Intraoperative Arrhythmias Research Articles

Can heartbeat recovery be improved with terminal non-cardioplegic warm blood perfusion prior to aortic unclamping in single-clamp technique coronary artery bypass surgery? A randomized controlled trial

BackgroundThe objective of this study is to investigate whether the use of antegrade perfusion with terminal non-cardioplegic warm blood (TNWB) before aortic unclamping in single-clamp technique coronary artery bypass has a positive impact on intraoperative heartbeat recovery.MethodsBetween December 2022 and May 2023, 40 consecutive patients undergoing coronary artery bypass using single-clamp technique were randomized into one of two groups: the TNWB group received an antegrade perfusion with TNWB before removing the aortic cross-clamp (n = 20), while the control group did not receive (n = 20). The time intervals between coronary perfusion and the onset of the first heartbeats and sinus rhythms, occurrences of spontaneous sinus rhythm, intraoperative defibrillation requirements, as well as postoperative CK-MB and troponin T levels were recorded and subjected to analysis.ResultsIn the TNWB group, the median onset of the first heartbeats after the initiation of coronary perfusion was 34 s (4-100), while in the control group, it was 90 s (15–340) (p < 0.001). The median onset of the sinus rhythms was 100 s (28–290) in the TNWB group and was 132 s (45–350) in the control group (p = 0.023). The occurrence of intraoperative arrhythmias was 15% in the TNWB group compared to 50% in the control group (p = 0.018), and the incidence for internal defibrillation was 5% in the TNWB group and was 30% in the control group (p = 0.037). The TNWB group showed the median CK-MB levels at 6 h postoperative was 14.10 ng/mL (9.78–19.26), compared to 18.31 ng/mL (13.98–23.80) in the control group (p = 0.045).ConclusionsDuring single clamp coronary artery bypass, administration TNWB into the aortic root before aortic unclamping has the potential to enhance heartbeat recovery, as evidenced by the shortened time to the initial heartbeat and the establishment of sinus beats following coronary perfusion.Trial registrationTrial registration number (Study ID): TCTR20231002003.

Development and external validation of a novel model for predicting new clinically important atrial fibrillation after thoracoscopic anatomical lung cancer surgery: a multicenter retrospective cohort study.

New clinically important postoperative atrial fibrillation (POAF) is the most common arrhythmia after thoracoscopic anatomical lung cancer surgery and is associated with increased morbidity and mortality. The full spectrum of predictors remains unclear, and effective assessment tools are lacking. This study aimed to develop and externally validate a novel model for predicting new clinically important POAF. This retrospective study included 14074 consecutive patients who received thoracoscopic anatomical lung cancer surgery from January 2016 to December 2018 in Shanghai Chest Hospital. Based on the split date of 1 January 2018, we selected 8717 participants for the training cohort and 5357 participants for the testing cohort. For external validation, we pooled 2941 consecutive patients who received this surgical treatment from July 2016 to July 2021 in Shanghai Ruijin Hospital. Independent predictors were used to develop a model and internally validated using a bootstrap-resampling approach. The area under the receiver operating characteristic curves (AUROCs) and Brier score were performed to assess the model discrimination and calibration. The decision curve analysis (DCA) was used to evaluate clinical validity and net benefit. New clinically important POAF was defined as a new-onset of POAF that causes symptoms or requires treatment. Multivariate analysis suggested that age, hypertension, preoperative treatment, clinical tumor stage, intraoperative arrhythmia and transfusion, and operative time were independent predictors of new clinically important POAF. These seven candidate predictors were used to develop a nomogram, which showed a concordance statistic (C-statistic) value of 0.740 and good calibration (Brier score; 0.025). Internal validation revealed similarly good discrimination (C-statistic, 0.736; 95% CI: 0.705-0.768) and calibration. The decision curve analysis showed positive net benefits with the threshold risk range of 0-100%. C-statistic value and Brier score were 0.717 and 0.028 in the testing cohort, and 0.768 and 0.012 in the external validation cohort, respectively. This study identified seven predictors of new clinically important POAF, among which preoperative treatment, intraoperative arrhythmia, and operative time were rarely reported. The established and externally validated model has good performance and clinical usefulness, which may promote the application of prevention and treatment in high-risk patients, and reduce the development and related adverse outcomes of this event.

Prognosis in Patients with ST-Segment Elevation Myocardial Infarction Reperfused by PHDP: 1-Year MACEs Follow-Up.

This study explored 1-year follow-up of Parmaco-invasive strategy with half-dose recombinant human prourokinase (PHDP) in patients with acute ST-segment elevation myocardial infarction (STEMI). The follow-up endpoints were major adverse cardiovascular events (MACEs) occurring within 30 days and 1 year, as well as postoperative bleeding events. The study ultimately included 150 subjects, with 75 in the primary percutaneous coronary intervention (PPCI) group and 75 in the PHDP group. This study found that the PHDP group had a shorter FMC-reperfusion time (42.00 min vs 96.00 min, P < 0.001). During PCI, the PHDP group had a lower percutaneous transluminal coronary angioplasty (PTCA) (P = 0.021), intropin (P = 0.002) and tirofiban (P < 0.001) use. And the incidence of intraoperative arrhythmia, malignant arrhythmia, and slow flow/no-reflow was lower in the PHDP group (P < 0.001). At the 30-day follow-up, there was a significantly higher proportion of patients in the PPCI group who were readmitted due to unstable angina (P = 0.037). After 1 year of follow-up, there was no statistically significant difference in MACEs between the two groups (P = 0.500). The incidence of postoperative major bleeding, intracranial bleeding, and minor bleeding did not differ between the PHDP and PPCI groups (P > 0.05). The PHDP facilitates early treatment of infarct-related vessels, shortens FMC-reperfusion time, and does not increase the risk of MACEs.

The Impact of Preoperative abnormal Electrocardiography on Anesthesia management among older surgical patients in southern Ethiopia: Prospective cohort study

BackgroundDue to their advanced age and the prevalence of numerous co-morbid conditions, elderly patients scheduled for surgery are at risk for preoperative ECG abnormalities. Although preoperative ECG is frequently used to identify cardiovascular diseases and reduce intraoperative morbidity and mortality, its impact in predicting perioperative cardiovascular complications is under debate. ObjectiveThe aim of this study was to determine the impact of preoperative abnormal ECG on anesthesia management among older surgical patients in southern Ethiopia, 2022. Methodology: A multicenter prospective observational study on 246 elderly surgical patients recruited consecutively was conducted at three teaching hospitals in southern Ethiopia. Data were entered into Epidata version 4.6, then exported and analyzed in STATA version 16. The data was presented in the appropriate manner, using numbers, frequencies, tables, charts, and figures. To test categorical variables, the Chi-square test was used. P-values of 0.05 were considered statistically significant. ResultIn this study, 120 (48.78%) of older surgical patients had abnormal preoperative ECGs. In terms of severity, 55.3% were classified as minor, while 44.16% were major ECG abnormalities. 26 (21.66%) of patients with abnormal ECG were decided as unfit for anesthesia and reasons for the decision were the need for further investigation, consultation, and optimization. In addition, 7.31% of patients were delayed due to an abnormal ECG with a mean operative delay of 4.23 days. Preoperative abnormal ECG influenced the decision of anesthesia plan in four (1.62%) of the cases. Patients with an abnormal ECG prior to surgery were more likely to experience an intraoperative arrhythmia (p-value = 0.001). Conclusionand recommendation: Almost half (48.78%) of elderly patients presenting for surgery have an abnormal ECG, which impacts patients by postponing surgery and necessitating further investigation. Preoperative ECG is recommended prior to any elective surgery as early as 50 years, especially for those with risk factors.

Evaluation of Arrhythmia Prevalence, Management, and Risk Factors in Patients with Transcatheter and Surgically Closed Secundum Atrial Septal Defects.

Atrial septal defect (ASD) accounts for 6-10% of all congenital heart disorders. Secundum ASD closure can be performed surgically or percutaneously. We aimed to identify the various arrhythmias that occur before, during, and after the procedure and evaluate their management. The study included a total of 427 patients aged 0-18 years who underwent transcatheter or surgical closure of isolated secundum ASD between January 2008 and January 2020. Postoperative electrocardiogram (ECG) traces, intraoperative arrhythmias, and treatments were recorded for both groups. Echocardiography and ECG were evaluated at postoperative 1 week, 1, 3, and 6 months, and annually thereafter. After transcatheter closure, follow-up basal ECG showed incomplete right bundle branch block pattern in 21 patients and sinus rhythm in 229 patients. After surgical closure, incomplete right bundle branch block pattern was detected in 23 patients, complete right bundle branch block in 3 patients, and complete AV-block (Atrioventricular Block) pattern in 1 patient. The other 150 patients showed sinus rhythm. At least one postoperative follow-up Holter ECG record could be obtained for 104 patients in the transcatheter group and 96 patients in the surgical group. Of 104 patients who underwent transcatheter closure, 97 (93.3%) had normal Holter ECG findings and 7 (6.7%) had arrhythmia. Of the 96 patients who underwent surgical closure, 85 (88.5%) had normal Holter ECG traces and 11 (11.5%) had arrhythmia. There was no statistically significant difference in the frequency of arrhythmia (P = 0.164). The higher frequency of arrhythmia in adult studies compared to the pediatric age group once again demonstrates the importance of early diagnosis and treatment of ASD in childhood. The similar incidence of arrhythmia in both groups supports the safety and effectiveness of both closure methods in eligible patients.

Adrenalectomy for Pheochromocytoma: Complications and Predictive Factors of Intraoperative Hemodynamic Instability.

Surgery is the treatment of choice for pheochromocytoma. However, this surgery carries a risk of hemodynamic instability (HDI). The aim of this study was to report complications associated with this procedure, to identify risk factors for HDI during surgery, and its impact on postoperative outcomes. The charts of all patients who underwent adrenalectomy for pheochromocytoma in two academic centers between 2006 and 2020 were retrospectively reviewed. The primary outcome was HDI defined by a systolic blood pressure >160mmHg or a mean blood pressure <60mmHg intraoperatively. The secondary outcomes of interest were the total duration of HDI, the occurrence of intraoperative arrhythmia, perioperative cardiovascular events, and postoperative complications. 205 patients were included. HDI occurred intraoperatively in 155 patients (75.6%) but only 6 (3.2%) experienced arrhythmia. Thirty-eight postoperative complications were reported (18.6%) but only nine were ≥3 according to Clavien-Dindo (4.4%). There were 10 postoperative cardiovascular events (5.7%). Patients with intraoperative HDI had higher rates of postoperative complications (21.3% vs 10%; P = .07), major postoperative complications (5.8% vs 0%; P = .12) and cardiovascular events (6.5% vs 0%; P = .12). Factors associated with intraoperative HDI in univariate analysis were age (OR = 8.14; P = .006), high blood pressure preoperatively (OR = 2.16; P = .04), tumor size (OR = 15.83; P = .0001), and urinary normetanephrine level (OR = 9.33; P = .04). In multidisciplinary centers, the overall morbidity of adrenalectomy for pheochromocytoma is low. HDI during adrenalectomy for pheochromocytoma is highly prevalent but rarely associated with major cardiovascular events. There might be a link between HDI and postoperative cardiovascular events.

Effect of goal-directed haemodynamic therapy guided by non-invasive monitoring on perioperative complications in elderly hip fracture patients within an enhanced recovery pathway

BackgroundGoal-directed haemodynamic therapy (GDHT) has been shown to reduce morbidity and mortality in high-risk surgical patients. However, there is little evidence of its efficacy in patients undergoing hip fracture surgery. This study aims to evaluate the effect of GDHT guided by non-invasive haemodynamic monitoring on perioperative complications in patients undergoing hip fracture surgery.MethodsPatients > 64 years undergoing hip fracture surgery within an enhanced recovery pathway (ERP) were enrolled in this single-centre, non-randomized, intervention study with a historical control group and 12-month follow-up. Exclusion criteria were patients with pathological fractures, traffic-related fractures and refractures. Control group (CG) patients received standard care treatment. Intervention group (IG) patients received a GDHT protocol based on achieving an optimal stroke volume, in addition to a systolic blood pressure > 90 mmHg and an individualized cardiac index. No changes were made between groups in the ERP during the study period. Primary outcome was percentage of patients who developed intraoperative haemodynamic instability. Secondary outcomes were intraoperative arrhythmias, postoperative complications (cardiovascular, respiratory, infectious and renal complications), administered fluids, vasopressor requirements, perioperative transfusion, length of hospital stay, readmission and 1-year survival.ResultsIn total, 551 patients (CG=272; IG=279) were included. Intraoperative haemodynamic instability was lower in the IG (37.5% vs 28.0%; p=0.017). GDHT patients had fewer postoperative cardiovascular (18.8% vs 7.2%; p < 0.001), respiratory (15.1% vs 3.6%; p<0.001) and infectious complications (21% vs 3.9%; p<0.001) but not renal (12.1% vs 33.7%; p<0.001). IG patients had less vasopressor requirements (25.5% vs 39.7%; p<0.001) and received less fluids [2.600 ml (IQR 1700 to 2700) vs 850 ml (IQR 750 to 1050); p=0.001] than control group. Fewer patients required transfusion in GDHT group (73.5% vs 44.4%; p<0.001). For IG patients, median length of hospital stay was shorter [11 days (IQR 8 to 16) vs 8 days; (IQR 6 to 11) p < 0.001] and 1-year survival higher [73.4% (95%CI 67.7 to 78.3 vs 83.8% (95%CI 78.8 to 87.7) p<0.003].ConclusionsThe use of GDHT decreases intraoperative complications and postoperative cardiovascular, respiratory and infectious but not postoperative renal complications. This strategy was associated with a shorter hospital stay and increased 1-year survival.Trial registrationClinicalTrials.gov NCT02479321.

Early postoperative pain after subxiphoid uniportal thoracoscopic major lung resection: a prospective, single- blinded, randomized controlled trial.

OBJECTIVESPreoperative selection bias led to the inability to generalize the proposed benefit of subxiphoid uniportal video-assisted thoracoscopic surgery (SVATS) as having less postoperative pain than uniportal intercostal VATS. So, we conducted this prospective, single-blinded, randomized controlled trial to investigate the hypothesis that SVATS may have less early postoperative pain than UVATS in patients who undergo major lung resection for early-stage lung cancer.METHODSA total of262 patients were randomly allocated between 2 groups (each with 131 patients), the first being the UVATS group and the second being the SVATS group. The values indicated on the numerical rating scale (NRS) of pain were collected at 24 h and 48 h during rest and during coughing. In addition, different perioperative variables were analysed and compared between the 2 groups.RESULTSMultiple linear regression analysis showed that the type of surgical approach was a significant predictor of the postoperative NRS values. The postoperative NRS pain values were significantly lower in the SVATS group after 24 h during rest and coughing and after 48 h during coughing. Postoperatively, patients in the SVATS group got out of bed significantly earlier [16.37 (2.54) vs 18.05 (3.29) h, p < 0.001]. The SVATS group showed a significantly higher rate of intraoperative arrhythmia [20 (15.3%) vs 3 (2.3%) patients, p = 0.03].CONCLUSIONSSVATS major pulmonary resection in early-stage lung cancer is associated with less early postoperative pain than the UVATS approach. Operating on patients with cardiac problems using the SVATS approach is still a limiting factor for randomization due to the potential compression on the heart with resulting arrhythmia.Clinical trial registrationThe trial was registered under clinical trials.gov Identifier: NCT03331588. https://clinicaltrials.gov/ct2/show/NCT03331588.

Anesthetic management of a patient with erythema multiforme for emergency appendectomy

Erythema multiforme (EM) is an acute, immune-mediated, mucocutaneous disease, caused by several factors such as infections, drugs, malignancy, autoimmune disease, radiation, and immunization. The anesthetic concerns in these patients include possibility of difficult airway, intraoperative steroid supplementation, avoidance of precipitating drugs, intraoperative arrhythmias, perioperative skin, and eye care. A 13-year-old boy, a known case of EM with a history of recurrent ocular herpes and impaired vision along with fibrosis at the bilateral angle of the mouth underwent emergency open appendectomy under spinal anesthesia. Spinal anesthesia with injection hyperbaric bupivacaine (0.5%) is a safe and suitable alternative in a patient with EM with recurrent herpes simplex virus.

Short-Term Results of Ivabradine versus Metoprolol: The Effects on Atrial Fibrillation in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting.

Classic coronary artery bypass grafting (CABG) surgery involves diastolic cardiac arrest under cardiopulmonary bypass, while off-pump CABG (OPCABG) has become widespread in recent years. 174 patients who underwent OPCABG were included in the study. Patients were divided into two groups. Group I (n=90) received ivabradine and Group M (n=84) received metoprolol before surgery until postoperative day 10. Intraoperative arrhythmias and hypotension were recorded. Postoperative atrial fibrillation (AF) and arrhythmia, mortality and morbidity rates were assessed based on the 30-day postoperative follow-up. There were no significant differences in the intraoperative amount of inotropic support and red blood cell transfusion between groups (P=0.87 and P=0.31). However, the rates of intraoperative arrhythmias and hypotension were not significantly higher in Group M (P=0.317 and P=0.47). Ventricular tachycardia/ventricular fibrillation (VT/VF) was observed in 2 patients in both groups. Postoperative AF occurred in 7 patients (7.7%) in Group I and in 10 patients (11.9%) in Group M. Although there was a trend towards a higher prevalence of AF in Group M patients, this did not reach statistical significance. In addition, mortality and morbidity rates were comparable between groups.

Acute Kidney Injury and Renal Replacement Therapy After Fontan Operation

Fontan circulation leads to chronic elevation of central venous pressure. We sought to identify the incidence, risk factors, and survival among patients who developed acute kidney injury (AKI) after the Fontan operation. We retrospectively reviewed 1,166 patients who had Fontan operation/revision at Mayo Clinic Rochester from 1973 to 2017 and identified patients who had AKI (defined by AKI Network criteria) within 7days of surgery. A total of 132 patients (11%) developed AKI after the Fontan operation with no significant era effect. Of those who developed AKI, severe (grade 3) kidney injury was present in 101 patients (76.5%). Multivariable risk factors for AKI were asplenia (odds ratio [OR] 4.2, p <0.0001), elevated preoperative pulmonary artery pressure (per 1 mm Hg increase, OR 1.04, p=0.0002), intraoperative arrhythmias (OR 1.9, p=0.02), and elevated post-bypass Fontan pressure (per 1 mm Hg increase, OR 1.12, p=0.0007). Renal replacement therapy (RRT) was used in 72 patients (54%), predominantly through peritoneal dialysis (n=56, 78%). Multivariable risk factors for RRT were age ≤3years (OR 9.7, p=0.0004), female gender (OR 2.6, p=0.02), and aortic cross-clamp time >60minutes (OR 3.1, p=0.01). Patients with AKI had more postoperative complications, including bleeding, stroke, pericardial tamponade, low cardiac output state and cardiac arrest, than those without AKI. This resulted in longer intensive care unit stay (39 vs 17days, p=0.0001). In-hospital mortality was exceedingly higher among patients with AKI versus no AKI (58%, 76 of 132 vs 10%, 99 of 1,034, p <0.0001); however, there was no significant difference based on the need for RRT. Recovery from AKI was observed in 56 patients (42%). Over 20-year follow-up, patients with AKI had a distinctly higher all-cause-mortality (82%) than those without AKI (35%). It is prudent to identity patients at a higher risk of developing postoperative AKI after Fontan operation to ensure renal protective strategies in the perioperative period. Postoperative AKI leads to substantial short and long-term morbidity and mortality, but the need for RRT does not affect the outcomes.

An Observational Study on Arrhythmia During Cesarean Section Under Spinal Anesthesia: Incidence, Risk Factors, and Effects on Immediate Post-delivery Neonatal Outcome.

Introduction: Various types of arrhythmia have been reported during cesarean section under spinal anesthesia. But the possible causative factors and the effects of arrhythmia on immediate post-delivery neonatal outcome are not well established.Methods: This prospective observational study was conducted over a period of one year in a tertiary care hospital on women undergoing cesarean section under spinal anesthesia. The objectives of the study were to determine the incidence of arrhythmia, its types, the possible factors influencing arrhythmia, and the immediate post-delivery neonatal outcome. Data collected were analyzed using Statistical Package for the Social Sciences (SPSS) software version 21 (IBM Corp. Armonk, NY).Results: In our study, the incidence of arrhythmia was 31.9% during cesarean section under spinal anesthesia; and sinus bradycardia was the most common type. Arrhythmia occurred more in women with hypotension, when maximum block height was above T4 level and dose of intrathecal hyperbaric bupivacaine was more than 2.2 mL (P value <0.05). Also, uterine manipulation led to sudden bradycardia and transient cardiac asystole in two patients which was preceded by subjective symptoms of pain and discomfort. None of the neonates required cardiopulmonary resuscitation or neonatal intensive care unit admission within an hour of birth. APGAR (Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration) scores at 1 and 5 minutes were similar in all the newborns born to mothers with or without arrhythmia.Conclusion: The occurrence of arrhythmia during cesarean section under spinal anesthesia, though very common, is rarely life-threatening. Keeping maximum level of block height between T4 and T6, using lower possible drug dose to provide adequate level of sensory block, prompt management of hypotension, and strict monitoring during uterine manipulation may reduce the overall incidence of arrhythmia. Intraoperative arrhythmia, however, does not adversely affect the immediate post-delivery neonatal outcome.

Transapical off-pump mitral valve repair with NeoChord implantation: A systematic review.

Mitral valve repair (MVr) is the gold standard for the treatment of degenerative mitral valve regurgitation (MR). The recently introduced NeoChord DS1000 has gained increasing recognition as a feasible, potentially safe, and effective procedure with minor complications and promising outcomes. This study aims to conduct a systematic review of the published literature that discusses the technical feasibility and outcome of transapical off-pump MVr with NeoChord DS1000 device implantation in the treatment of degenerative MR. This review was performed according to the PRISMA statement. Databases searched in this review included Pubmed, Web of Science, Scopus, and Cochrane databases for systematic reviews. All English articles on humans reporting isolated MVr using NeoChord DS1000 device were included provided that basic preoperative data, operative specifications,and postoperative mortality and morbidity were reported. This review included six studies comprised 249 patients who had NeoChord mitral procedure. Almost all patients included had severe MR (243/249, 97.6%). Operative success was achieved in 241 out of the 249 patients (96.8%). No intraoperative mortality was reported. Intraoperative arrhythmia was reported in six patients (2.4%) and significant bleeding was reported in eight patients (3.2%). Awaiting more evidence, NeoChord mitral procedure appears to be a promising procedure that can be considered in selected cases.

Cost-Minimization Analysis of Transcatheter versus Surgical Closure of Secundum Atrial Septal Defect in Children

Objective: Secundum atrial septal defect (ASD) is one of the congenital heart diseases commonly found in children, which can be treated by transcatheter closure as a standard treatment or by surgical treatment. Few studies have analyzed the cost of these two strategies. The present study is aimed to compare the short-term cost-minimization of both procedures. Materials and Methods: A retrospective single-center study analyzed all children aged 1 to 18 years, diagnosed with isolated secundum atrial septal defect, who were entirely treated by transcatheter or surgical ASD closure at Ramathibodi Hospital, Mahidol University between January 2005 and August 2016. The baseline characteristics, total hospital days, cost per case, clinical outcomes, and complications between these two procedures are compared. Results: Thirty-five patients were enrolled in the present study, divided into two groups, with 43% in the transcatheter group and 57% in the surgical group. The baseline characteristics of the transcatheter and surgical groups were not significantly different except for weight, which was 28.6 kg versus 16.5 kg (p=0.045), and for medical history of asymptomatic, which was seven versus 16 patients (p=0.04), respectively. Patients with transcatheter procedures had a shorter length of hospital stay at 2.3 days versus 8.1 days (p&lt;0.001), respectively. The direct medical cost per case of surgical procedure was less than the transcatheter procedure at 116,993 Baht or 3,878 US Dollar versus 206,204.7 Baht or 6,835 US Dollar (p&lt;0.001), respectively. The major complication of the transcatheter procedure was bleeding from the puncture site while it was intraoperative arrhythmia for the surgical procedure. Conclusion: The short-term clinical outcomes of the transcatheter and the surgical ASD closure were excellent. The cost analysis suggests that surgical procedures may incur fewer costs than transcatheter procedures from the hospital’s perspective. Surgical ASD closure may be a less costly strategy for Ramathibodi pediatric patients. Keywords: Atrial septal defect, ASD, Transcatheter, Cost-minimizing analysis, Device, Surgery

Pericardial Effusions in Patients With Cancer: Anesthetic Management and Survival Outcomes

The objective of this study was to describe practice patterns of anesthetic management during pericardial window creation. Retrospective observational cohort study. Single tertiary cancer center. A total of 150 patients treated for cancer between 2011 and 2015 were included in the study. The primary objective was to evaluate anesthetic management in pericardial window creation. Secondary outcomes were 30-day mortality and overall survival after pericardial window creation. Thirty-day mortality was 19.3%, and median survival was 5.84 months. Higher American Society of Anesthesiologists (ASA) physical status of patients was associated with preinduction arterial line placement (51% ASA 3 v 79% ASA 4; p = 0.002) and use of etomidate for anesthetic induction (34% ASA 3 v 60% ASA 4; p = 0.003). However, there was no association between anesthetic management and presence of tamponade in these patients. Cardiac aspirate volume (per 10 mL: odds ratio [OR], 1.02 [95% CI, 1.0-1.04]; p = 0.026) and intraoperative arrhythmia (atrial fibrillation: OR, 6.76 [95% CI, 1.2-37.49]; p = 0.029; sinus tachycardia: OR, 4.59 [95% CI, 1.25-16.90]; p = 0.022) were associated independently with increased 30-day mortality. High initial heart rate (per 10 beats per minute: hazard ratio [HR], 1.18 [95% CI, 1.05-1.33]; p = 0.005) in the operating room and intraoperative sinus tachycardia (HR, 1.86 [95% CI, 1.15-3.03]; p = 0.012) were associated independently with worse overall survival. Risk of death after pericardial window creation remains high in patients with cancer. Variations in anesthetic management did not affect survival in oncologic patients with pericardial effusions.

Preoperative left stellate ganglion block: Does it offer arrhythmia-protection during off-pump CABG surgery? A randomized clinical trial

ABSTRACT Background Cardiac arrhythmias are not uncommon during and after coronary artery bypass graft cardiac surgeries. Preliminary studies showed the preventive effects of stellate ganglion block upon cardiac arrhythmias; however, this could be the 1st study focusing upon intraoperative arrhythmias during offpump coronary artery bypass graft surgery as a main goal. Methods This is a randomized controlled trial. The study involved forty adult patients undergoing elective offpump coronary artery bypass graft surgery. Twenty patients received left SGB with 10 ml of 2% lidocaine before induction of anesthesia (B group), and twenty patients as a control group (A group). Intraoperative and 24-hours postoperative electrocardiogram and hemodynamics were monitored, in addition to the mean postoperative 24-hours inotropic score. Results There was a significantly higher incidence of intraoperative arrhythmias in the control group in the form of bradyarrhythmia (25%), supraventricular tachycardia (30%), atrial fibrillation (5%), ventricular tachycardia (10%), and ventricular fibrillation (5%) in comparison to the block group where atrial fibrillation occurred only in 4 patients (20%) with the p value of 0.007. Mean arterial blood pressure and heart rate showed significantly lower values in the SGB group intraoperatively. Postoperative mean 24-hour inotropic score and hemodynamics showed insignificant differences. Conclusion Preoperative left stellate ganglion block can decrease incidence of arrhythmias during offpump coronary artery bypass graft surgeries. The technique showed a safe profile upon hemodynamics during the study period.

Persistent intraoperative arrhythmias due to cannabis: Report of two cases.

Persistent intraoperative arrhythmias due to cannabis: Report of two cases.

Safety and efficacy of radial access in trauma in 65 trauma endovascular cases

ObjectiveEndovascular techniques in trauma surgery are becoming increasingly important in patient management, with procedures such as pelvic and splenic angioembolization becoming the standard of care for certain injuries. Traditionally, such interventions are performed via femoral access, although the morbidity of this approach is not insignificant (3%-10%). Transradial access (TRA) is an attractive alternative, pioneered by cardiologists, with low rates of access site complications in patients undergoing coronary intervention. Recently, this technology has extended to other interventions. The aim of this study was to present the initial experience of a radial program in a busy trauma center, with specific regard to safety and complications. MethodsThe medical records of trauma patients undergoing endovascular procedures via TRA between March 2018 and December 2018 were queried for procedural and postoperative data. Demography and injury characteristics were presented for the overall cohort, followed by a comparison of procedural data and complications between laterality. Continuous variables were compared using a two-tailed t-test and categorical variables were compared using a χ2 test. ResultsOver a 9-month period, 65 patients underwent 81 interventions via TRA, most commonly solid organ or pelvic angiography/embolization. Radial artery access was achieved in all patients, with procedural success achieved in all but two patients (n = 63 [96.9%]) who had hypoplastic radial artery anatomy, who underwent ulnar access. The overall technique-related complication rate was 1.5% with no difference observed between laterality (n = 1; P = .523). One patient with an admission Glasgow Coma Score of 3 and coagulopathy developed radial artery thrombosis after pelvic angiography via right TRA. Mortality was seen in seven patients (10.8%) owing to hemorrhagic shock (n = 3 [42.8%]) or multiorgan failure (n = 4 [57.1%]). There were no cases of postprocedural access site bleeding, hematoma, pseudoaneurysm, vascular injury, intraoperative arrhythmia or cerebrovascular accident, arteriovenous fistula formation, or infection. ConclusionsTRA is a feasible and low-risk alternative for endovascular intervention in the trauma patient. It yields good technical success with low morbidity. Although larger studies are needed to establish the full efficacy of TRA at the multi-institutional level, this single-institution study demonstrates the legitimacy of an alternative means for endovascular intervention in the trauma patient.

IF16. Safety and Efficacy of Radial Access for the Management of Endovascular Trauma

Endovascular techniques in trauma surgery are becoming increasingly important in patient management, with procedures such as pelvic and splenic angioembolization becoming the standard of care for certain injuries. Traditionally, such interventions are performed via femoral access, although the morbidity of this approach is not insignificant (3%-10%). Transradial access (TRA) is an attractive alternative, pioneered by cardiologists with low rates of access site complications in patients undergoing coronary intervention. Recently, this technology has extended to other interventions. The aim of this study was to present the initial experience of a radial program in a busy trauma center, with specific regard to safety and complications. The medical records of trauma patients undergoing endovascular procedures via TRA between March 2018 and December 2018 were queried for procedural and postoperative data. Demography and injury characteristics were presented for the overall cohort (Table I), followed by a comparison of procedural data and complications between laterality (Table II). Continuous variables were compared using a two-tailed t-test and categorical variables were compared using a χ2 test. Over a 9-month period, 65 patients received 81 interventions via TRA, most commonly solid organ or pelvic angiography/embolization. Access success was achieved in all but two patients (n = 63, 96.9%) who had hypoplastic radial artery anatomy and who underwent ulnar access. Overall complication rate was 4.6% with no difference observed between laterality (n = 3; P = .512). One patient with an admission a Glasgow Coma Score of 3 and coagulopathy developed radial artery thrombosis after pelvic angiography via a right TRA. Another patient with penetrating injuries to the head and neck developed an acute cerebrovascular attack after internal carotid artery stenting via left TRA. One patient with a pelvic crush injury developed acute kidney injury after undergoing pelvic angioembolization, with full resolution within 2 weeks. Mortality was seen in seven patients (10.8%), owing to hemorrhagic shock or multiorgan failure (n = 3 [42.8%] and n = 4 [57.1%], respectively). There were no cases of postprocedural access site bleeding, hematoma, pseudoaneurysm, vascular injury, intraoperative arrhythmia, arteriovenous fistula formation, or infection. TRA is a feasible and low-risk alternative for endovascular intervention in the trauma patient. It yields good technical success with low morbidity. Although larger studies are needed to establish the full efficacy of TRA at the multi-institutional level, this single-institution study demonstrates the legitimacy of an alternative means for endovascular intervention in the trauma patient.Table IDemographic data, comorbidities, injury patterns, and physiology of the cohortVariableDemographic data Age, years44.5 ± 18.5 Male sex55 (84.6) Height, cm173.5 ± 8.9 BMI25.6 ± 5.7Comorbidities HTN13 (20) DM11 (16.9) PAD4 (6.2) CKD3 (4.6)Injury characteristics Blunt57 (87.7) Penetrating8 (12.3) ISS23 ± 11 Pelvic fracture12 (18.5) Hostile groin11 (16.9)Physiology GCS <88 (12.3) SBP (at puncture)120.9 ± 25.2 Coagulopathy9 (13.8)BMI, body mass index; CKD, chronic kidney disease; DM, diabetes mellitus; HTN, hypertension; ISS, Injury Severity Score; GCS, Glasgow Coma Score; PAD, peripheral arterial disease.Values are number (%) or mean ± standard deviation Open table in a new tab Table IIProcedural data based on lateralityaVariableTotalRightLeftP valueN653332Target artery/organ Splenic artery34 (52.3)19 (29.2)15 (23.1).269 Hepatic artery7 (10.8)5 (7.6)2 (3.1).500 Celiac Artery5 (7.6)1 (1.5)4 (6.1).121 Iliac arteries10 (15.4)5 (7.6)5 (7.6).681 Renal artery1 (1.5)0 (0)1 (1.5).400 Lower extremity8 (12.3)4 (6.1)4 (6.1).601 Subclavian Artery4 (6.1)3 (4.6)1 (1.5).530 Internal carotid artery1 (1.5)0 (0)1 (1.5).455 Aorta5 (7.6)2 (3.1)3 (4.6).552Intervention Solid organ angiography8 (12.3)4 (6.1)4 (6.1).556 Solid organ AE36 (55.4)19 (29.2)17 (26.1).541 Visceral vessel angiography6 (9.2)1 (1.5)5 (7.6).107 Pelvic angiography4 (6.1)1 (1.5)3 (4.6).371 Pelvic AE7 (10.8)4 (6.1)3 (4.6).667 Lower extremity angiography8 (12.3)5 (7.6)3 (4.6).667 Lower extremity AE1 (1.5)1 (1.5)0 (0).750 Upper extremity angiography1 (1.5)1 (1.5)0 (0).750 Cervical vessel angiography3 (4.6)2 (3.1)1 (1.5).700 Carotid stenting1 (1.5)0 (0)1 (1.5).500 Aortography6 (9.2)4 (6.1)2 (3.1).429Outcomes Procedural success63 (96.9)31 (93.9)32 (100.0).254 LOS8.0 (4.0-15.0)6.5 (3.0-15.5)8.5 (4.0-15.5).909 Mortality7 (10.8)4 (6.1)3 (4.6).518 Complications3 (4.6)2 (3.1)1 (1.5).512AE, Angioembolization; LOS, length of stay.aAll proportions are presented as number (percent), with comparisons using a χ2 test. Open table in a new tab

Intraoperative Arrhythmia during Oral Malignancy Surgery in Geriatric Patient with Ischemic Heart Disease – A Case Report

Intraoperative Arrhythmia during Oral Malignancy Surgery in Geriatric Patient with Ischemic Heart Disease – A Case Report