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Background: The coronavirus-2019 (COVID-19) pandemic highlighted the unfortunate reality that many hospitals have insufficient intensive care unit (ICU) capacity to meet massive, unanticipated increases in demand. To drastically increase ICU capacity, NewYork-Presbyterian/Weill Cornell Medical Center modified its existing operating rooms and post-anaesthesia care units during the initial expansion phase to accommodate the surge of critically ill patients., Methods: This retrospective chart review examined patient care in non-standard Expansion ICUs as compared to standard ICUs. We compared clinical data between the two settings to determine whether the expeditious development and deployment of critical care resources during an evolving medical crisis could provide appropriate care., Results: Sixty-six patients were admitted to Expansion ICUs from March 1 st to April 30 th , 2020 and 343 were admitted to standard ICUs. Most patients were male (70%), White (30%), 45-64 years old (35%), non-smokers (73%), had hypertension (58%), and were hospitalized for a median of 40 days. For patients that died, there was no difference in treatment management, but the Expansion cohort had a higher median ICU length of stay (q = 0.037) and ventilatory length (q = 0.015). The cohorts had similar rates of discharge to home, but the Expansion ICU cohort had higher rates of discharge to a rehabilitation facility and overall lower mortality., Conclusions: We found no significantly worse outcomes for the Expansion ICU cohort compared to the standard ICU cohort at our institution during the COVID-19 pandemic, which demonstrates the feasibility of providing safe and effective care for patients in an Expansion ICU., (© 2022. The Author(s).)

Objective: In this study of women in cardiothoracic anesthesiology, the authors aimed to characterize demographics, roles in leadership, and perceived professional challenges., Design: A prospective cross-sectional survey of female cardiothoracic anesthesiologists in the United States., Setting: An internet-based survey of 43 questions was sent to women in cardiothoracic anesthesiology. The survey included questions on demographics, leadership, and perceptions of professional challenges including career advancement, compensation, promotion, harassment, and intimidation., Participants: A database of women in cardiothoracic anesthesiology was created via personal contacts and snowball sampling., Interventions: None., Measurements and Main Results: A total of 153 responses were analyzed, for a response rate of 65.1%. Most respondents were at the Clinical Instructor or Assistant Professor rank. Many women perceived that compensation, promotion, authorship, and career advancement were affected by gender. Furthermore, 67% of respondents identified having children as having a negative impact on career advancement. Many women reported experiencing derogatory comments (55.6%), intimidation (57.8%), microaggression (69.6%), sexual harassment (25.2%), verbal harassment (45.2%), and unwanted physical or sexual advances (24.4%). These behaviors were most often from a surgical attending, anesthesia attending, or patient., Conclusion: This survey study of women in cardiothoracic anesthesiology found that many women perceived inequities in financial compensation, authorship opportunities, and promotion; in addition, many felt that their career advancement was impacted negatively by having children. A striking finding was that the majority of women have experienced intimidation, derogatory comments, and microaggressions in the workplace., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Mechanical life support therapies exist in many forms to temporarily replace the function of vital organs. Generally speaking, these tools are supportive therapy to allow for organ recovery but, at times, require transition to long-term mechanical support. This review will examine nonrenal extracorporeal life support for cardiac and pulmonary support as well as other mechanical circulatory support options. This is intended as a general primer and overview to assist nephrologist consultants participating in the care of these critically ill patients who often experience acute renal injury as a result of cardiopulmonary shock and from their exposure to mechanical circulatory support., (Copyright © 2022 by the American Society of Nephrology.)

As New York State quickly became the epicenter of the COVID-19 pandemic, innovative strategies to provide care for the COVID-19 negative patients with urgent or immediately life threatening cardiovascular conditions became imperative. To date, there has not been a focused analysis of patients undergoing cardiothoracic surgery in the United States during the COVID-19 pandemic. Therefore, we seek to summarize the selection, screening, exposure/conversion, and recovery of patients undergoing cardiac surgery during the peak of the COVID-19 pandemic. We retrospectively reviewed a prospectively maintained institutional database for patients undergoing urgent or emergency cardiac surgery from March 16, 2020 to May 15, 2020, encompassing the peak of the COVID-19 pandemic. All patients were operated on in a single institution in New York City. Preoperative demographics, imaging studies, intraoperative findings, and postoperative outcomes were reviewed. Between March 16, 2020 and May 15, 2020, a total of 54 adult patients underwent cardiac surgery. Five patients required reoperative sternotomy and cardiopulmonary bypass was utilized in 81% of cases. Median age was 64.3 (56.0; 75.3) years. Two patients converted to COVID-19 positive during the admission. There was one operative mortality (1.9%) associated with an acute perioperative COVID-19 infection. Median length of hospital stay was 5 days (4.0; 8.0) and 46 patients were discharged to home. There was 100% postoperative follow up and no patient had COVID-19 conversion following discharge. The delivery of cardiac surgical care was safely maintained in the midst of a global pandemic. The outcomes demonstrated herein suggest that with proper infection control, isolation, and patient selection, results similar to those observed in non-COVID series can be replicated., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and Aim: First reported in December of 2019, the COVID-19 pandemic caused by SARS-CoV-2 has had a profound impact on the implementation of care. Here, we describe our institutional experience with a rapid influx of patients at the epicenter of the pandemic., Methods: We retrospectively review our experience with the departments of cardiology, cardiothoracic surgery, anesthesia, and critical care medicine and summarize protocols developed in the midst of the pandemic., Results: The rapid influx of patients requiring an intensive level of care required a complete restructuring of units, including the establishment of a new COVID-19 negative unit for the care of patients requiring urgent or emergent non-COVID-19 related care including open-heart surgery. This unique unit allowed for the delivery of safe and effective care in the epicenter of the pandemic., Conclusions: Here, we demonstrate the response of a large tertiary academic medical center to the COVID-19 pandemic. Specifically, we demonstrate how rapid structural changes can allow for the continued delivery of cardiac surgical care with similar outcomes as those reported before the pandemic., (© 2020 Wiley Periodicals LLC.)

Objective: To examine sex differences in inpatient mortality and 30-day and 90-day readmissions after coronary artery bypass grafting (CABG) among a multistate population., Design: A retrospective analysis of patient hospitalization and discharge records., Setting: All-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California., Participants: A total of 304,080 patients from the State Inpatient Databases Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality from January 2007 to December 2014 who underwent CABG surgery., Interventions: Bivariate analysis and multivariate logistic regression were performed to obtain unadjusted rates and adjusted odds ratios, respectively, for in-hospital mortality and readmissions by sex., Measurements and Main Results: Of the patients who underwent CABG, 5,699 patients (1.87%) died, including 2,131 women (2.65%) and 3,568 men (1.60%). The authors found that women were 32% more likely to die compared with men (adjusted odds ratio [aOR]: 1.32, 95% confidence interval [CI]: 1.25-1.40) after adjusting for age, race, insurance status, median income, Elixhauser comorbidity index measures, year of procedure, state, and hospital surgical volume. Women, compared with men, also had significantly increased adjusted odds of 30-day and 90-day readmissions (30-day aOR: 1.24, 95% CI: 1.21-1.28; 90-day aOR: 1.25, 95% CI: 1.22-1.28)., Conclusion: This study demonstrated that female patients who undergo CABG are at a greater risk of in-hospital death and 30-day and 90-day readmission compared with men. This sex-based disparity in outcomes has persisted since identification some 40 years ago., Competing Interests: Conflict of Interest The authors report no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest.

Venoarterial extracorporeal membrane oxygenation (ECMO) is a well-established technique to rescue patients experiencing cardiogenic shock. As a form of temporary mechanical circulatory support, venoarterial ECMO can be life-saving, but it is resource intensive and associated with substantial morbidity and mortality. Optimal clinical outcomes require specific expertise in the principles and nuances of ECMO physiology and management. Key considerations discussed in this review include hemodynamic assessment and goals; pharmacologic anticoagulation; ECMO weaning strategies; and the prevention, evaluation, and treatment of common complications., (Copyright © 2020. Published by Elsevier Inc.)

In response to the estimated potential impact of coronavirus disease (COVID-19) on New York City hospitals, our institution prepared for an influx of critically ill patients. Multiple areas of surge planning progressed, simultaneously focused on infection control, clinical operational challenges, ICU surge capacity, staffing, ethics, and maintenance of staff wellness. The protocols developed focused on clinical decisions regarding intubation, the use of high-flow oxygen, engagement with infectious disease consultants, and cardiac arrest. Mechanisms to increase bed capacity and increase efficiency in ICUs by outsourcing procedures were implemented. Novel uses of technology to minimize staff exposure to COVID-19 as well as to facilitate family engagement and end-of-life discussions were encouraged. Education and communication remained key in our attempts to standardize care, stay apprised on emerging data, and review seminal literature on respiratory failure. Challenges were encountered and overcome through interdisciplinary collaboration and iterative surge planning as ICU admissions rose. Support was provided for both clinical and nonclinical staff affected by the profound impact COVID-19 had on our city. We describe in granular detail the procedures and processes that were developed during a 1-month period while surge planning was ongoing and the need for ICU capacity rose exponentially. The approaches described here provide a potential roadmap for centers that must rapidly adapt to the tremendous challenge posed by this and potential future pandemics.

This annual article summarizes key findings from notable studies published in 2019 relevant to the practice of cardiothoracic critical care medicine. This year's article encompasses updates to the literature on enhanced recovery after cardiac surgery, extracorporeal membranous oxygenation, delirium, and primary graft dysfunction after heart transplant.

The application and evolution of total endoscopic robotic cardiac surgery (TERCS) has become greater as institutions and surgeons become more comfortable with robotic technology. Over the years many improvements have been made to facilitate technically challenging cardiac procedures using robotics and increase overall survival and quality of life for these patients. However, a dedicated multidisciplinary approach led by a core group of clinicians is necessary for good patient experience and outcomes. In addition, good communication and performance improvement measures with attention to detailed perioperative management are essential to a successful robotic cardiac program., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The primary objective of this study was to identify the specific predictors of early and late stroke in patients after open heart surgery. Secondary outcomes included (a) risk factors for perioperative stroke, (b) anatomic location of stroke according to time of presentation, and (c) the impact of stroke on operative mortality., Methods: Adult patients undergoing open cardiac surgery with cardiopulmonary bypass from 2006 to 2016 at the New York Presbyterian Hospital/Weill Cornell Medicine were retrospectively reviewed. In total 7957 patients were included. We compared the demographic and perioperative variables in three groups: no stroke, early stroke, and late stroke using regression analysis., Results: The incidence of perioperative stroke for the entire study period was 1.5% (117 of 7957). Early stroke occurred in 84 (71.8%) patients, whereas late stroke occurred in 33 (28.2%). Early strokes were usually embolic events (64 of 66, 97.0%, P = .66) on the right side (30 of 66, 45.5%, P < .001), in the anterior circulation (38 of 66, 57.6%, P = .001), or in multiple distributions (28 of 66, 42.4%, P = .002). Late strokes were more likely left-sided (16 of 28, 57.1%, P < .001) and uncommonly in both the anterior and posterior hemispheres (1 of 28, 3.6%, P = .001). Stroke, regardless of timing, was a significant predictor of operative mortality (odds ratio, 11.0, confidence interval, 6.1-19.7, P < .001)., Conclusions: Early and late strokes after cardiac surgery have distinct incidence, location, and likely etiology. Both early and late strokes portend a very high incidence of operative mortality., (© 2019 Wiley Periodicals, Inc.)

In this article, we present the annual review of the literature relevant for the practice of cardiovascular critical care.

Patients undergoing cardiovascular surgery may be exposed to heparin before surgery, during cardiopulmonary bypass (CPB), or in the immediate postoperative period. For this reason, cardiovascular surgery patients are at increased risk for heparin-induced thrombocytopenia (HIT), occurring in 1 to 3% of patients. The diagnosis of HIT can be difficult, if based solely on the development of thrombocytopenia, because cardiac surgical patients have multiple reasons to be thrombocytopenic. Several clinical scoring systems have been developed to reduce unnecessary testing and better define the pretest probability of HIT, which we will review in detail with a diagnostic algorithm. In addition, we will cover the prevention and treatment HIT., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Vasoplegic syndrome, characterized by low systemic vascular resistance and hypotension in the presence of normal or supranormal cardiac function, is a frequent complication of cardiovascular surgery. It is associated with a diffuse systemic inflammatory response and is mediated largely through cellular hyperpolarization, high levels of inducible nitric oxide, and a relative vasopressin deficiency. Cardiopulmonary bypass is a particularly strong precipitant of the vasoplegic syndrome, largely due to its association with nitric oxide production and severe vasopressin deficiency. Postoperative vasoplegic shock generally is managed with vasopressors, of which catecholamines are the traditional agents of choice. Norepinephrine is considered to be the first-line agent and may have a mortality benefit over other drugs. Recent investigations support the use of noncatecholamine vasopressors, vasopressin in particular, to restore vascular tone. Alternative agents, including methylene blue, hydroxocobalamin, corticosteroids, and angiotensin II, also are capable of restoring vascular tone and improving vasoplegia, but their effect on patient outcomes is unclear., (Copyright © 2017 Elsevier Inc. All rights reserved.)

In 2017, many high-impact articles appeared in the literature. This is the third edition of an annual review of articles related to postoperative cardiac critical care that may affect the cardiac anesthesiologist. This year explores vasopressor and inotropic support, timing of renal replacement therapy, management of postoperative respiratory insufficiency, and targeted temperature therapy.

Background: Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery. POAF is associated with increased morbidity and hospital costs. We herein describe the protocol for a randomized controlled trial to determine if performing a posterior left pericardiotomy prevents POAF after cardiac surgery., Methods/design: All patients submitted to cardiac surgery at our institution will be screened for inclusion into the study. The study will consist of two parallel arms with random allocation between groups to either receive a posterior left pericardiotomy or serve as a control. Masking will be done in a single-blinded fashion to the patient. Patients will be continuously monitored postoperatively for the occurrence of atrial fibrillation until discharge. At the follow-up clinic visit (15-30 days after surgery), the primary endpoint (atrial fibrillation) and other secondary endpoints, such as pleural or pericardial effusion, will be assessed. A total sample size of 350 subjects will be recruited., Discussion: POAF is associated with increased morbidity, prolonged hospital stay, and increased costs after cardiac surgery. Several strategies aimed at reducing the incidence of POAF have been investigated, including beta-blockers, amiodarone, and statins, all with suboptimal results. Posterior left pericardiotomy has been associated with a reduction of POAF in previous series. However, these studies had limited sample sizes and suboptimal methodology, so that the efficacy of posterior pericardiotomy in preventing POAF remains to be definitively proven. Our randomized trial aims to determine the effect of a posterior left pericardiotomy on the incidence of POAF., Trial Registration: ClinicalTrials.gov, ID: NCT02875405 , protocol record 1502015867. Registered on July 2016.

Objective: Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians' attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus., Design, Setting, Participants: A survey of resident/fellow physicians and internal medicine attendings at an academic medical center, May to August 2013., Measurements: We used a 24-item, internet-based survey assessing physician-respondents' demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected., Main Results: A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/fellows. Only 32 percent of the respondents indicated that a surrogate's consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate's objection. Those who self-reported as "knowledgeable" about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VA-ECMO over a surrogate's objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005)., Conclusions: Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians' hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study., (Copyright 2016 The Journal of Clinical Ethics. All rights reserved.)

In 2015, the demand for the presence of cardiothoracic anesthesiologists outside of the cardiac operating rooms continues to expand. Most notably, cardiothoracic anesthesiologists now find themselves called on to care for patients postoperatively in the cardiothoracic surgical intensive care unit. This article is the first in this annual series to review relevant contributions in postoperative cardiac critical care that may influence the cardiac anesthesiologist. We explore the use of extracorporeal membrane oxygenation, management of postoperative atrial fibrillation and coagulopathy, metabolic support of the critically ill cardiothoracic surgical patient, and new insights into delirium and acute kidney injury., (© The Author(s) 2016.)

Background: Postoperative seizure (PS) is an infrequent, yet distressing, complication after cardiac surgery. We wished to determine the prognostic significance of these complicated neurologic events., Methods: The Weill Cornell Medical College Department of Cardiothoracic Surgery database and the New York State Department of Health Database were reviewed to identify all patients having PS after cardiac surgery between January 1, 2008, and December 31, 2011., Results: During the study period 3,518 patients had cardiac surgery at the index hospital; 45 of them had PS (1.27%). Overall, patients having PS had a significant increase in 30-day mortality when compared with those not having PS (6.7% versus 1.5%; p < 0.006). The incidence of major postoperative complications in those having PS was also significantly higher (53.3% versus 10.5%; p < 0.001). However, logistic regression failed to demonstrate PS as an independent predictor of perioperative mortality. When the PS group was further stratified by the presence or absence of cerebrovascular accident, those having both PS and cerebrovascular accident had substantially increased morbidity and mortality (mortality, 0 of 33 versus 3 of 12; major morbidity, 12 of 12 versus 12 of 33; p < 0.01 for both), whereas PS patients without cerebrovascular accident did not have greater risk for either major adverse events or mortality., Conclusions: When PS is associated with acute cerebrovascular accident, a significant increase in postoperative morbidity and mortality can be expected. However, in those with isolated PS (without evidence of new neurologic injury), perioperative mortality and morbidity are comparable to those without any neurologic complications., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Given the pace, distribution, and uptake of technological innovation, patients experiencing respiratory failure, heart failure, or cardiac arrest are, with greater frequency, being treated with extracorporeal membrane oxygenation (ECMO). Although most hospitalists will not be responsible for ordering or managing ECMO, in-hospital healthcare providers continue to be a vital source of patient referral and, accordingly, need to understand the rudiments of these technologies so as to co-manage patients, counsel families, and help ensure that the provision of ECMO is consistent with patient preferences and appropriate goals of care. In an effort to prepare hospitalists for these clinical responsibilities, we review the history and technology behind modern-day ECMO, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and venovenous extracorporeal membrane oxygenation. Building upon that foundation, we further highlight special ethical considerations that may arise in VA-ECMO, and present an ethically grounded approach to the initiation, continuation, and discontinuation of treatment., (© 2014 Society of Hospital Medicine.)

Objective: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiopulmonary support offers survival possibilities to patients who otherwise would succumb to cardiac failure. Often referred to as "a bridge to recovery," involving a ventricular assist device or cardiac transplantation, this technology only affords temporary cardiopulmonary support. Physicians may have concerns about initiating VA-ECMO in patients who, in the absence of recovery or transfer to longer-term therapies, might assert religious or cultural objections to the terminal discontinuation of life-sustaining therapy (LST). We present a novel case of VA-ECMO use in an Orthodox Jewish woman with potentially curable lymphoma encasing her heart to demonstrate the value of anticipating and preemptively resolving foreseeable disputes., Patient: A 40-year-old Hasidic Orthodox Jewish woman with lymphoma encasing her right and left ventricles decompensated from heart failure before chemotherapy induction. The medical team, at an academic medical center in New York City, proposed VA-ECMO as a means for providing cardiopulmonary support to enable receipt of chemotherapy. Owing to the patient's religious tradition, which customarily prohibits terminal discontinuation of LST, clinical staff asked for an ethics consultation to plan for initiation and discontinuation of VA-ECMO., Interventions: Meetings were held with the treating clinicians, clinical ethics consultants, family, religious leaders, and cultural liaisons. Through a deliberative process, VA-ECMO was reconceptualized as a bridge to treatment and not as an LST, a designation assigned to the chemotherapy on this occasion, given the mortal threat posed by the encasing tumor., Conclusion: Traditional religious objections to the terminal discontinuation of LST need not preclude initiation of VA-ECMO. The potential for disputes should be anticipated and steps taken to preemptively address such conflicts. The reconceptualization of VA-ECMO as a bridge to treatment, rather than as an LST, can allow patients with objections to the terminal discontinuation of LST to receive interventions, such as chemotherapy, that might otherwise be precluded by critical physiology., (©AlphaMed Press.)

Extracorporeal membrane oxygenation (ECMO) provides continuous circulation and/or oxygenation to adults with cardiac failure, pulmonary dysfunction, or both. The technology is similar to the traditional heart-lung bypass machines used during surgical procedures, however ECMO may be used outside the confines of the operating room and for extended periods of time. This paper explores the complexities, both clinical and ethical, of a do-not-resuscitate (DNR) order for patients with cardiopulmonary failure on veno-arterial (VA-ECMO), a type of ECMO that provides resuscitation superior to the chest compressions that DNR is intended to prevent. Clinically, a DNR order has limited utility for patients on VA-ECMO and its presence can serve to create confusion. Symbolically, however, the designation may serve as a stepping-stone for surrogates facing difficult end-of-life decisions. The paper concludes by suggesting that it is prudent to avoid DNR discussions in the context of VA-ECMO

Objective: To determine the prevalence of pica and its characteristics among children with sickle cell disease., Design: Retrospective, observational study., Setting: An urban, ambulatory care, interdisciplinary center., Patients: The medical records of all 480 patients who visited the center from March 1, 1998, to June 30, 1999, were reviewed. Patients were excluded for history of stroke, long-term transfusions, pregnancy, acute illness, or age younger than 3 years., Main Outcome Measures: Sex, age, weight, height, Tanner stage, complete blood cell count, sickle cell genotype, pica history, and levels of iron, zinc, lead, and fetal hemoglobin (Hb)., Results: Of 395 study patients, 134 (33.9%) reported pica. Ingested items included paper, foam, and powders. There was a significantly higher prevalence of pica among patients homozygous for Hb S (Hb SS, sickle cell anemia) compared with the combined group of double heterozygous patients with Hb SC, Hb SD, and Hb Sbeta thallasemia (Sbeta(+)or Sbeta(0)) (35.6% vs 25.5%; P =.03). Within genotype, mean Hb levels were significantly lower and reticulocyte counts were significantly higher in the patients with pica. Overall, the mean age of patients with pica was significantly lower; however, the prevalence was 23.3% (27/116) among those aged 10.0 to 14.9 years and 14.8% (8/54) among those aged 15.0 to 19.0 years. Within age groups, patients with pica weighed significantly less., Conclusions: Pica appeared to have an unusually high prevalence in patients with sickle cell disease and a correlation with lower Hb levels. It is unclear whether pica is a specific marker of disease severity, because our review did not show a relationship to increased number and duration of hospitalizations. The association between pica and low body weight suggests a nutritional effect on its prevalence.