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Every year, two-million hospitalised patients develop healthcare-associated infections with a consequent mortality eclipsing 90,000. The literature suggests that dental infections are one of many potential sources of these infections and may be associated with an increased risk of endocarditis in surgical patients, especially those undergoing cardiac procedures, though some studies have conversely shown no heightened risk of cardiac infections in patients forgoing pre-surgical dental screenings. We sought to elucidate whether patients seen at our preoperative evaluation clinic who obtained pre-surgical dental clearance experienced improved outcomes compared to those who did not receive dental clearance prior to their surgical interventions. The medical records of 196 consecutive patients were reviewed who were seen at the pre-anaesthesia evaluation prior to elective cardiac surgery from July 2017 to February 2018. Of this cohort, 102 patients had pre-surgical dental clearance, while 94 did not have dental clearance. Preoperative demographic and comorbidity data were analysed using independent t-tests. We found no significant differences between these group in terms of post-operation infections (zero instances versus four instances, p > 0.05), length of intensive care unit stay (two days versus two days, p = 0.815), or mortality associated with elective cardiac procedures (zero instances). Further evaluation of preoperative dental clearance and its potential to prevent morbidity (e.g. postoperative infections) is warranted.

Thoracic aortic aneurysms present significant challenges to clinicians, especially due to their complex nature and an evolving understanding of the safest and most effective ways to manage this condition in the perioperative setting. Thoracic aortic aneurysms have a prevalence rate of 1.3–8.9% in men and 1.0–2.2% in women, and they are estimated to affect more than five per 100,000 person-years. This is notable because the complications of thoracic aortic aneurysms can be catastrophic. The current understanding of the optimal intraoperative management of thoracic aortic aneurysms is changing, as more evidence becomes available regarding lung protective ventilation and its role in enhancing patient safety and wellbeing. This review strives to provide a brief historical understanding of thoracic aortic aneurysms and highlight some of the key discoveries and advances in the management of this condition. This review then describes an overview of the general anaesthetic principles associated with thoracic aortic aneurysms, including ventilatory modalities and how these impact a patient’s physiology and intraoperative haemodynamics. A brief discussion on one-lung ventilation is then provided, drawing from current literature in the field, to describe the most up-to-date management of thoracic aortic aneurysms.

Preoperative evaluation of incidentalomas for pheochromocytoma is imperative. This case report describes a scheduled adrenalectomy in an asymptomatic patient with what was eventually determined to be an incomplete biochemical workup. The intraoperative course was complicated by labile and rapid increases in blood pressure and heart rate, suggesting the missed diagnosis of pheochromocytoma. It is important for anesthesiologists to ensure adequate preoperative biochemical workup before excluding the possibility of coexisting pheochromocytoma.

Admission on the day of surgery for elective cardiac and noncardiac surgery is the prevalent practice in North America and Canada. This approach realizes medical, psychological and logistical benefits, and its success is predicated on an effective outpatient preoperative evaluation. The establishment of a highly functional preoperative clinic with a comprehensive set up and efficient logistical pathways is invaluable. This notion in recent years has included the entire perioperative period, and the concept of a perioperative anesthesia/surgical home (PASH) is gaining popularity. The anesthesiologists as perioperative physicians can organize and lead the entire process from the preoperative evaluation, through the hosptial discharge. The functions of the PASH include preoperative optimization of medical conditions and psychological preparation of the patients and their support system; the care in the operating room and intensive care unit; pain management; respiratory therapy; cardiac rehabilitation; and specialized nutrition. Along with oversight of the medical issues, the preoperative visit is an opportune time for counseling, clarification of expectations and discussion of research, as well as for utilization of various informatics systems to consolidate the pertinent information and distribute it to relevant health care providers. We review the scientific foundation and practical applications of a preoperative visit and share our experience with the development of the preoperative evaluation clinic, designed specifically for cardiac and major vascular patients scheduled for day admission surgery. The ultimate goal of preoperative evaluation clinic is to ensure a safe, efficient, and cost-effective perioperative care for patients undergoing a complex type of surgery.

We present a case of a patient with complete tracheal dehiscence and multiple false passages after recent tracheal resection and anastomosis. Loss of tracheal continuity after disruption of anastomosis with distal stump retraction presents a unique anesthetic challenge given lack of access to the trachea and the need for adequate anesthesia and analgesia for surgical neck dissection. Traditional airway management, including awake fiberoptic intubation, intubation via direct laryngoscopy, needle cricothyrotomy, and awake tracheostomy are not viable options. Using total intravenous anesthesia with spontaneous ventilation, surgeons dissected the neck, retrieved the distal tracheal stump, repaired the trachea, and formalized the tracheostomy. We highlight the importance of recognizing the symptoms of a tracheal rupture, understanding the extreme limitation of securing the airway with traditional techniques, and discuss the alternative techniques including use of extracorporeal membrane oxygenation to avoid airway management. Awareness of increased mortality risk with tracheal reoperation and the significance of close communication between the anesthesiologists, the surgeons, and the patient is necessary for successful management.

Marfan syndrome is a multisystem connective tissue disorder, with primary involvement of the cardiovascular, ocular, and skeletal systems. This autosomal heritable disease is mainly attributable to a defect in the FBN1 gene. Clinical diagnosis of Marfan syndrome has been based on the Ghent criteria since 1996. In 2010, these criteria were updated, and the revised guidelines place more emphasis on aortic root dilation, ectopia lentis, and FBN1 mutation testing in the diagnostic assessment of Marfan syndrome. Among its many different clinical manifestations, cardiovascular involvement deserves special consideration, owing to its impact on prognosis. Recent molecular, surgical, and clinical research has yielded profound new insights into the pathological mechanisms that ultimately lead to tissue degradation and weakening of the aortic wall, which has led to exciting new treatment strategies. Furthermore, with the increasing life expectancy of patients with Marfan syndrome, there has been a subtle shift in the spectrum of medical problems. Consequently, this article focuses on recent advances to highlight their potential impact on future concepts of patient care from a clinical, surgical, and anesthetic perspective.

Pemphigus vulgaris is an autoimmune disorder that causes blistering of the skin and mucous membranes. We present a patient with pemphigus vulgaris who required combined coronary artery bypass grafting and mitral valve repair. The challenges that we faced and modifications to the technique required in this situation are described and reviewed.

Advances in the surgical approach to thoracic aortic aneurysm repairs have led to the increasing use of one-lung ventilation. Today’s practice of cardiothoracic and vascular anesthesia requires a clear understanding of the techniques available for lung separation and the technical skills necessary to employ them. In this article, we discuss and evaluate the options for one-lung ventilation in thoracic aortic aneurysm repair with regard to preoperative, intraoperative, and postoperative management.

Cardiac risk stratification before noncardiac surgery remains important. Two major areas have been emphaized, namely, cost-effective risk stratification and enhanced identification of high risk populations. Recent studies have highlighted the lack of quality and affordable medical consultation. The indications for resting preoperative echocardiography merit streamlining, given recent data that failed to demonstrate tangible benefit. Further more, noninvasive cardiac stress testing is expensive and unnecessary in low risk patients. Perioperative troponin determination significantly improves the detection of myocardial infarction, facilitating its early management. The revised cardiac risk index is a standard tool for risk stratification, despite multiple limitations. The first approach has been tore calibrate the traditional risk index to specific high-risk surgical subgroups. The second approach has been to develop new cardiac risk models with more power. Both approaches have yielded risk calculators that out perform the traditional risk model. Furthermore, this latest generation of risk models is available as online calculators that can be accessed at the bedside. Further clinical trials are indicated to test the validity, clinical utility, and cost-effectiveness of these novel risk calculators. It is likely that these powerful instruments will refine the indications for specialized cardiac testing, offering multiple opportunities to reduce perioperative risk and cost simultaneously.

The intra-aortic balloon pump (IABP) enhances myocardial performance by minimizing oxygen supply/demand mismatch [1–6]. Balloon inflation during diastole enhances myocardial oxygen delivery due to increased diastolic coronary perfusion pressure [4–6]. Balloon deflation just prior to systole reduces myocardial oxygen demand by unloading the left ventricle [4–6]. Recent evidence has identified the IABP as a therapeutic modality that may reduce perioperative mortality due to these myocardial benefits [1–3].

We report the case of successful resuscitation after prolonged cardiac arrest during orthotopic liver transplantation. After reperfusion, the patient developed ventricular tachycardia, complicated by intracardiac clot formation and massive hemorrhage. Transesophageal echocardiography demonstrated stunned and nonfunctioning right and left ventricles, with developing intracardiac clots. Treatment with heparin, massive transfusion and prolonged cardiopulmonary resuscitation ensued for 51 minutes. Serial arterial blood gases demonstrated adequate oxygenation and ventilation during cardiopulmonary resuscitation. Cardiothoracic surgery was consulted for potential use of extracorporeal membrane oxygenation, however, the myocardial function improved and the surgery was completed without further intervention. On postoperative day 6, the patient was extubated without neurologic or cardiac impairment. The patient continues to do well 2 years posttransplant, able to perform independent daily activities of living and his previous job. This case underscores the potential for positive outcomes with profoundly prolonged, effective advanced cardiovascular life support in patients who experience postreperfusion syndrome.

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet-based process with a final meeting on 28 June 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic β-blockade, early aspirin therapy, the use of pre-operative intra-aortic balloon counterpulsation, and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic β-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Many patients requiring surgery possess poor oral health. The presence of decayed teeth and periodontitis represent potentially potent causes of odontogenic infection that could significantly compromise the surgical outcome. Geriatric patients presenting for surgery who have not had a dental examination for years may be harboring an undetected oral infection. In the perioperative period, the harmful effects of such an infection are amplified in terms of treatment and expenses. This article will elaborate on the association between oral health and systemic disease, present unique intraoral characteristics of elderly patients, and emphasize the importance of obtaining a dental evaluation and treating any acute oral infection before surgery. Augmenting the awareness of the perioperative dental considerations in the geriatric population can lead to the implementation of effective and preventive measures that can contain costs and achieve optimal patient care.

Objectives Patients with a kidney allograft are at high risk for the development of cardiovascular diseases that may require surgical intervention. Little is known about the outcome of cardiac surgery in these patients. Design A retrospective study. Setting A university hospital (single institution). Participants Twenty-nine patients with a kidney allograft who underwent cardiac surgery between January 1998 and December 2006. Interventions None. Measurements and Main Results Main outcome measures were hospital mortality, postoperative complications, allograft function, and late survival. Twenty-nine patients (mean age, 53 ± 14 years; 18 (62%) male; 22 preserved allograft function, 2 acute failure, and 5 chronic failure) were identified. Hospital mortality was 3.4% (n = 1). Temporary allograft dysfunction determined by a >30% increase of creatinine and blood urea nitrogen was noticed in 5 (23%) patients with preserved allograft and recovered before discharge. Two patients required postoperative dialysis (1 temporary and 1 permanent). Six (21%) other major complications occurred and included respiratory failure (n = 4, 14%) and sepsis (n = 2, 7%). One- and 5-year survival was 89% ± 6% and 50% ± 14%, respectively. Four of 9 patients who died during follow-up had chronic allograft failure. Conclusions Cardiac surgery can be performed safely in kidney transplant recipients with low mortality and acceptable morbidities. Allograft dysfunction is a common finding, but it is transient with early functional recovery. Late survival of kidney recipients with chronic allograft failure undergoing cardiac procedures is limited when compared with that of the general cardiac surgery population. The present data suggest that these patients should be considered for cardiac surgery in reference centers with expertise in complex cardiac procedures and perioperative management of these highly specific patients.

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is “too old” for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.

OBJECTIVES: To investigate early and late outcome of aortic valve replacement (AVR) in a large cohort of patients aged 80 and older. DESIGN: Retrospective study of consecutive patients undergoing AVR using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. SETTING: University hospital (single institution). PARTICIPANTS: One thousand three hundred eight patients undergoing AVR (231 (17.6%) aged ≥80, 1,077 (82.4%)

Objectives: The aim of this study was to investigate early and late outcomes of coronary artery bypass graft (CABG) surgery in a large cohort of octogenarian patients. The results were compared with 2 other age groups including septuagenarians and patients Design: A retrospective study of consecutive patients undergoing CABG surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. Setting: A university hospital (single institution). Participants: Two thousand nine hundred eighty-five patients undergoing CABG surgery including 282 (9.4%) octogenarians, 852 (28.6%) septuagenarians, and 1851 (62%) patients younger than 70 years old. Interventions: None. Measurements and Main Results: Patient characteristics, hospital mortality, morbidity, length of stay, and long-term survival were analyzed. Octogenarians were more likely female and presented significantly more often with comorbidities such as heart failure, an ejection fraction 80 years was not a predictor of hospital mortality. The length of stay was significantly higher in octogenarians compared with nonoctogenarians (16 ± 24 days v 10 ± 13 days, p Conclusions: Excellent results after CABG surgery can be expected in octogenarians, with a minimal increase in postoperative mortality and acceptable postoperative morbidity. Respiratory failure is the main postoperative complication in octogenarians. Recent advances in operative techniques and perioperative management have contributed in improving surgical outcome in these patients compared with historic reports.

A P y PATIENT’S TEETH and intraoral tissues are not an anesthesiologist’s primary concern before a cardiothoracic rocedure. However, the potentially deleterious effects of an ntreated oral infection can have wide-reaching implications.1,2 ecognizing this hazard preoperatively is paramount in order to aximize the overall benefit of the procedure.3-5 This review laborates on the association between oral health and cardioascular disease (CVD) by presenting the rationale for optiizing dentition before cardiac surgery, and reviews the unerstated role that an anesthesiologist may play in this scenario. The patient’s airway has long been the principal focus for the nesthesiologist. Appropriately, an evaluation of the various redictors of a potentially difficult endotracheal intubation ocurs during the preoperative patient assessment. This assessent usually includes a very cursory examination of the paient’s dentition or lack thereof. Such an examination is often irected toward the presence of any loose or chipped teeth, any xed or removable prosthetic dental appliances, and the meaurement of the width in finger breadths with respect to a atient’s maximal interincisal distance. Determining the suseptibility of any loose teeth and taking appropriate precautions o avoid dental damage in the perioperative period are necesary, yet are not necessarily enough. Preoperatively, the aneshesiologist’s attention should extend beyond noting which eeth are vulnerable to a traumatic intubation and include a ore thorough evaluation of the overall condition of the paient’s dentition.

Admission on the day of surgery for elective cardiac and non-cardiac surgery has been established as a prevalent, critical practice. This approach realizes medical, logistical, psychological and fiscal benefits, and its success is predicated on an effective outpatient pre-operative evaluation. The establishment of a highly functional pre-operative clinic with a comprehensive set-up and efficient logistical pathways is invaluable. This notion has been expanded in recent years to include the entire peri-operative period and the concept of a 'peri-operative anesthesia/surgical home' is gaining popularity and support. Evaluating patients prior to admission for surgery, anesthesiologists can place themselves at the forefront of reducing unnecessary pre-operative hospital admissions, excess lab tests, unneeded consultations, and ultimately decrease the cancellations on the day of surgery. Furthermore, by taking a leadership role in the pre-operative clinic, anesthesiologists place themselves squarely at the forefront of the burgeoning movement for the peri-operative surgical home and continue to cement the indispensability of the anesthesiologist during the entire peri-operative course. The authors present this review as a follow-up describing the successful implementation of a pre-operative same-day cardiac surgery clinic and offer these experiences over the last 8 years as a guide to helping other anesthesiologists do the same.

BOLA VIRUS DISEASE (EVD), caused by infection with the filovirus Zaire ebolavirus, has a wide range of cardiovascular and pulmonary effects. The disease was first observed in 1976 in the Ebola River valley in what is now the Democratic Republic of the Congo, Africa. 1 Since then, Zaire ebolavirus has caused a number of outbreaks over the past 3 decades 2 (Table 1) and has culminated in the current largest outbreak, which has spanned a number of West African countries and spread throughout the world (Table 2). 3

The anesthetic approach to the patient with a thoracic aortic aneurysm depends on the urgency of repair. Symptomatic patients with leaking aneurysms require urgent intervention, and there is generally little time to perform more than the most basic preoperative assessment. For elective repair, however, one must consider nearly every organ system. Many of the specific issues are inherent to the underlying pathophysiology that has resulted in aneurysm formation, and some stem from the requirements of the surgical procedure itself. A thorough knowledge of the extent and location of the aneurysm, the functional status of the heart, and the coronary artery anatomy are critical. Most patients aged older than 40 years undergo coronary angiography preoperatively, as do younger patients with specific risk factors for myocardial ischemia. Respiratory failure is one of the most common sequelae of these procedures, and a thorough preoperative pulmonary work-up is mandatory. Neurologic deficits are not uncommon postoperatively, and pre-existing deficits in the central nervous system must be sought. Coagulopathy is common in the immediate postoperative period, and preoperative assurance of hemo-static competence is important. Computed tomography scans and magnetic resonance imaging are the mainstay of diagnosis, although the adjunctive use of echocardiography provides important information. Routine preoperative laboratory studies include complete blood count, chemistries, coagulation profile, and indices of renal function; an electrocardiogram, and chest radiograph. Close communication with the surgeon regarding the operative procedure, cannulation strategy (where applicable), and planned evoked potential monitoring is necessary to ensure appropriate perioperative management. Prophylactic antibiotics and antifibrinolytics are routine.

Recent international consensus has identified intra-aortic balloon counterpulsation (IABP) as a therapeutic modality that may reduce perioperative mortality [Landoni et al. (Acta Anesthesiol Scand 55:259-66, 2011), Landoni et al. (J Cardiothorac Vasc Anesth 26:764-72, 2012)]. The therapeutic benefit of IABP stems from its improvement of left ventricular performance by minimizing oxygen supply/demand mismatch [Peura et al. (Circulation 126:2648-67, 2012)]. Balloon inflation during diastole enhances coronary perfusion pressure to boost myocardial oxygen delivery. Balloon deflation just prior to systole reduces myocardial oxygen demand by unloading the left ventricle.

This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs that require a precise prescription with respect to type, dose, and duration. The final theme is patient safety in the cardiac perioperative environment. A recent expert scientific statement has focused attention on this issue because most perioperative errors are preventable. It is likely that clinical research in this area will blossom because this is a major opportunity for improvement in our specialty. The patient care processes identified in these research highlights will further improve perioperative outcomes for our patients.

Preoperative platelet-rich plasmapheresis has been suggested as a means of reducing homologous blood transfusions in cardiac surgical patients. The current study evaluated this technique in patients undergoing repeat cardiac operations. Fifty-two patients undergoing repeat myocardial revascularization and/or valve replacement were evaluated in a prospective randomized controlled study design. Autologous platelet-rich plasma (PRP) was harvested after the induction of anesthesia in the experimental group. After reversal of heparin, each patient received his or her autologous plasma. Patients in the control group did not have plasmapheresis and received standard transfusion therapy if coagulation variables were abnormal and a coagulopathy was clinically evident. Routine coagulation tests, thromboelastography (TEG), perioperative bleeding, and transfusion requirements were compared in the two groups. Forty-four patients completed the study. A significantly larger volume of packed red blood cells (PRBCs) was transfused in the PRP group than in the control group (P = 0.03). Platelet and fresh frozen plasma (FFP) transfusions did not differ between the two groups. Mediastinal tube drainage did not differ between the two groups. During PRP infusion, 60% of the patients required treatment for moderate hypotension (mean arterial pressure [MAP] < 60 mm Hg). Only 16% of control patients required treatment for hypotension during the comparable time period (P < 0.05). No patient who completed the study returned to the operating room for postoperative bleeding. These data suggest that PRP did not reduce postbypass bleeding or transfusion requirements in repeat cardiac surgical patients. Moreover, the incidence of hypotension during PRP reinfusion introduces a potential risk to the procedure in the absence of any obvious benefit.

Carcinoid tumors are neuroendocrine tumors with a very unpredictable clinical behavior. In the setting of hepatic metastases, the tumor’s release of bioactive substances into the systemic circulation results in carcinoid syndrome: a constellation of symptoms among which cutaneous flushing, gastrointestinal hypermotility, and cardiac involvement are the most prominent. Cardiac manifestations, also known as carcinoid heart disease, are secondary to a severe fibrotic reaction which frequently involves the right-sided valves and may extend towards the subvalvular apparatus leading to valve thickening and retraction. Left-sided involvement is rare and mostly observed in the presence of an interatrial shunt, endobronchial tumor localization, and high tumor activity. Echocardiographic techniques often reveal noncoaptation of the valves, which are fixed in a semiopen position. In patients with advanced lesions and severe valvular dysfunction, surgery is currently the only definitive treatment to potentially improve quality of life and provide survival benefit. Although cardiac surgery has been traditionally reserved for those patients with symptomatic right ventricular failure, a significant trend towards improved surgical outcomes has triggered a more liberal referral for valve replacement. Carcinoid heart disease poses two distinct challenges for the anesthesiologist: carcinoid crisis and low cardiac output syndrome secondary to right ventricular failure. Carcinoid crisis, characterized by flushing, hypotension, and bronchospasm, may be precipitated by catecholamines and histamine releasing drugs used routinely in patients undergoing valve surgery. Although a broader utilization of octreotide have significantly simplified the anesthetic and perioperative management of these patients, a very balanced anesthetic technique is required to identify and manage low cardiac output syndrome.

REOPERATIVE CORONARY ARTERY bypass grafting (CABG) has decreased significantly in the previous 20 ears, likely because of the increased availability of percutaeous coronary intervention (PCI).1 Reoperative surgery using he classic trans-sternal approach is more technically challengng than primary surgery and is associated with an increased isk of major complications and death.2,3 There is an increased isk of injury to patent bypass grafts, the great vessels, and right entricle during sternal re-entry. Manipulation of the aorta or iseased bypass grafts can precipitate embolization and cause troke or myocardial infarction.2,4,5 Reoperative sternotomy also is associated with prolonged cardiopulmonary bypass (CPB) time, an increased risk of sternal wound infections, and postoperative mediastinitis.2,5 Patients undergoing reoperative sternotomy often have regional ischemia with patent grafts or native vessels to other territories. Although sternotomy provides the best exposure for global access to the myocardium, when only regional access is required, limited-access nonsternotomy approaches are an attractive option. Collectively, these are known as minimally invasive direct CABG (MIDCAB). In addition to the standard monitoring, there are specific anesthetic considerations for nonsternotomy approaches in reoperative coronary surgery. These include the possible use of lung separation techniques and the need for external defibrillator pads. In addition, it is imperative to be prepared for catastrophic events and longer surgical times. An avoidance of CPB affords the benefit of avoiding the coagulopathic derangements that occur on CPB, including platelet, fibrinogen, and coagulation factor dysfunction and dilution. Another common coagulopathic consequence of CPB is fibrinolysis. During off-pump CABG, the use of fibrinolytics usually is not needed. The authors present 3 patients who underwent nonsternotomy approaches to CABG. The surgical approach for each patient was chosen based on vessel involvement.

In a complicated and specialized population, such as patients undergoing cardiac and major vascular procedures, patients, clinicians, and hospitals may be best served and resources conserved with a specialized preanesthesia clinic. A specialized preanesthesia clinic for cardiac and major vascular procedures has a focused staff usually consisting of practitioners with cardiac and major vascular surgical care experience designed to address the patient evaluation, the information gathering, the necessary consultations, the required testing, and specific needs for the day of cardiac and major vascular surgery. Specialized preanesthesia clinics increase patient satisfaction and may also provide cost containment by decreasing the amount of indiscriminate ordering of expensive preoperative tests and potentially may decrease patient litigation. Resident trainee education can also be enhanced by a specialized preanesthesia clinic for cardiac and major vascular rotations. The ultimate goal of a specialized preanesthesia clinic is to ensure a safe and efficient perioperative cardiac and major vascular surgical experience in complicated patients undergoing complex procedures.

Worldwide, nearly 4 million patients currently have cardiac implantable electronic devices. Due to the increasing number of candidates to receive either pacemakers or implantable cardiac defibrillators, there is no doubt that primary care physicians or anesthesiologists are very likely to interact and deal with this particular patient population. However, besides technologic advancements, several factors have been frequently reported to cause confusion regarding their perioperative care. Therefore, it has become extremely valuable to understand the basic functions and operation of these devices, as well as their functional limitations, to prevent iatrogenic complications and detect potential failure in an early stage. Mt Sinai J Med 79:25–33, 2012.© 2012 Mount Sinai School of Medicine

In the primary care setting, use of the BATHE (Background, Affect, Trouble, Handling, and Empathy) method of interviewing has been shown to increase patient satisfaction. This technique is a brief psychotherapeutic method used to address patients' physical and psychosocial problems. The BATHE technique has not been evaluated in the perioperative setting as a way of improving patient satisfaction. In this study, we sought to determine whether satisfaction could be enhanced by use of the BATHE technique during the preoperative evaluation by anesthesiologists.Fifty cardiac and 50 general surgery patients were interviewed in the preanesthesia clinic (PAC) of an academic hospital. They were randomly enrolled in the BATHE group or the control group and asked to complete an anonymous satisfaction survey after their visit. This survey was modified from current studies and not validated elsewhere. The relative influence of the BATHE condition was examined as it pertained to interview duration, patient satisfaction, and patient report of the BATHE items being asked.Ninety-two percent of patients approached by the study group voluntarily enrolled. Patients interviewed using the BATHE method reported being asked about all BATHE questions significantly more often than control patients: t(98)=19.10, P=0.001 (95% confidence interval [CI]=2.59, 3.20). Patients in the BATHE group were more satisfied with their visit to the PAC than those in the control group: t(98)=5.37, P=0.001 (95% CI=0.19, 0.41). The use of the BATHE method did not significantly increase the amount of time physicians spent evaluating patients: t(98)=0.110, P=0.912 (95% CI=-1.519, 1.359).Use of the BATHE method in an academic medical center's cardiac and general PAC showed promising results in this preliminary study. A validated and fully developed survey instrument is needed before we can convincingly conclude that the BATHE method is an effective way of improving patient satisfaction.

Surgical repair of thoraco-abdominal aortic aneurysms is a technically demanding procedure which often mandates the participation of very experienced anesthetists, surgeons, and intensivists. Its complexity resides not only in challenging surgical aspects such as the need for interrupting the natural cerebral perfusion, but also in the requirement for meticulous monitoring strategies during the perioperative period. In order to coordinate and establish an advanced aortic program, Randall B. Griepp joined Mount Sinai in 1985. His incorporation to the hospital brought the subsequent introduction of several institutional changes, including the use of deep hypothermic circulatory arrest and selective antegrade cerebral perfusion, the application of neuroprotection methods, the creation of an aortic surveillance program, and the establishment of an aortic clinic with a focus on personalized anesthetic treatment for each patient. Additionally, Griepp built a productive animal research laboratory to develop new strategies for spinal cord protection. In this chapter, we aim to detail our tailored anesthetic approach to patients undergoing thoracoabdominal aortic aneurysm repair, based on our 25-year clinical and research experience.

Thirty-Sixth Annual Meeting & Workshops Society of Cardiovascular Anesthesiologists. New Orleans, LA. March 27-April 3, 2014. Contact: e-mail: www.scahq.org61st. Aortic Symposium 2014. New York, NY. April 24-25, 2014. Contact: e-mail: aortic@aats.org. Fifth World Anesthesia Convention. Vienna, Austria. April 30-May 3, 2014. Contact: www.nwac.org. IARS 2014 Annual Meeting. Montreal, Quebec, Canada. May 17-20, 2014. Contact: www.iars.org/2014Meeting. Twenty-First Annual Congress Slovak Society of Anesthesiology and Critical Care. Piestany, Slovak Republic. May 21-23, 2014. Contact: www.ssaim.sk. Annual Meeting Association of University Anesthesiologists. Stanford, CA. April 24-26, 2014. Contact: www.auahq.org. Innovation, Technologies and Techniques in Cardiothoracic and Cardiovascular/Vascular Surgery. Annual Scientific Meeting. Boston, MA. May 28-31, 2014. Contact: www.ISMICS.org. Twenty-Second European Conference on General Thoracic Surgery. Copenhagen, Denmark. June 15-18, 2014. Contact: e-mail: sue@ests.org.uk. European Pediatric Surgeons Association. Dublin, Ireland. June 18-21, 2014. Contact: e-mail: eupsa2014@mci-group.com. ASAIO Sixtieth Annual Conference. Washington, DC. June 18-21, 2014. Contact: e-mail: infp@asaio.com. AATS Cardiovascular Valve Symposium. Istanbul, Turkey. September 4-6, 2014. Contact: www.aats.org@valveistanbul. Twenty-Ninth Joint EACTA-ICCVA Meeting. Florence, Italy. September 17-19, 2014. Contact: www.eacta.org, e-mail: fabiodoc64@hotmail.com. Twenty-First Congress Czech Society of Anesthesiology and Critical Care. Olomouc, Czech Republic. October 2-4, 2014. Contact: www.csarim2014.cz, e-mail: csarim2014@guarant.cz. ASA Annual Meeting. New Orleans, LA. October 11-15, 2014. Contact: www.asahq.org. Twenty-Eighth EACTS Annual Meeting. Milan, Italy. October 11-15, 2014. Contact: e-mail: louise.mcleod@eacts.co.uk. Ninety-First Annual Scientific Meeting of the Korean Society of Anesthesiology. Seoul, Korea. Contact: www.ksa-conference.org. Sixth International Congress: Aortic Surgery and Anesthesia “How to Do It.” Milano, Italy. December 11-13, 2014. Contact: www. aorticsurgery.it. Sixty-Eighth Postgraduate Assembly, New York State of Anesthesiologists. New York, NY. December 12-16, 2014. Contact: www. nyssa-pga.org. Thirty-Third Annual Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine. St. Kitts, West Indies. January 18-23, 2015. Contact: www.clinicalupdateinanesthesiology.org, e-mail: george.silvay@mountsinai.org. Thirty-Fifth Annual Cardiothoracic Surgery Symposium CREF 2015. San Diego, CA. February 11-15, 2015. Contact: www. crefmeeting.com. Thirty-Fifth International Symposium on Intensive Care and Emergency Medicine. Brussels, Belgium. March 17-20, 2015. Contact: e-mail: Veronique.de.vlaeminck@ulb.ac.be. Sixty-Second Annual Meeting Association of University Anesthesiologists. Nashville, TN. April 30-May 2, 2015. Contact: www. AUAhq.org. European Society of Anesthesiologists. Berlin, Germany. May 28-June 2, 2015. Contact: e-mail: info@esahq.org.

Ninety-first Annual Scientific Meeting of the Korean Society of Anesthesiologists. Seoul, Korea. November 6-8, 2014. Contact: www.ksa-conference.org Annual Scientific Meeting Australian and New Zealand College of Perfusionists. Auckland, New Zealand. November 6-8, 2014. Contact: Taryn@adhb.govt.nz Sixth International Congress: Aortic Surgery and Anesthesia “How to Do It.” Milano, Italy. December 11-13, 2014. Contact: www. aorticsurgery.it Sixty-eighth Postgraduate Assembly. New York State Association of Anesthesiologists. New York, New York. December 12-16, 2014. Contact: www.nyssa-pga.org Thirty-third Annual Symposium: Clinical Update in Anesthesiology, Surgery, and Perioperative Medicine. St. Kitts, West Indies. January 18-23, 2015. E-mail: george.silvay@mountsinai.org. Contact: www.clinicalupdateinanesthesiology.org Thirty-fifth Annual Cardiothoracic Surgery Symposium CREF. San Diego, California. February 11-15, 2015. Contact: www. crefmeeting.com Thirtieth International Symposium Interventional Cardiology. Snowmass, Colorado. March 1-6, 2015. Info: rlaw@promedicacme. com Thirty-fifth International Symposium on Intensive Care and Emergency Medicine. Brussels, Belgium. March 17-20, 2015. Contact: www.intensive.org International Anesthesia Research Society (IARS). Honolulu, Hawaii. March 21-24, 2015. Info: www.iars.org/2015meeting The Eighth International Symposium: Diabetes, Hypertension, Metabolic Syndrome. Berlin, Germany. April 15-18, 2015. Info: www.comtecmed.com/DIP Sixty-second Annual Meeting. Association of University Anesthesiologists. Nashville, Tennessee. April 30-May 2, 2015. Contact: www.AUAhq.org European Society of Anesthesiologists. Berlin, Germany. May 28-June 2, 2015. Contact e-mail: info@esahq.org Third International Symposium: Perioperative Care for Seniors. Prague, Czech Republic. June 4-6, 2015. Contact: www. anesthesiaforseniors2015.cz EACTA Annual Meeting. Gothenburg, Sweden. June 11-12, 2015. Contact: anne.westerlind@medfak.se Canadian Association of Thoracic Surgeons. Montreal, Quebec, Canada. September 17-20, 2015. Info: cats@canadianthoracic surgeons.ca ASA Annual Meeting. San Diego, California. October 24-28, 2015. Contact: www.asahq.org Eighth Postgraduate Course—Surgery of the Thoracic Aorta. Bologna, Italy. November 9-10, 2015. Contact: www.noemacongressi.it Sixty-ninth Postgraduate Assembly. New York State Association of Anesthesiologists. New York, New York. December 11-15, 2015. Contact: www.nyssa-pga.org Thirty-fourth Annual Symposium: Clinical Update in Anesthesiology, Surgery, and Perioperative Medicine. San Juan, Puerto Rico. January 16-23, 2016. Contact: George.silvay@mountsinai.org Thirty-sixth International Symposium on Intensive Care and Emergency Medicine. Brussels, Belgium. March 22-25, 2016. Contact: www.intensive.org

Many patients requiring surgery possess poor oral health. The presence of decayed teeth and periodontitis represent potentially potent causes of odontogenic infection that could significantly compromise the surgical outcome. Geriatric patients presenting for surgery who have not had a dental examination for years may be harboring an undetected oral infection. In the perioperative period, the harmful effects of such an infection are amplified in terms of treatment and expenses. This article will elaborate on the association between oral health and systemic disease, present unique intraoral characteristics of elderly patients, and emphasize the importance of obtaining a dental evaluation and treating any acute oral infection before surgery. Augmenting the awareness of the perioperative dental considerations in the geriatric population can lead to the implementation of effective and preventive measures that can contain costs and achieve optimal patient care.