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Contains fulltext : 244115.pdf (Publisher’s version ) (Closed access) The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

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

The European Association of Cardiothoracic Anaesthesiology (EACTA) and the Society of Cardiovascular Anesthesiologists (SCA) aimed to create joint recommendations for the perioperative management of patients with suspected or proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection undergoing cardiac surgery or invasive cardiac procedures. To produce appropriate recommendations, the authors combined the evidence from the literature review, reevaluating the clinical experience of routine cardiac surgery in similar cases during the Middle East Respiratory Syndrome (MERS-CoV) outbreak and the current pandemic with suspected coronavirus disease 2019 (COVID-19) patients, and the expert opinions through broad discussions within the EACTA and SCA. The authors took into consideration the balance between established procedures and the feasibility during the present outbreak. The authors present an agreement between the European and US practices in managing patients during the COVID-19 pandemic. The recommendations take into consideration a broad spectrum of issues, with a focus on preoperative testing, safety concerns, overall approaches to general and specific aspects of preparation for anesthesia, airway management, transesophageal echocardiography, perioperative ventilation, coagulation, hemodynamic control, and postoperative care. As the COVID-19 pandemic is spreading, it will continue to present a challenge for the worldwide anesthesiology community. To allow these recommendations to be updated as long as possible, the authors provided weblinks to international public and academic sources providing timely updated data. This document should be the basis of future task forces to develop a more comprehensive consensus considering new evidence uncovered during the COVID-19 pandemic. ispartof: JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA vol:35 issue:7 pages:1953-1963 ispartof: location:United States status: published

Objectives Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe. Design Structured web-based, anonymized, voluntary survey. Setting Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018. Participants Physicians. Measurements and Main Results The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only ≤30%. Postprocedurally, patients were transferred to an intensive care unit by 51.43% of the respondents with a reported nurse-to-patient ratio of 1:2 or 1:3, to a post-anesthesia care unit by 27.14%, to a postoperative recovery room by 11.43%, and to a peripheral ward by 10%. Conclusion The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe.

Objective Transapical aortic valve implantation (TAVI) may lead to obstruction of coronary arteries during deployment. To prevent this, it is essential to determine the distance of the coronary ostium to the aortic annulus prior to valve placement. Multidetector computed tomography (MDCT) commonly is used to determine these measurements, but even marginal exposure to contrast agents can result in acute kidney injury in this high-risk group of multi-morbid patients. The aim of the study was to determine the feasibility of real-time 3D transesophageal echocardiography (RT 3D TEE) as the first-choice technique for noninvasive evaluation of the coronary ostium during TAVI. Design Retrospective study. Setting University hospital. Interventions Fifty patients underwent MDCT the evening before surgery. RT 3D TEE was performed intraoperatively before valve deployment. The dataset from both of these examinations was digitally stored and evaluated. MDCT was performed in nonanesthetized patients; however, in the RT 3D TEE group, general anesthesia was established. Measurements and Main Results The distances from the right coronary artery and the left coronary artery ostium were measured retrospectively. Bland-Altman Plots and linear regression analysis showed excellent correlation between the 2 methodologies; intraobserver and interobserver variance were calculated using analysis of variance. Krippendorff's α indicated excellent agreement between the 2 observers (0.96 and 0.98) as well as between RT 3D TEE and MDCT (0.97 and 0.98). Conclusions The observations showed that RT 3D TEE reliably can measure the coronary ostium distance from the aortic annulus. It is feasible and an alternative method for evaluating these measurements and thereby preventing contrast exposure during MDCT, which may jeopardize the safety of patients with pre-existing renal disease.

Objective The purpose of this study was to review the management of anesthesia for transapical transcatheter aortic valve implantation. Design Retrospective review of collected data. Setting University-affiliated heart center. Participants One hundred consecutive patients with severe aortic stenosis. Interventions General anesthesia followed by an established fast-track protocol. Materials and Methods A total of 100 patients with significant AS received transapical transcatheter aortic valve implantation. The patients were treated following a fast-track protocol. The mean arterial pressure was maintained above 65 mmHg by volume and/or inotropes during the procedure. The mean arterial pressure was increased above 75 mmHg to avoid hemodynamic deterioration before starting rapid ventricular pacing for the balloon valvuloplasty and the valve implantation. Transesophageal echocardiography was used to assess valve size and for hemodynamic monitoring. Eighty-one patients were treated completely off pump. There was a significant decline in mean arterial pressure from pre- to postvalvuloplasty (74.7 ± 9.1 mmHg v 63.6 ± 11.3 mmHg, p Conclusion A well-designed anesthetic plan as well as an understanding of the surgical procedure and the hemodynamic effects of rapid ventricular pacing are required to ensure successful outcomes in this new surgical option for high-risk patients.

Objective The purpose of the study was to report the anesthetic management and immediate procedural success in the initial 20 patients undergoing percutaneous transapical mitral valve replacement. Design Retrospective review of collected data. Setting University-affiliated heart center. Participants Twenty patients with mitral regurgitation or stenosis due to a degenerated valve or ring in the mitral position. Interventions TEE-guided transapical mitral valve replacement under general anesthesia and early extubation by means of an established fast-track protocol. Measurements and Main Methods Twenty patients underwent transapical mitral valve replacement by a beating heart procedure, avoiding cardiopulmonary bypass. The valve was either deployed due to a previously implanted bioprosthetic valve (valve-in-valve group), which degenerated, or a ring (valve-in-ring group), which predominantly showed regurgitation. There was a significant increase in the mitral valve opening area in stenosed valve pathology from 1.3-1.9 sq. cm (p = 0.004), and an increase in ejection fraction from 40% to 45% (p = 0.52). In the valve-in-ring group, valve area increased from 2.0 sq. cm to 2.6 sq. cm (p = 0.21), with an increase in ejection fraction from 30% to 35% (p = 0.18). Eighteen patients underwent successful deployment of the valve. The anesthesia duration for the procedure lasted 185.5±25.4 minutes. Conclusions There was a significant increase in opening area of the valve and improvement in ejection fraction in this patient group. TEE and fluoroscopy-guided imaging is necessary for the procedure’s success and is an evolving alternative treatment for high-risk mitral valve patients who would otherwise be considered inoperable for routine surgery using sternotomy.

Objective To optimize the conditions for the surgeon during minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB) procedures, one-lung ventilation (OLV) is required using double-lumen tubes (DLT). This prospective study was designed to compare high-frequency jet ventilation (HFJV) of both lungs with the conventional method of OLV via DLT. Design Prospective, randomized, clinical study. Setting University-affiliated heart center. Participants Forty patients with coronary artery disease and scheduled for elective MIDCAB or TECAB procedures were equally randomized into a DLT and an HFJV group. Interventions In the DLT group, OLV of the right lung was performed throughout the surgical procedure. In the HFJV group, patients received a conventional single-lumen endotracheal tube and both lungs were ventilated using HFJV. Measurements Hemodynamic, oxygenation and ventilation parameters were measured at the beginning of the operation, then 5, 15, 30, and 60 minutes after OLV/HFJV, as well as immediately before transfer to the ICU. Main Results Regarding the view of the surgical field, surgeons' comfort did not differ between methods. The intraoperative PaO 2 was significantly higher in the HFJV group compared with the DLT group at 5 (336.8 ± 123.3 v 228.6 ± 124.0; p = 0.009) and 15 minutes (301.7 ± 133.9 v 192.6 ± 92.8; p = 0.012). The PaCO 2 was significantly higher in the HFJV group after 5 minutes and persisted through 60 minutes of ventilation. The peak inspiratory pressure was significantly lower during HFJV (10.0 ± 2.8 mbar v 32.1 ± 5.9 mbar). Conclusions HFJV in MIDCAB or TECAB procedures appears to be a feasible alternative to OLV using a DLT, although study in a larger population is required.

Objective: Compare changes in P-wave amplitude of the intra-atrial electrocardiogram (ECG) and its corresponding transesophageal echocardiography (TEE)-controlled position to verify the exact localization of a central venous catheter (CVC) tip. Design: A prospective study. Setting: University, single-institutional setting. Participants: Two hundred patients undergoing elective cardiac surgery. Interventions: CVC placement via the right internal jugular vein with ECG control using the guidewire technique and TEE control in 4 different phases: phase 1: CVC placement with normalized P wave and measurement of distance from the crista terminalis to the CVC tip; phase 2: TEE-controlled placement of the CVC tip; parallel to the superior vena cava (SVC) and measurements of P-wave amplitude; phase 3: influence of head positioning on CVC migration; and phase 4: evaluation of positioning of the CVC postoperatively using a chest x-ray. Measurements and Main Results: The CVC tip could only be visualized in 67 patients on TEE with a normalized P wave. In 198 patients with the CVC parallel to the SVC wall controlled by TEE (phase 2), an elevated P wave was observed. Different head movements led to no significant migration of the CVC (phase 3). On a postoperative chest-x-ray, the CVC position was correct in 87.6% (phase 4). Conclusion: The study suggests that the position of the CVC tip is located parallel to the SVC and 1.5 cm above the crista terminalis if the P wave starts to decrease during withdrawal of the catheter. The authors recommend that ECG control as per their study should be routinely used for placement of central venous catheters via the right internal jugular vein.

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