned, 3D modeled, and 3D printed a variety of human hearts both healthy and diseased. We have made the models available in the cardiac operating rooms and routinely use them for teaching anesthesia residents and cardiothoracic anesthesia fellows about basic and advanced echocardiographic views, cardiopulmonary bypass cannulation strategies, and valvular pathology and planned interventions. We have generated a library of 3D printed hearts to display the recommended echocardiographic views as a unique educational tool designed to safely accelerate the understanding of absolute and relative human cardiac anatomy and pathology, especially related to gaining advanced appreciation of clinically employed perioperative echocardiography.

Expert consensus on the prevention of catheter-related bloodstream infection in the department of anesthesiology

Endovascular catheters play an important role in modern medical diagnosis and treatment. Catheter-related bloodstream infection (CRBSI) is one of the common complications during catheter indwelling, which seriously affects the prognosis of patients. In order to standardize the prevention, diagnosis and treatment strategies of catheter-related bloodstream infections in the Department of Anesthesiology in China, the perioperative Infection Control Branch of the Chinese Society of Cardiothoracic Anesthesia reached a consensus based on the current evidence-based medicine. The consensus elaborates on the aspects of diagnosis, prevention strategy, maintenance and treatment of catheter-associated bloodstream infection, aiming to provide reference for the standardized diagnosis, treatment and management of catheter-associated bloodstream infection in the Department of Anesthesiology.

Focused transoesophageal TOE (fTOE): A new accreditation pathway.

The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients.

Ultrasound Guidance Versus Palpation Technique for Arterial Line Insertion: A Prospective Randomised Trial

Arterial line (IAL) insertion is a core procedure in cardiothoracic anaesthesia and can prove challenging at times. Anaesthetic trainees (ATs) in the current era are experienced in the use of ultrasound (US) guidance for vascular access, which has become common practice and increasingly available. This study sought to determine the impact of US on IAL success by ATs in cardiothoracic patients at the current institution.

The Year in Perioperative Echocardiography: Selected Highlights From 2022

THIS SPECIAL article is part of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the Editorial Board for the opportunity to continue this series, which focuses on the past year's research highlights that pertain to perioperative echocardiography in relation to cardiothoracic and vascular anesthesia. The major selected themes for 2022 include (1) updates on mitral valve assessments and interventions, (2) training and simulation updates, (3) outcomes and complications of transesophageal echocardiography, and (4) point-of-care cardiac ultrasound. The themes selected for this special article are just a sample of the advances in perioperative echocardiography during 2022. An appreciation and understanding of these highlights will help to ensure and improve the perioperative outcomes for patients with cardiovascular disease undergoing cardiac surgery.

Mechanical circulatory support in cardiogenic shock: it is not just a matter of device.

aDepartment of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria bDivision of Cardiothoracic Intensive Care, Cardiothoracic Department, ASST Spedali Civili, Brescia, Italy Correspondence to Andrea Montisci, MD, Division of Cardiothoracic Intensive Care, Cardiothoracic Department, ASST Spedali Civili, Brescia, Italy Tel: +39 30 399 5688; Mob: 39 349 83 79707; e-mail: [email protected] Received 15 October, 2022 Revised 25 January, 2023 Accepted 11 February, 2023