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Objectives: Previous studies in other settings suggested that urine output (UO) might affect NephroCheck predictive value. We investigated the correlation between NephroCheck and UO in cardiac surgery patients., Design: Post hoc analysis of a multicenter study., Setting: University hospital., Participants: Patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) and crystalloid cardioplegia., Measurements and Main Results: All patients underwent NephroCheck testing 4 hours after CPB discontinuation. The primary outcome was the correlation between UO, NephroCheck results, and acute kidney injury (AKI, defined according to Kidney Disease: Improving Global Outcomes). Of 354 patients, 337 were included. Median NephroCheck values were 0.06 (ng/mL) 2 /1,000) for the overall population and 0.15 (ng/mL) 2 /1,000) for patients with moderate to severe AKI. NephroCheck showed a significant inverse correlation with UO (ρ = -0.17; p = 0.002) at the time of measurement. The area under the receiver characteristic curve (AUROC) for NephroCheck was 0.60 (95% confidence interval [CI], 0.54-0.65), whereas for serum creatinine was 0.82 (95% CI, 0.78-0.86; p < 0.001). When limiting the analysis to the prediction of moderate to severe AKI, NephroCheck had a AUROC of 0.82 (95% CI, 0.77 to 0.86; p<0.0001), while creatinine an AUROC of 0.83 (95% CI, 0.79-0.87; p = 0.001)., Conclusions: NephroCheck measured 4 hours after the discontinuation from the CPB predicts moderate to severe AKI. However, a lower threshold may be necessary in patients undergoing cardiac surgery with CPB. Creatinine measured at the same time of the test remains a reliable marker of subsequent development of renal failure., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objectives: Caval valve implantation (CAVI) represents a minimally invasive strategy for managing severe tricuspid regurgitation in high-risk patients unsuitable for surgical or transcatheter tricuspid valve implantation. This case series aimed to assess the anesthesia management challenges and outcomes associated with this procedure, seeking to generate insights that can inform and refine anesthesia protocols., Design: A case series., Setting: At a cardiac catheterization laboratory of a teaching hospital., Participants: Eight patients undergoing CAVI with the Tricvalve system INTERVENTIONS: The anesthetic protocol included preprocedural planning, fast-track general anesthesia, and postprocedural debriefing. Intraoperative management involved anesthesia depth monitoring, real-time guidance via transesophageal echocardiography, and hemodynamic stability maintenance. Postoperative analgesia involved preemptive intravenous paracetamol and morphine as needed., Measurements and Main Results: No anesthesia-related or implantation-related complications were observed, with a mean procedure duration of 112 ± 44 minutes. The median hospital stay was 4 days, and only 1 patient required brief intensive care unit monitoring. Postoperative right shoulder pain was reported by half of the patients, and was managed with morphine bolus administration (average dose 4.75 ± 3.6 mg). All patients had the device correctly positioned, as confirmed by postoperative transthoracic echocardiograms. None of the patients required outpatient analgesic therapy upon discharge., Conclusions: The authors' study demonstrated the potential of TricValve implantation in effectively managing severe tricuspid regurgitation with no procedure-related complications and a 100% survival rate. A collaborative, interdisciplinary approach and targeted anesthesia management proved crucial for this success. Postoperative shoulder pain emerged as a frequent complication, whose pathogenesis is still not clear, and successfully was managed using targeted analgesic therapy., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: The aim of the current study was to assess the relationship among thrombin receptor activator peptide 6 (TRAP test), adenosine-5'-diphosphate (ADP test), arachidonic acid (ASPI test), and stroke/transient ischemic attack (TIA), using the multiple electrode aggregometry (Multiplate) in patients undergoing carotid thromboendarterectomy (CEA)., Design: A retrospective study., Setting: Vascular surgery operating rooms of a university hospital., Participants: One hundred thirty-one out of 474 patients undergoing CEA between November 2020 and October 2022., Interventions: None., Measurements and Main Results: A preoperative blood sample of all enrolled patients was analyzed using the Multiplate analyzer. Receiver operating characteristics curves, were generated to test the ability of TRAP, ADP, and ASPI in discriminating perioperative thromboembolic stroke/TIA. A logistic LASSO regression model was used to identify factors independently associated with stroke/TIA. Eight patients experienced a perioperative stroke/TIA. Although all the platelet functional assays showed excellent predictive performance, an ADP value exceeding 72 U showed the highest specificity (87%) and sensitivity (68%) in discriminating patients who had a perioperative thromboembolic stroke/TIA, with a negative predictive value of 99% and a positive predictive value of 15%. After LASSO regression, an ADP >72 U and the need for a shunt during CEA were the only 2 variables independently associated with perioperative stroke/TIA., Conclusion: Because the ADP test was independently associated with perioperative stroke/TIA, the assessment of platelet reactivity using Multiplate may offer potential utility in monitoring patients undergoing CEA., Competing Interests: Declaration of competing interest None, (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest None.

Objective: To compare the outcomes of patients receiving del Nido solution versus any other type of cardioplegia., Design: A systematic review and meta-analysis of randomized trials., Setting: Cardiac operating rooms., Participants: Adult patients (≥18 years old) undergoing cardiac surgery., Interventions: The EMBASE, MEDLINE, and CENTRAL databases were searched systematically from their inception until August 2022 for randomized controlled trials comparing del Nido versus other cardioplegias., Measurements and Main Results: Ten studies were included, including 1,812 patients (871 in the del Nido group and 941 in the control group), and published after 2017. There were significant reductions in postoperative stroke and/or transient ischemic attack rate in the del Nido group: 9/467 (1.9%) v 25/540 (4.6%); odds ratio (OR), 0.43; 95% CI, 0.20-0.92 (p = 0.007). Del Nido cardioplegia was also associated with significantly shorter aortic cross-clamp time (mean difference, -8.99 minutes; 95% CI, -17.24 to -0.73 [p < 0.001]), significantly reduced need for defibrillation (89/582 [15%] v 252/655 [38%]; OR, 0.33; 95% CI, 0.15-0.72 [p < 0.001]), significantly lower risk of postoperative acute kidney injury (21/235 [8.9%] v 34/301 [11%]; OR, 0.50; 95% CI, 0.26-0.97 [p = 0.04]), with no effect on mortality (14/607 [2.3%] v 12/681 [1.8%]; p = 0.5)., Conclusion: According to the authors' meta-analysis of recent randomized clinical trials, del Nido is a safe cardioplegic solution, which might provide better organ protection in adult cardiac surgery without differences in mortality when compared to other cardioplegic solutions., Competing Interests: Conflict of Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG)., Design: A post hoc analysis of a randomized trial., Setting: Cardiac surgical operating rooms., Participants: Patients undergoing elective, isolated CABG., Interventions: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes., Measurements and Main Results: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03)., Conclusions: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality., Competing Interests: Declaration of Competing Interest V.V.L. received a speaking honorarium from Baxter., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The authors investigated the preprocedural predictors of postprocedural intra-aortic balloon pump (IABP) need in patients undergoing transcatheter ventricular tachycardia (VT) ablation on venoarterial (VA) extracorporeal membrane oxygenation (ECMO)., Design: Observational study., Setting: Hybrid operating room and intensive care unit of a teaching hospital., Patients: Participants were 121 consecutive patients with unstable VT undergoing transcatheter ablation with VA-ECMO., Interventions: In patients with postprocedural echocardiographic, radiographic, or hemodynamic signs of increased left ventricle afterload, an IABP was positioned., Measurements and Main Results: Patients in the IABP group were more frequently on angiotensin-converting enzyme inhibitors (58% v 37%; p = 0.03) and had lower median baseline ejection fraction (25% v 28% p = 0.05), larger end-diastolic diameter (69.7 mm ± 13.0 v 65.7 mm ± 11.3; p = 0.03), and more frequent ischemic etiology as the reason for dilated cardiomyopathy (76% v 47%; p = 0.04,) when compared with patients not requiring IABP. Postoperatively, the IABP group required longer mechanical ventilation (24 hours [20-56.5] v 23 hours [15-28]; p = 0.003), intensive care unit stay (78 hours [46-174] v 48 hours [24-72]; p < 0.001), and continuous renal replacement therapy (13.3% v 1.3%; p = 0.006). By multivariate analysis, end-diastolic diameter (odds ratio [OR]:1.08; confidence interval [CI]: 1.00-1.16; p = 0.049), ischemic dilated cardiomyopathy (OR: 8.40; CI: 2.15-32.88; p = 0.002), and more-than-moderate mitral regurgitation (OR: 4.83; CI: 1.22-19.22; p = 0.025) were independent predictors of need for IABP., Conclusions: The need for an IABP to unload the left ventricle can be predicted by ventricular size, medium-severe mitral valvular defect, and ischemic etiology of the dilated cardiomyopathy., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To assess whether the administration of the ultra-short-acting β-blocker esmolol in cardiac surgery could have a cardioprotective effect that translates into improved postoperative outcomes., Design: Single-center, double-blinded, parallel-group randomized controlled trial., Setting: A tertiary care referral center., Participants: Patients undergoing elective cardiac surgery with preoperative evidence of left ventricular end-diastolic diameter >60 mm and/or left ventricular ejection fraction <50%., Interventions: Patients were assigned randomly to receive either esmolol (1 mg/kg as a bolus before aortic cross-clamping and 2 mg/kg mixed in the cardioplegia solution) or placebo in a 1:1 allocation ratio., Measurements and Main Results: The primary composite endpoint of prolonged intensive care unit stay and/or in-hospital mortality occurred in 36/98 patients (36%) in the placebo group versus 27/102 patients (27%) in the esmolol group (p = 0.13). In the esmolol group, a reduction in the maximum inotropic score during the first 24 postoperative hours was observed (10 [interquartile range 5-15] v 7 [interquartile range 5-10.5]; p = 0.04), as well as a trend toward a reduction in postoperative low-cardiac-output syndrome (13/98 v 6/102; p = 0.08) and the rate of hospital admission at one year (26/95 v 16/96; p = 0.08). A trend toward an increase in the number of patients with ejection fraction ≥60% at hospital discharge also was observed (4/95 v 11/92; p = 0.06)., Conclusions: In the present trial, esmolol as a cardioplegia adjuvant enhanced postoperative cardiac performance but did not reduce a composite endpoint of prolonged intensive care unit stay and/or mortality., (Copyright © 2020 Elsevier Inc. All rights reserved.)

SEPARATION from cardiopulmonary bypass (CPB) after cardiac surgery is a progressive transition from full mechanical circulatory and respiratory support to spontaneous mechanical activity of the lungs and heart. During the separation phase, measurements of cardiac performance with transesophageal echocardiography (TEE) provide the rationale behind the diagnostic and therapeutic decision-making process. In many cases, it is possible to predict a complex separation from CPB, such as when there is known preoperative left or right ventricular dysfunction, bleeding, hypovolemia, vasoplegia, pulmonary hypertension, or owing to technical complications related to the surgery. Prompt diagnosis and therapeutic decisions regarding mechanical or pharmacologic support have to be made within a few minutes. In fact, a complex separation from CPB if not adequately treated leads to a poor outcome in the vast majority of cases. Unfortunately, no specific criteria defining complex separation from CPB and no management guidelines for these patients currently exist. Taking into account the above considerations, the aim of the present review is to describe the most common scenarios associated with a complex CPB separation and to suggest strategies, pharmacologic agents, and para-corporeal mechanical devices that can be adopted to manage patients with complex separation from CPB. The routine management strategies of complex CPB separation of 17 large cardiac centers from 14 countries in 5 continents will also be described., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Delirium after cardiac surgery is associated with adverse outcomes, including prolonged hospital stay, prolonged intensive care unit stay, and increased mortality. Effective preventive interventions and treatments still are largely unknown., Aim: This systematic review aimed to gather and summarize the existing evidence from randomized trials concerning interventions studied in the prevention or treatment of delirium in adult patients undergoing cardiac surgery., Methods: A systematic review of the literature using a key word strategy and Boolean operators was performed. PubMed and the Cochrane and Scopus databases were searched for pertinent studies until July 2018 (no inception limit)., Results: Of 2,556 articles identified, 56 studies met the inclusion criteria and were included in the review-39 addressed pharmacologic strategies and 17 nonpharmacologic interventions. Interestingly, 51 (91%) trials focused on delirium prevention and only 5 (9%) on delirium treatment. Most of the analyzed studies were recent double-blind, single-center trials conducted in Europe or North America, with a low risk of bias. Overall, 38 different interventions were identified: 15 (26%) interventions were performed before surgery, 20 (36%) in the operating room, and 21 (38%) after surgery. The most frequently analyzed strategies were the administration of dexmedetomidine, ketamine, antipsychotics, glucocorticoids, propofol, opioids, volatile anesthetics, local anesthetics, and remote ischemic preconditioning. The analyzed strategies were extremely heterogenous, and dexmedetomidine was the most promising measure able to prevent the development of postoperative delirium., Conclusions: In the present systematic review of 56 randomized controlled trials that examined 38 interventions, the authors found that dexmedetomidine was the most frequently studied agent and that it might reduce the occurrence of delirium after cardiac surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To find out if there are any differences in biomarkers between severe isolated right ventricular (RV) dysfunction and severe isolated left ventricular (LV) dysfunction after cardiac surgery using cardiopulmonary bypass., Design: Observational study., Setting: Teaching hospital., Participants: A total of 46 patients who had severe isolated RV or LV dysfunction after cardiac surgery., Intervention: The authors collected perioperative clinical and biomarker data., Measurements and Main Results: Severe isolated RV dysfunction patients (n = 20) had higher postoperative direct bilirubin (p = 0.030), total bilirubin (p = 0.044), glucose (p = 0.011), and international normalized ratio (INR) (p = 0.050) by repeated measure analysis of variance when compared with patients with severe isolated LV dysfunction (n = 26). The RV group also showed lower preoperative alanine transferase (19.3 ± 1.5 v 32.7 ± 4.2, p = 0.001), higher 4-hour INR (1.5 ± 0.3 v 1.4 ± 0.2, p = 0.008), and higher 48-hour INR (1.8 ± 0.4 v 1.4 ± 0.1, p < 0.001). None in the LV group died, whereas 4 patients in the RV group died (all of them had preoperative atrial fibrillation and underwent double valve replacement surgery)., Conclusion: The authors observed biomarkers differences between severe isolated RV dysfunction and severe isolated RV dysfunction., Competing Interests: Declaration of Competing Interest There is no conflict of interest related to any of the authors., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings., Design: A systematic review of the literature followed by a consensus-based voting process., Setting: A web-based international consensus conference., Participants: Two hundred fifty-one physicians from 46 countries., Interventions: The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines., Measurements and Main Results: The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed., Conclusion: The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Patients undergoing transapical cardiac procedure are a minority of cardiac surgery patients but represent a challenge for cardiac anesthesiologists because they generally are older and have more comorbidities than do open heart cardiac surgery patients. The aims of this study were to describe the anesthetic experience with transapical procedures in a single high-volume center and to analyze the most critical aspects for anesthetic management., Design: Retrospective study., Setting: IRCCS San Raffaele Scientific Institute, Milan, Italy., Participants: All patients undergoing a cardiac transapical procedure from January 2009 to April 2018 were included in this case series., Interventions: Patients were managed by a multidisciplinary heart team. The perioperative anesthetic approach and hemodynamic management were consistent and performed by a group of trained cardiac anesthesiologists., Measurements and Main Results: The study population comprised 143 patients: 81 (57%) underwent an aortic valve procedure, 60 (42%) a mitral valve intervention, 1 patient underwent a procedure involving both the aortic and mitral valves, and 1 patient underwent correction of a congenital heart defect. A major intraoperative complication occurred in 5 (3.5%) patients, the procedure was not technically feasible because of unsuitable anatomy in 3 patients, and conversion to open heart surgery was needed in 2 patients. All patients were admitted to the intensive care unit. Intensive care unit stay was 1 (1-3) days, and hospital stay was 6 (5-8) days. Hospital survival was 94%., Conclusions: Patients undergoing transapical cardiac procedures are a minority of cardiac surgery patients, but represent a high-risk population. A patient-tailored anesthetic approach, in the context of the therapeutic strategy shared by the heart team, is crucial to improve outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To identify reliable predictors of periprocedural intensive care unit (ICU) admission after transvenous lead extraction (LE) in a high-volume center., Design: Retrospective observational study., Setting: University tertiary-care hospital., Participants: All patients undergoing LE at San Raffaele Scientific Institute, Milan, Italy, from 2005 to 2015., Interventions: LE procedures were performed in the electrophysiology laboratories with a cardiac operating room on standby between the end of the morning surgical case and before the start of the afternoon surgical case. Most procedures were conducted with the patient under procedural sedation and analgesia. After LE, patients were admitted either to the ward or to the ICU. Medical history and intraprocedural data were recorded., Measurements and Main Results: Of the 389 procedures performed during the study period, 50 patients (13%) were admitted to the ICU owing to persistent hemodynamic instability or intraoperative complications requiring endotracheal intubation. Complete procedural success was achieved in 370 patients (95%), and the clinical success rate was 98.4%. No deaths were recorded. Five complications requiring emergency surgery (1.3%) were reported. Preprocedural right ventricular dysfunction (odds ratio (OR) 7.41; confidence interval 1.85-29.7; p < 0.01) and the need for general anesthesia (OR 12; confidence interval 1.49-97.06; p = 0.019) were independent predictors of ICU admission., Conclusions: Preoperative identification of patients who need ICU admission after LE is crucial to increase patient safety and decrease hospital costs. Severe right ventricular dysfunction and need for general anesthesia identify patients with low cardiac reserve who are at increased risk for ICU admission after the procedure., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To assess the beneficial effects of noninvasive ventilation in treating postoperative pulmonary complications in patients undergoing thoracoabdominal aortic aneurysm (TAAA) open repair surgery., Design: Randomized controlled trial., Setting: University tertiary-care hospital., Participants: Forty patients who underwent elective TAAA open repair., Interventions: Patients were randomized to the "noninvasive ventilation" group, receiving 2-hour cycles of noninvasive ventilation every 8 hours for at least 3 days in addition to the best available postoperative treatment currently in use at the authors' institution versus the "standard" group, not receiving noninvasive ventilation treatment MEASUREMENTS AND MAIN RESULTS: The primary outcome of clinical worsening, described as a composite outcome of need for therapeutic noninvasive ventilation, need for mechanical ventilation owing to respiratory causes, need for intensive care unit admission owing to respiratory causes, and in-hospital mortality, occurred in 2 (11%) patients in the noninvasive ventilation group versus 12 (57%) in the standard group (p = 0.002; relative risk 0.18; 95% confidence interval 0.047-0.72)., Conclusion: Noninvasive ventilation is a promising, affordable, and easy-to-use tool to prevent postoperative respiratory complications after TAAA open surgical repair., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Acute kidney injury (AKI) occurs frequently after cardiac surgery. Levosimendan might reduce the incidence of AKI in patients undergoing cardiac surgery. The authors investigated whether levosimendan administration could reduce AKI incidence in a high-risk cardiac surgical population., Design: Post hoc analysis of a multicenter randomized trial., Setting: Cardiac surgery operating rooms and intensive care units of 14 centers in 3 countries., Participants: The study comprised 90 patients who underwent mitral valve surgery with an estimated glomerular filtration rate <60 mL/min/1.73 m 2 and perioperative myocardial dysfunction., Interventions: Patients were assigned randomly to receive levosimendan (0.025-0.2 μg/kg/min) or placebo in addition to standard inotropic treatment., Measurements and Main Results: Forty-six patients were assigned to receive levosimendan and 44 to receive placebo. Postoperative AKI occurred in 14 (30%) patients in the levosimendan group versus 23 (52%) in the placebo group (absolute difference -21.8; 95% confidence interval -41.7 to -1.97; p = 0.035). The incidence of major complications also was lower (18 [39%]) in the levosimendan group versus that in the placebo group (29 [66%]) (absolute difference -26.8 [-46.7 to -6.90]; p = 0.011). A trend toward lower serum creatinine at intensive care unit discharge was observed in the levosimendan group (1.18 [0.99-1.49] mg/dL) versus that in the placebo group (1.39 [1.05-1.76] mg/dL) (95% confidence interval -0.23 [-0.49 to 0.01]; p = 0.07)., Conclusions: Levosimendan may improve renal outcome in cardiac surgery patients with chronic kidney disease undergoing mitral valve surgery who develop perioperative myocardial dysfunction. Results of this exploratory analysis should be investigated in future properly designed randomized controlled trials., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Extracorporeal membrane oxygenation (ECMO) is used with increasing frequency to treat severe cardiac or respiratory failure as it can provide respiratory only or combined circulatory and respiratory support. Despite efforts aimed at increasing its diffusion however, ECMO is currently reserved, usually as last resort, in very severe cases, which are managed almost exclusively in the intensive care unit (ICU). Recent improvements in both technology and patients' management is leading to constant improvement in patients' outcome, especially in centers with a high caseload volume and after ensuring careful patients' selection. Moreover, since short ECMO runs are associated with limited complications, there are now several potential situations outside the ICU and outside the cardiac surgery setting where ECMO is being (or could be) successfully employed to provide cardio-respiratory support, including: high-risk structural heart interventions, ventricular tachycardia ablation, cesarean section, trauma, and, most interestingly, non-cardiac elective procedures in patients at high risk for perioperative cardiac or respiratory complications. Given the increased availability and the good outcomes of ECMO, when carefully employed, we are thus moving towards a future in which no patient should be denied diagnostic or therapeutic procedure exclusively due to high cardiorespiratory risk., (Copyright © 2018 Elsevier Inc. All rights reserved.)

β-Blockers are useful drugs in several clinical cardiologic scenarios. Their use in the perioperative period and in critically ill patients is increasing, but their effect on clinically relevant outcomes remains controversial. Long-acting β-blockers can have detrimental effects that are difficult to be counteracted in these settings. The authors describe the possible clinical uses of ultra-short-acting β-blockers (esmolol and landiolol) in the perioperative period and in critically ill patients because these drugs have the beneficial effects of β-blockers, but do not have the detrimental effects of long-acting agents. This narrative review focuses on ultra-short-acting β-blockers in the following clinical settings: prevention and treatment of arrhythmias and myocardial ischemia in noncardiac and cardiac surgery, usage as cardioplegia adjuvants or to test the reversibility of systolic anterior motion of the mitral valve in cardiac surgery, medical treatment of aortic dissection before surgery, improvement of microcirculation and oxygenation in critically ill patients experiencing sepsis or undergoing extracorporeal membrane oxygenation, anesthesia induction, and coronary computed tomography angiography., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: There is experimental evidence that phosphocreatine (PCr) can decrease ischemia/reperfusion injury of the heart. The authors investigated if PCr would improve heart performance as compared with standard treatment in cardiac surgery., Design: Meta-analysis of randomized controlled trials., Setting: Hospitals., Participants: Adult and pediatric patients undergoing cardiac surgery., Interventions: The ability of PCr to improve cardiac outcomes as compared with standard treatment was investigated., Measurements and Main Results: PubMed/Medline, Embase, Scopus, Cochrane Library, China National Knowledge Infrastructure, WANGFANG DATA, and VIP Paper Check System were searched to March 1 2017. The authors included 26 randomized controlled trials comprising 1,948 patients. Random and fixed-effects models were used to estimate odds ratio (OR) and mean difference (MD) with 95% confidence interval (CI). PCr use was associated with reduced rates of intraoperative inotropic support (27% v 44%; OR 0.47, 95% CI 0.35-0.61; p < 0.001), major arrhythmias (16% v 28%; OR 0.44, 95% CI 0.27-0.69; p < 0.001), as well as increased spontaneous recovery of the cardiac rhythm immediately after aortic declamping (50% v 34%; OR 2.45, 95% CI 1.82-3.30; p < 0.001) as compared with standard treatment. The use of PCr decreased myocardial damage and augmented left ventricular ejection fraction in the postoperative period; however, MD for these outcomes were small and do not seem to be clinically significant., Conclusions: In randomized trials, PCr administration was associated with reduced rates of intraoperative inotropic support and major arrhythmias, and increased spontaneous recovery of the cardiac rhythm after aortic declamping. Large multicenter evidence is needed to validate these findings., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: A careful choice of perioperative care strategies is pivotal to improve survival in cardiac surgery. However, there is no general agreement or particular attention to which nonsurgical interventions can reduce mortality in this setting. The authors sought to address this issue with a consensus-based approach., Design: A systematic review of the literature followed by a consensus-based voting process., Setting: A web-based international consensus conference., Participants: More than 400 physicians from 52 countries participated in this web-based consensus conference., Interventions: The authors identified all studies published in peer-reviewed journals that reported on interventions with a statistically significant effect on mortality in the setting of cardiac surgery through a systematic Medline/PubMed search and contacts with experts. These studies were discussed during a consensus meeting and those considered eligible for inclusion in this study were voted on by clinicians worldwide., Measurements and Main Results: Eleven interventions finally were selected: 10 were shown to reduce mortality (aspirin, glycemic control, high-volume surgeons, prophylactic intra-aortic balloon pump, levosimendan, leuko-depleted red blood cells transfusion, noninvasive ventilation, tranexamic acid, vacuum-assisted closure, and volatile agents), whereas 1 (aprotinin) increased mortality. A significant difference in the percentages of agreement among different countries and a variable gap between agreement and clinical practice were found for most of the interventions., Conclusions: This updated consensus process identified 11 nonsurgical interventions with possible survival implications for patients undergoing cardiac surgery. This list of interventions may help cardiac anesthesiologists and intensivists worldwide in their daily clinical practice and can contribute to direct future research in the field., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Of the 230 million patients undergoing major surgical procedures every year, more than 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. The authors have updated a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality., Design and Setting: A web-based international consensus conference., Participants: The study comprised 500 clinicians from 61 countries., Interventions: A systematic literature search was performed to identify published literature about nonsurgical interventions, supported by randomized evidence, showing a statistically significant impact on mortality. A consensus conference of experts discussed eligible papers. The interventions identified by the conference then were submitted to colleagues worldwide through a web-based survey., Measurements and Main Results: The authors identified 11 interventions contributing to increased survival (perioperative hemodynamic optimization, neuraxial anesthesia, noninvasive ventilation, tranexamic acid, selective decontamination of the gastrointestinal tract, insulin for tight glycemic control, preoperative intra-aortic balloon pump, leuko-depleted red blood cells transfusion, levosimendan, volatile agents, and remote ischemic preconditioning) and 2 interventions showing increased mortality (beta-blocker therapy and aprotinin). Interventions then were voted on by participating clinicians. Percentages of agreement among clinicians in different countries differed significantly for 6 interventions, and a variable gap between evidence and clinical practice was noted., Conclusions: The authors identified 13 nonsurgical interventions that may decrease or increase perioperative mortality, with variable agreement by clinicians. Such interventions may be optimal candidates for investigation in high-quality trials and discussion in international guidelines to reduce perioperative mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Percutaneous procedures for the treatment of mitral valve disease represent valuable therapeutic options for high-risk patients. The anesthetic management of these patients is complex, as they often suffer from cardiac failure and present multiple comorbidities. A recently developed device for transcatheter mitral valve annuloplasty (Cardioband - Valtech Cardio, Or Yehuda, Israel) is now available in clinical practice. The aim of this study was to present the authors' experience with Cardioband device implantation and to describe their anesthetic strategy., Design: Retrospective study., Setting: Cardiac catheterization laboratory of a teaching hospital., Participants: Thirteen patients undergoing Cardioband implantation., Interventions: All the procedures were performed under general anesthesia with continuous transesophageal echocardiographic monitoring. Three-dimensional echocardiography, inotropic therapy, cardiac pacing, and mechanical circulatory support always were available and performed as needed., Measurements and Main Results: Mean age was 73±7.1 years, and mean preoperative ejection fraction was 38±7.4%. No complications related to anesthetic management were recorded. The authors observed 1 episode of device malfunction and 1 case of accidental damage to the circumflex artery. Postoperative complications were observed in 3 patients, involving detachment of the anchors, anemia requiring transfusions, vascular injury, and new-onset atrial fibrillation. Six patients (46%) required ICU admission. All patients (100%) were discharged from the hospital., Conclusions: Cardioband device implantation under general anesthesia is a feasible approach when performed by skilled physicians with all the expertise and the resources of high-volume centers used to dealing with severely ill patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Democracy-based medicine is a combination of evidence-based medicine (systematic review), expert assessment, and worldwide voting by physicians to express their opinions and self-reported practice via the Internet. The authors applied democracy-based medicine to key trials in critical care medicine., Design and Setting: A systematic review of literature followed by web-based voting on findings of a consensus conference., Participants: A total of 555 clinicians from 61 countries., Interventions: The authors performed a systematic literature review (via searching MEDLINE/PubMed, Scopus, and Embase) and selected all multicenter randomized clinical trials in critical care that reported a significant effect on survival and were endorsed by expert clinicians. Then they solicited voting and self-reported practice on such evidence via an interactive Internet questionnaire. Relationships among trial sample size, design, and respondents' agreement were investigated. The gap between agreement and use/avoidance and the influence of country origin on physicians' approach to interventions also were investigated., Measurements and Main Results: According to 24 multicenter randomized controlled trials, 15 interventions affecting mortality were identified. Wide variabilities in both the level of agreement and reported practice among different interventions and countries were found. Moreover, agreement and reported practice often did not coincide. Finally, a positive correlation among agreement, trial sample size, and number of included centers was found. On the contrary, trial design did not influence clinicians' agreement., Conclusions: Physicians' clinical practice and agreement with the literature vary among different interventions and countries. The role of these interventions in affecting survival should be further investigated to reduce both the gap between evidence and clinical practice and transnational differences., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To identify all interventions that increase or reduce mortality in patients with acute kidney injury (AKI) and to establish the agreement between stated beliefs and actual practice in this setting., Design and Setting: Systematic literature review and international web-based survey., Participants: More than 300 physicians from 62 countries., Interventions: Several databases, including MEDLINE/PubMed, were searched with no time limits (updated February 14, 2012) to identify all the drugs/techniques/strategies that fulfilled all the following criteria: (a) published in a peer-reviewed journal, (b) dealing with critically ill adult patients with or at risk for acute kidney injury, and (c) reporting a statistically significant reduction or increase in mortality., Measurements and Main Results: Of the 18 identified interventions, 15 reduced mortality and 3 increased mortality. Perioperative hemodynamic optimization, albumin in cirrhotic patients, terlipressin for hepatorenal syndrome type 1, human immunoglobulin, peri-angiography hemofiltration, fenoldopam, plasma exchange in multiple-myeloma-associated AKI, increased intensity of renal replacement therapy (RRT), CVVH in severely burned patients, vasopressin in septic shock, furosemide by continuous infusion, citrate in continuous RRT, N-acetylcysteine, continuous and early RRT might reduce mortality in critically ill patients with or at risk for AKI; positive fluid balance, hydroxyethyl starch and loop diuretics might increase mortality in critically ill patients with or at risk for AKI. Web-based opinion differed from consensus opinion for 30% of interventions and self-reported practice for 3 interventions., Conclusion: The authors identified all interventions with at least 1 study suggesting a significant effect on mortality in patients with or at risk of AKI and found that there is discordance between participant stated beliefs and actual practice regarding these topics., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: There are no large studies that investigate the effect of thoracic epidural anesthesia (TEA) combined with general anesthesia (GA) in patients undergoing valvular surgery. The authors hypothesized that TEA might improve clinically relevant endpoints in patients with primary mitral regurgitation., Design: Propensity-matched study., Setting: Cardiac surgery., Participants: Patients scheduled for mitral valve repair or replacement were studied., Interventions: A propensity model was constructed to match 33 patients receiving TEA combined with GA with 33 patients receiving standard GA alone., Measurements and Main Results: Overall, the TEA group suffered fewer adverse events than the GA group: 10 (30%) v 23 (10%) with p = 0.002. In particular, the TEA group had a lower incidence of pulmonary events, 6 (18%) v 15 (45%) with p = 0.02, and of cardiac events, 8 (24%) v 16 (49%) with p = 0.04. Median (interquartile) time on mechanical ventilation was reduced in the TEA group, 11 (9-15) v 17 (12-36) with p = 0.007., Conclusions: This propensity-matched study suggested that TEA might be advantageous in patients undergoing surgery for mitral regurgitation., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: Recombinant activated factor VII (rFVIIa) is used in various surgical procedures to reduce the incidence of major blood loss and the need for re-exploration. Few clinical trials have investigated rFVIIa in cardiac surgery. The authors performed a meta-analysis focusing on the rate of stroke and surgical re-exploration., Design: Meta-analysis., Setting: Hospitals., Participants: A total of 470 patients., Interventions: None., Measurements and Main Results: Four investigators independently searched PubMed and conference proceedings including backward snowballing (ie, scanning of reference of retrieved articles and pertinent reviews) and contacted international experts. A total of 470 patients (254 receiving rFVIIa and 216 controls) from 6 clinical trials (2 randomized, 3 propensity matched, and 1 case matched) were included in the analysis. The use of rFVIIa was associated with an increased rate of stroke (12/254 [4.7%] in the rFVIIa group v 2/216 [0.9%] in the control arm, odds ratio [OR] = 3.69 [1.1-12.38], p = 0.03) with a nonsignificant reduction in rate of surgical re-exploration (13% v 42% [OR = 0.27 (0.04-1.9), p = 0.19]). The authors observed a trend toward an increase of overall perioperative thromboembolic events (19/254 [7.5%] in the rFVIIa group v 10/216 [5.6%] in the control arm [OR = 1.84 (0.82-4.09), p = 0.14]). No difference in the rate of death was observed., Conclusions: The administration of rFVIIa in cardiac surgery patients could result in a significant increase of stroke with a trend toward a reduction of the need for surgical re-exploration. The authors do not recommend routine use in cardiac surgery patients. rFVIIa may be considered with caution in patients with refractory life-threatening bleeding., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: Most-Care (powered by the pressure-recording analytic method [PRAM]; Vytech HealthTM, Padova, Italy) is a minimally invasive cardiac output monitoring. This system already has been studied and validated in cardiac surgery and in children. It already showed a correlation with thermodilution methods in hemodynamically unstable patients. The purpose of this study was to confirm the reliability of cardiac index determinations by Most-Care in unstable patients with atrial fibrillation., Design: A prospective study., Setting: A teaching hospital., Participants: Forty-nine patients., Interventions: Simultaneous cardiac index measurements by bolus thermodilution and by PRAM from a standard arterial access (radial and femoral) were obtained. The thermodilution cardiac index was calculated as the mean of 3 separate measurements. Because PRAM is a beat-to-beat monitoring system, the mean cardiac index of 12 consecutive beats was considered for the analysis. Correlations were calculated and differences compared by Bland-Altman analysis., Measurements: Eight patients were excluded because the signal was altered by the arterial catheter resonance so that the study described the remaining 41 patients. The overall estimates of cardiac index measured by PRAM did not show agreement with the reference cardiac index by thermodilution (mean difference = 0.136 L/min/m(2) [0,43 L/min/m(2)-0.15 L/min/m(2)], with an upper limit of agreement of 1.94 L/min/m(2) and a lower limit of agreement of -1.665 L/min/m(2), respectively). The median (interquartile) value of cardiac index assessed by thermodilution was 2.42 L/min/m(2) (2.21-2.98 L/min/m(2)), and by PRAM it was 2.48 L/min/m(2) (1.80-3.00 L/min/m(2), p = 0.6)., Conclusions: The authors concluded that PRAM did not compare well with thermodilution in unstable patients with atrial fibrillation., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: Although cardiac troponin I (cTnI) measurement is used extensively as a marker of perioperative myocardial injury, limited knowledge exists in noncoronary artery bypass graft surgery., Design: Observational study., Setting: Single-center intensive care unit., Intervention: None., Participants: One hundred eighty-five consecutive adult patients undergoing mitral valve surgery for predominant mitral regurgitation were enrolled and underwent measurement of cTnI at 24 hours after surgery., Measurements and Main Results: CTnI release after mitral valve surgery was significantly associated with an adverse outcome. The optimal cTnI value for predicting adverse outcomes was 14 ng/mL. Univariate preoperative predictors of cTnI release were prior use of diuretics (p = 0.04) or a rheumatic (p = 0.006), ischemic (p = 0.004), or myxomatous (p = 0.005) etiology to mitral disease, whereas intraoperative variables predictive of cTnI release were cross-clamp time (p = 0.005), cardiopulmonary bypass time (p < 0.001), need for mitral valve replacement (p = 0.024), number of electrical cardioversions (p = 0.03), patent foramen ovale closure (p = 0.03), tricuspid valve repair (p = 0.04), need for epinephrine/norepinephrine (p = 0.004) or intra-aortic balloon pump (p = 0.03) in the operating room; and, finally, the surgeon who performed the surgery (p = 0.014). There were no postoperative predictors of excessive cTnI release. In multivariate analysis, the only predictors of cTnI release were the cardiopulmonary bypass time (odds ratio, 1.42; confidence intervals, 1.019-1.064; p = 0.001) and the infusion of epinephrine/norepinephrine in the operating room (odds ratio, 4.002; confidence intervals, 1.238-12.929; p = 0.02)., Conclusions: After mitral surgery, the need for epinephrine/norepinephrine perioperatively and the cardiopulmonary bypass time independently predict a cTnI release significantly related to an adverse outcome., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: The authors investigated the accuracy and precision of the pressure recording analytic method (PRAM) in cardiac index measurement compared with thermodilution in unstable patients, a setting in which minimally invasive monitoring devices often fail., Design: Criterion standard., Setting: Intensive care unit., Patients: Thirty-two consecutive patients with low cardiac output syndrome treated with an intra-aortic balloon pump and/or high doses of inotropic drugs but without atrial fibrillation were studied after cardiac surgery., Interventions: None. Pulmonary and radial artery catheters were already in situ for clinical reasons., Measurements and Main Results: Four patients (12.5%) were excluded from the study because of artifacts caused by under- or overdamping of the arterial pressure monitoring system. The authors performed 3 injections of the thermal indicator in 5 minutes through the pulmonary artery catheter. Mean cardiac index values of 12 consecutive beats were considered for the PRAM. A significant correlation was found between the cardiac index assessed by thermodilution and PRAM (r = 0.72, p < 0.001). The mean bias between the 2 techniques was 0.072 +/- 0.41 L/min/m(2) with lower and upper 95% limits of confidence of -0.089 and 0.233 L/min/m(2), respectively. The percentage error was 30%. Sufficient agreement between the two techniques was evidenced by the Bland-Altman plot with only two points above the limits of agreement., Conclusions: This study showed that PRAM, a minimally invasive method for cardiac index assessment, is clinically useful even in unstable patients such as those receiving intra-aortic balloon pump and/or ongoing high doses of a inotropic drugs because of a low cardiac output syndrome but without atrial fibrillation., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to evaluate the effects of thoracic epidural anesthesia on postoperative N-terminal pro B-natriuretic peptide (NT-proBNP) release in elderly patients undergoing elective coronary artery bypass graft (CABG) surgery., Design: A case-matched, nonrandomized study., Setting: A university hospital, single institution., Participants: 46 consecutive and 46 control patients., Interventions: Ninety-two elderly patients (>65 years old) undergoing elective CABG surgery were recruited. Forty-six patients receiving general and epidural anesthesia were case matched (preoperative medications, ejection fraction, and comorbidities) with 46 control subjects receiving general anesthesia. The primary outcome measure was postoperative NT-proBNP release. The preoperative or intraoperative variables significantly associated with an intensive care unit stay longer than 4 days were determined by logistic regression., Measurements and Main Results: The median (interquartile range) plasma concentrations of NT-proBNP before surgery were 402 (115-887 pg/mL) in the epidural group versus 508 (228-1,285 pg/mL) in the general anesthesia group (p = 0.9), whereas 24 hours after surgery it increased to 1846 (1,135-3,687 pg/mL) versus 5,005 (2,220-11,377 pg/mL) (p = 0.001), respectively. There were more patients (p = 0.043) in the control group (9/46 = 19.5%) than in the thoracic epidural anesthesia group (4/46 = 8.8%) with an intensive care unit stay longer than 4 days. The absence of preoperative beta-blocker therapy (odds ratio = 3.94; 95% confidence interval, 1.123-13.833; p =0.03) and of an epidural catheter (odds ratio = 3.91; 95% confidence interval, 1.068-14.619; p = 0.04) were the only preoperative and intraoperative variables independently associated with a prolonged intensive care unit stay., Conclusions: Epidural anesthesia added to general anesthesia for CABG surgery significantly attenuates NT-proBNP release in elderly patients and reduces the incidence of prolonged intensive care unit stay.

Objective: beta-Blockers were associated with a reduction of mortality and morbidity in noncardiac surgery until recently when the POISE trial showed that beta-blockers could be harmful in the perioperative period because of hypotension and bradycardia. Esmolol is an ultra-short-acting beta-blocker mostly used in emergency and high-risk patients. The authors performed a meta-analysis to evaluate the clinical effects of esmolol in cardiac surgery., Design: Meta-analysis., Setting: Hospitals., Participants: A total of 778 patients from 20 randomized trials., Interventions: None., Measurements and Main Result: Three investigators independently searched BioMedCentral and PubMed. Inclusion criteria were random allocation to treatment and comparison of esmolol versus other drugs, placebo, or standard of care in cardiac surgery. Exclusion criteria were duplicate publications, nonhuman experimental studies, and no data on clinical outcomes. The use of esmolol was associated with a significant reduction of myocardial ischemia episodes (15/122 [12.2%] in the esmolol group v 36/140 [25.7%] in the control arm, odds ratio [OR] =0.42 [0.23-0.79], p = 0.007) and development of arrhythmias after cardiopulmonary bypass (15/65 [23.07%] v 23/64 [35.9%], OR = 0.42 [0.18-1.01], p = 0.05). The authors did not find a reduction in the use of inotropic drugs in esmolol-treated patients (29/153 [18.9%] v 48/146 [32.8%], OR = 0.43 [0.16-1.10], p = 0.08). Esmolol-treated patients had more episodes of bradycardia (19/129 [14.72%] v 3/133 [2.25%], OR = 5.49 [2.21-13.62], p = 0.0002) and hypotension (28/113 [24.77%] v 14/119 [11.76%], OR = 2.73 [0.83-9.04], p = 0.10)., Conclusions: Esmolol reduces the incidence of myocardial ischemia and arrhythmias in cardiac surgery. An increase in bradycardia was noted as well.