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Objective The objective was to develop a novel scoring system that would be predictive of postoperative pulmonary complications in critically ill patients after cardiac and major vascular surgery. Methods A total of 17,433 postoperative patients after coronary artery bypass graft, valve, or thoracic aorta repair surgery admitted to the cardiovascular intensive care units at Cleveland Clinic Main Campus from 2009 to 2015. The primary outcome was the composite of postoperative pulmonary complications, including pneumonia, prolonged postoperative mechanical ventilation (>48 hours), or reintubation occurring during the hospital stay. Elastic net logistic regression was used on the training subset to build a prediction model that included perioperative predictors. Five-fold cross-validation was used to select an appropriate subset of the predictors. The predictive efficacy was assessed with calibration and discrimination statistics. Post hoc, of 13,353 adult patients, we tested the clinical usefulness of our risk prediction model on 12,956 patients who underwent surgery from 2015 to 2019. Results Postoperative pulmonary complications were observed in 1669 patients (9.6%). A prediction model that included baseline and demographic risk factors along with perioperative predictors had a C-statistic of 0.87 (95% confidence interval, 0.86-0.88), with a corrected Brier score of 0.06. Our prediction model maintains satisfactory discrimination (C-statistics of 0.87) and calibration (Brier score of 0.07) abilities when evaluated on an independent dataset of 12,843 recent adult patients who underwent cardiovascular surgery. Conclusions A novel prediction nomogram accurately predicted postoperative pulmonary complications after major cardiac and vascular surgery. Intensivists may use these predictors to allow for proactive and preventative interventions in this patient population.

The recent integration of regional anesthesia techniques into the cardiac surgical patient population has become a component of enhanced recovery after cardiac surgery pathways. Fascial planes of the chest wall enable single-injection or catheter-based infusions to spread local anesthetic over multiple levels of innervation. Although median sternotomy remains a common approach to cardiac surgery, minimally invasive techniques have integrated additional methods of performing cardiac surgery. Understanding the surgical approach and chest wall innervation is crucial to success in choosing the appropriate chest wall block. Parasternal intercostal plane techniques (previously termed "pectointercostal fascial plane" and "transversus thoracic muscle plane") provide anterior chest and ipsilateral sternal coverage. Anterolateral chest wall coverage is feasible with the interpectoral plane and pectoserratus plane blocks (previously termed "pectoralis") and superficial and deep serratus anterior plane blocks. The erector spinae plane block provides extensive coverage of the ipsilateral chest wall. Any of these techniques has the potential to provide bilateral chest wall analgesia. The relative novelty of these techniques requires ongoing research to be strategic, thoughtful, and focused on clinically meaningful outcomes to enable widespread evidence-based implementation. This review article discusses the key perspectives for performing and assessing chest wall blocks in a cardiac surgical population.

To examine E-aminocaproic acid effectiveness in reducing transfusion requirements in overall and less-invasive cardiac surgery, and to assess its safety.Retrospective cohort study.Single-center tertiary academic medical center.A total of 19,111 adult patients who underwent elective surgery requiring cardiopulmonary bypass from January 1, 2008, through December 31, 2016.None.Propensity matching was used to create well-balanced groups and separately compare both overall cohort and less-invasive surgery with and without E-aminocaproic acid. Supplementary zero-inflated negative binomial regression analysis was used because outcome data were zero-inflated. Effectiveness was assessed by transfusion requirements, and safety by comparison of in-hospital outcomes. In the overall cohort, patients receiving E-aminocaproic acid received fewer red blood cells postoperatively and fewer intra- and postoperativel blood products. In a less-invasive cohort, there was no significant difference in red blood cell transfusion either intra- or postoperatively, but the E-aminocaproic group received fewer intra- and postoperative platelets, intraoperative cryoprecipitate, and postoperative plasma. There were no significant differences for in-hospital outcomes in both less-invasive and overall cohorts.The reduction of postoperative red blood cell requirement observed when analyzing the overall cohort did not translate to less-invasive cardiac surgery in the authors' patient population; however, both overall and less-invasive cohorts had lower requirements for other blood components with E-aminocaproic acid. There was no association with major Society of thoracic surgeons (STS)-defined morbidity and mortality in both groups.

The demand for well-tolerated, effective, and opioid reducing pain management has become imperative in thoracic surgery. With the recent movement away from neuraxial analgesia for thoracic surgical patients, great interest in alternative analgesic techniques of the chest wall has developed. Multiple fascial plane blocks have been developed for pain management of the lateral chest wall and we present an up-to-date review of these popular new interventions.The pectoralis and serratus anterior plane blocks may offer effective analgesia of the lateral chest wall for thoracic surgical patients. The erector spinae plane block may offer more extensive analgesic coverage but requires further investigation.Fascial plane blocks hold the potential for well-tolerated and effective analgesia for thoracic surgical patients as part of a multimodal regimen of pain relief. However, many questions remain regarding block characteristics. As the literature matures, more formal recommendations will be made but quality trials are needed to provide this guidance.

Objectives To investigate short-term outcomes in patients with chronic thromboembolic pulmonary hypertension (CTEPH) presenting for pulmonary endarterectomy (PEA) and requiring extracorporeal membrane oxygenation (ECMO) during the perioperative period. Design Retrospective observational case series involving patients who underwent PEA for CTEPH, with focus on a subpopulation requiring perioperative ECMO support. Setting Single academic tertiary center. Participants Patients who underwent PEA for CTEPH between January 1997 and December 2015 and required ECMO support. Interventions PEA for CTEPH with ECMO support at any time during the perioperative period. Measurements and Main Results A total of 150 patients underwent PEA for CEPTH during the study period. Of the 150 patients, 14 (9.3%) required ECMO support and (43%) survived, were discharged, and were alive at the time of the review. A total of 8 (57%) ECMO patients died during hospitalization. Although indications and type of support changed in some patients during their hospital course, the majority of patients required venovenous ECMO support for hypoxia (N = 9) versus venoarterial ECMO for hemodynamic support (N = 5) as initial indication. The mean length of stay among survivors was 42.2 ± 22 days. Severe RV dysfunction was present preoperatively among 6 patients in the nonsurvivors group (75%) and 2 in the survivors group (33%). The overall mean duration of ECMO support was 7.3 ± 5.3 days (8.3 ± 7.3 days among survivors and 6.5 ± 3.5 days among nonsurvivors). Four patients died while on ECMO. Conclusions Although still associated with high morbidity and mortality, ECMO appears to be an important treatment adjunct providing additional time for healing and recovery of cardiopulmonary function in patients who develop severe hypoxemia or right ventricular failure after PEA.

Objective Adoption of robotic mitral valve surgery has been slow, likely in part because of its perceived technical complexity and a poorly understood learning curve. We sought to correlate changes in technical performance and outcome with surgeon experience in the “learning curve” part of our series. Methods From 2006 to 2011, two surgeons undertook robotically assisted mitral valve repair in 458 patients (intent-to-treat); 404 procedures were completed entirely robotically (as-treated). Learning curves were constructed by modeling surgical sequence number semiparametrically with flexible penalized spline smoothing best-fit curves. Results Operative efficiency, reflecting technical performance, improved for (1) operating room time for case 1 to cases 200 (early experience) and 400 (later experience), from 414 to 364 to 321 minutes (12% and 22% decrease, respectively), (2) cardiopulmonary bypass time, from 148 to 102 to 91 minutes (31% and 39% decrease), and (3) myocardial ischemic time, from 119 to 75 to 68 minutes (37% and 43% decrease). Composite postoperative complications, reflecting safety, decreased from 17% to 6% to 2% (63% and 85% decrease). Intensive care unit stay decreased from 32 to 28 to 24 hours (13% and 25% decrease). Postoperative stay fell from 5.2 to 4.5 to 3.8 days (13% and 27% decrease). There were no in-hospital deaths. Predischarge mitral regurgitation of less than 2+, reflecting effectiveness, was achieved in 395 (97.8%), without correlation to experience; return-to-work times did not change substantially with experience. Conclusions Technical efficiency of robotic mitral valve repair improves with experience and permits its safe and effective conduct.

Optimal analgesia is an integral part of enhanced recovery after surgery (ERAS) programs designed to improve patients' perioperative experience and outcomes. Regional anesthetic techniques in a form of various fascial plane chest wall blocks are an important adjunct to the optimal postoperative analgesia in cardiac surgery. The most common application of fascial plane chest wall blocks has been for minimally invasive cardiac surgical procedures. An abundance of case reports has been described in the anesthesia literature and reports appear promising, yet higher-level safety and efficacy evidence is lacking. Those providing anesthesia for minimally invasive cardiac procedures should become familiar with fascial plane anatomy and block techniques to be able to provide enhanced postsurgical analgesia and facilitate faster functional recovery and earlier discharge. The purpose of this review is to provide an overview of contemporary fascial plane chest wall blocks used for analgesia in cardiothoracic surgery. Specifically, we focus on relevant anatomic considerations and technical descriptions including pectoralis I and II, serratus anterior, pectointercostal fascial, transverse thoracic muscle, and erector spine plane blocks. In addition, we provide a summary of reported local anesthetic doses used for these blocks and a current state of the literature investigating their efficacy, duration, and comparisons with standard practices. Finally, we hope to stimulate further research with a focus on delineating mechanisms of action of novel emerging blocks, appropriate dosing regimens, and subsequent analysis of their effect on patient outcomes.

Right ventricular failure after left ventricular assist device implantation increases postoperative morbidity and mortality. Whether intraoperative echocardiographic and hemodynamic measurements predict right ventricular failure is unclear. Speckle-tracking-derived tricuspid annulus displacement may provide a useful, effective, and straightforward predictor of severe right ventricular failure in patients having left ventricular device implantation. The aim of this study was to determine if intraoperative tricuspid annulus displacement is a stronger discriminator compared with the global longitudinal strain and modified tricuspid annular plane systolic excursion, the Michigan risk score, and pulmonary artery pulsatility index.Retrospective analysis.A tertiary-care referral center.Patients scheduled for left ventricular assist device implantation from January 2010 to December 2017.None MEASUREMENTS AND MAIN RESULTS: The authors examined 86 patients undergoing left ventricular assist device implantation with adequate intraoperative echocardiographic images. The analyses did not demonstrate an association between tricuspid annulus displacement and severe right ventricular failure (univariate C-statistics0.60 for all 4 echocardiographic measures). The discrimination ability was not significantly better than strain (DeLong test p = 0.44) and modified tricuspid annular plane systolic excursion (p = 0.89). The discrimination ability of tricuspid annulus displacement measurements was not better than the Michigan risk score (p = 0.65) and pulmonary artery pulsatility index (p = 0.73).Intraoperative echocardiographic parameters, including tricuspid annulus displacement, modified tricuspid annular plane systolic excursion, and strain, are poor discriminators of severe right ventricular failure after left ventricular assist device implantation. The preoperative Michigan risk-scoring system and intraoperative pulmonary artery pulsatility index are equally unreliable.

BACKGROUND Patients with obstructive sleep apnea (OSA) experience intermittent hypoxia, hypercarbia, and sympathetic activation during sleep, which increases risk for paroxysmal atrial fibrillation and other cardiac arrhythmias. Whether patients with OSA experience increased episodes of atrial fibrillation after cardiac surgery is unclear. We examined whether patients at increased risk for OSA, assessed by the STOP-BANG (snoring, tired during the day, observed stop breathing during sleep, high blood pressure, body mass index more than 35 kg/m, age more than 50 years, neck circumference more than 40 cm, and male gender) questionnaire, had a higher incidence of new-onset postoperative atrial fibrillation after cardiac surgery. Because both postoperative atrial fibrillation and OSA increase resource utilization, we secondarily examined whether patients at increased OSA risk had longer duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay. METHODS With institutional review board approval, this retrospective observational study evaluated adult patients who underwent elective cardiac surgery requiring cardiopulmonary bypass between 2014 and 2015 with preoperative assessment of OSA risk using the STOP-BANG questionnaire. Patients with a history of atrial fibrillation were excluded. The association between the STOP-BANG score and postoperative atrial fibrillation was examined using a multivariable logistic regression model. Secondarily, we estimated the association between the STOP-BANG score and duration of initial intubation using multivariable linear regression and ICU length of stay using Cox proportional hazards regression. We also descriptively summarized the percentage of patients requiring tracheal reintubation for mechanical ventilation. RESULTS Of 4228 cardiac surgery patients, 1593 met inclusion and exclusion criteria. An increased STOP-BANG score was associated with higher odds of postoperative atrial fibrillation (odds ratio [95% confidence interval {CI}], 1.16 [1.09-1.23] per-point increase in the STOP-BANG score; P < .001). The STOP-BANG score was not associated with ICU length of stay (estimated hazard ratio [97.5% CI], 0.99 [0.96-1.03] per-point increase in the STOP-BANG score; P = .99) or duration of initial intubation (ratio of geometric means [97.5% CI], 1.01 [1.00-1.04]; P = .03; significance criterion [Bonferroni correction] < 0.025). One percent of patients required reintubation. DISCUSSION Increasing risk for OSA, assessed by STOP-BANG, was associated with higher odds of postoperative atrial fibrillation, but not prolonged duration of mechanical ventilation or ICU length of stay.

The goal of this chapter is to provide an overview of both major types of resuscitation fluids: crystalloids and colloids. This includes a discussion of types of crystalloids and indications for the use of specific types of crystalloids. In addition, an overview of commonly used colloids (albumin and hetastarches) and their side effects is included. The concept of early goal-directed fluid therapy and the literature supporting its use is also presented. Finally, the difference between static and dynamic parameters of fluid responsiveness is discussed, including a description of the only available dynamic measure of fluid responsiveness in spontaneously breathing patients: the passive leg raising test. In a nutshell, the chapter reviews choice of fluid resuscitation type, amount of fluid that should be given, and mechanisms to assess adequacy of fluid resuscitation.

The quadratus lumborum (QL) block provides analgesia to the abdominal wall while sparing the side effects of neuraxial blocks. We describe a case series of eight patients treated with a continuous infusion of local anesthetic via bilateral posterior QL catheters infusion block for analgesia after abdominal surgeries. We found that the median duration of the procedure was 26 min and the median opioid consumption over the first postoperative 72 h was 110 mg of morphine equivalents. The bilateral continuous posterior QL block is a feasible analgesic intervention and can be considered as a component of multimodal analgesic pathways.

Given the increasing age of the US population and the accompanying rise in cardiovascular disease, we expect to see an increasing number of patients affected by degenerative mitral valve disease in a more complex patient population. Therefore, increasing the overall rate of mitral valve repair will become even more important than it is today, and the capability to provide a universally and uniformly accepted quality of repair will have important medical, economic, and societal implications. This article will describe preoperative and intraoperative considerations and the currently practiced mitral valve repair approaches and techniques. The aim of the article is to present our contemporary approach to mitral valve repair in the hope that it can be adopted at other institutions that may have low repair rates. Adoption of simple and reproducible mitral valve repair techniques is of paramount importance if we as a profession are to accomplish overall higher rates of mitral valve repair with optimal outcomes.

Mechanical circulatory support devices are the mainstay of treatment for severe cardiogenic shock refractory to pharmacologic therapy. Their evolution over the past few decades has been remarkable with a common theme of developing reliable, less bulky and more easily percutaneously implantable devices. The goal of this article is to review existing devices and advances in technology and provide insight into direction of further research and evolution of mechanical circulatory support devices for temporary support.

Coronary artery disease (CAD) remains a relative contraindication for lung transplantation, but should it be if amenable to effective palliation?From January 2005 to July 2010, 356 adults undergoing primary lung transplantation had no significant (50%) coronary arterial stenosis and 70 had significant (≥50%) CAD requiring prior or concomitant revascularization. Propensity matching on 38 pre-transplant patient characteristics identified 61 well-matched pairs (87% of possible matches) and 295 no-CAD unmatched patients to compare post-operative morbidity, graft function, and time-related pulmonary function and survival.Compared with no-CAD patients, those with CAD intervention were older, more likely to be male, had more comorbidities, and were more likely to have idiopathic pulmonary fibrosis. Among propensity-matched patients, 5 died in-hospital in the CAD intervention group and 6 in the no-CAD group (p = 0.7). Intensive care unit stay (5 vs 7 days), post-operative stay (14 vs 15 days), tracheostomy requirement (12 vs 11 patients), primary graft dysfunction scores (p0.8), and early longitudinal post-transplant pulmonary function (p = 0.2) were similar, as was time-related mortality (20% vs 22% and 51% vs 52% at 1 and 4 years, respectively; p = 0.6). Unmatched no-CAD patients had fewer comorbidities and lower mortality than matched patients (15% and 39% at 1 and 4 years, respectively; p = 0.01).CAD is an important risk factor in lung transplant candidates, but its influence can be minimized in experienced centers by effective palliation. Surprisingly, however, CAD is a marker for an unfavorable patient phenotype with worse than typical post-transplant survival, irrespective of whether CAD is present.