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OBJECTIVES Neuroprotection during aortic arch surgery involves selective antegrade cerebral perfusion. The parameters of cerebral perfusion, e.g. flow rate, are inconsistent across centres and are subject of debate. The aim of this study was to determine the cerebral perfusion flow rate during hypothermic circulatory arrest required to meet preoperative awake baseline regional cerebral oxygen saturation (rSO2). METHODS Patients scheduled for aortic arch surgery with hypothermic circulatory arrest were enrolled in this prospective observational study. After initiation of hypothermic circulatory arrest, bilateral selective antegrade cerebral perfusion was established and cerebral flow rate was continuously increased. The primary end point was the difference of cerebral saturation from baseline during cerebral perfusion flow rates of 6, 8 and 10 ml/kg/min. RESULTS A total of 40 patients were included. During antegrade cerebral perfusion, rSO2 was significantly lower than the baseline at 6 ml/kg/min [−7.3, 95% confidence interval (CI): −1.7, −12.9; P = 0.0015]. In contrast, flow rates of 8 and 10 ml/kg/min resulted in rSO2 that did not significantly differ from the baseline (−2; 95% CI: −4.3, 8.3; P > 0.99 and 1.8; 95% CI: −8.5%, 4.8%; P > 0.99). Cerebral saturation was significantly more likely to meet baseline values during selective antegrade cerebral perfusion with 8 ml/kg/min than at 6 ml/kg/min (44.1%; 95% CI: 27.4%, 60.8% vs 11.8%; 95% CI: 0.9%, 22.6%; P = 0.0001). CONCLUSIONS At 8 ml/kg/min cerebral flow rate during selective antegrade cerebral perfusion, regional cerebral oximetry baseline values are significantly more likely to be achieved than at 6 ml/kg/min. Further increasing the cerebral flow rate to 10 ml/kg/min does not significantly improve rSO2.

BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used in patients with out-of-hospital or in-hospital cardiac arrest in whom conventional cardiopulmonary resuscitation remains unsuccessful. The aim of this study was to analyze the impact of initial cardiac rhythm - detected on-site of the cardiac arrest - on mortality. METHODS We performed a retrospective cohort study of patients who received ECPR in our tertiary care cardiac arrest center. Patients were divided into three groups depending on their cardiac rhythm: shockable rhythm, pulseless electrical activity, and asystole. The primary endpoint was mortality within the first 7���days after ECPR deployment. Secondary endpoints were mortality within 28���days and impact of pre-ECPR potassium, serum lactate, pH and pCO2 on mortality. The association of the initial cardiac rhythm and the location of arrhythmia detection (patient monitored in hospital [category: monitored], not monitored but hospitalized [in-hospital], not monitored, not hospitalized [out-of hospital]) with the primary and secondary outcome was examined by means of univariable and multivariable logistic regression. RESULTS Sixty-five patients could be included in the final analysis. Thirty-two patients (49.2%, 95%CI 36.6% - 61.9%) died within the first 7���days. In terms of 7-day-mortality patients differed in the initial cardiac rhythm (p=0.040) and with respect of the location of arrhythmia detection (p=0.002). Shockable cardiac rhythm (crude OR 0.21; 95%CI 0.03 - 0.98) and pulseless electrical activity (0.13; 0.02 - 0.61) as the initial rhythm on-site showed better odds for survival compared to asystole. However, this association did neither persist in adjusted analysis nor in pairwise comparison. DISCUSSION The study could not demonstrate a better outcome with shockable rhythm after ECPR. More homogeneous and adequately powered cohorts are needed to better understand the impact of cardiac rhythm on patient outcome after ECPR.

Supplemental oxygen (OA single-center randomized cross-over clinical trial will be conducted, enrolling 106 patients undergoing elective coronary artery bypass graft surgery. After the induction of anesthesia and prior to the start of surgery, cardiac function will be assessed by 2D and 3D TEE. Images will be acquired at two different oxygen states for each patient in randomized order. The fraction of inspired oxygen (FBy using myocardial strain assessed by TEE, early and subtle signs of biventricular systolic and diastolic dysfunction can be promptly measured intraoperatively prior to the onset of severe signs of ischemia. The results may help anesthesiologists to better understand the effects of F

Background: Extracorporeal cardiopulmonary resuscitation has become a recommended treatment option for patients with severe hypothermia with cardiac arrest. Minimal invasive extracorporeal circulation (MiECC) may offer advantages over the current standard extracorporeal membrane oxygenation (ECMO). Methods: Retrospective cohort analysis of hospital database for patients with accidental hypothermia and extracorporeal rewarming with MiECC admitted between 2010 and 2019. Results: Overall, six of 17 patients survived to hospital discharge. Eleven patients suffered accidental hypothermia in an alpine and six in an urban setting. Sixteen patients arrived at the hospital under ongoing cardiopulmonary resuscitation (CPR). CPR time was 90 minutes (0-150). Four patients survived from an alpine setting and two from an urban setting with CPR duration of 90 minutes (0-150) and 85 minutes (25-100), respectively. Asphyctic patients tended to have lower survival (one of seven patients). Two patients of six with major trauma survived. Conclusion: MiECC for extracorporeal rewarming from severe accidental hypothermia is a feasible alternative to ECMO, with comparable survival rates.

Extracorporeal cardiopulmonary resuscitation is a rescue intervention for refractory cardiac arrest. Based on a case description this article summarizes the indications, contraindications, the current literature and guidelines related to this topic. Further, challenges during a patient's course are described and potential problems are addressed.

Purpose of Review The purpose of this chapter is to provide a brief review on current anesthesia techniques for transfemoral transcatheter aortic valve implantation (TF-TAVI). Recent Findings TF-TAVI has become a standard treatment option for high risk patients with severe aortic stenosis. Increasing experience with prosthetic durability and equivalent or superior outcomes of transcatheter over surgical aortic valve replacement will boost the caseload of high- and intermediate-risk patients. For TF-TAVI, general anesthesia (GA) had initially been widely preferred over local anesthesia with monitored anesthesia care (LA-MAC), but with large national practice variation. Institutional routines are changing now since evidence from large registries accrues that LA-MAC represents a feasible, safe, and economically sound alternative to GA, if no contraindications apply. Although prospective randomized TAVI anesthesia trials are lacking, observational data show that GA is associated with higher patient risk, longer procedural time, more vasopressor and transfusion requirement, and more resource use and costs, whereas periprocedural mortality is comparable or non-significantly better with LA-MAC. In summary, GA remains a robust solution for specific situations and teams. In many experienced centers, however, LA-MAC has become first choice whenever possible. Whether LA-MAC is an option should be decided upon by the anesthesiologist and the heart team in consultation with the patient, following prospectively defined decision pathways. With increasing caseload and decreasing invasiveness of TAVI technology, anesthesia providers must meet the challenge to reduce resource use and costs without compromising patient safety and satisfaction.

Introduction Levosimendan is a potent inodilator agent. The net effect of haemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. To assess the haemodynamic effects in cardiac surgery patients treated with levosimendan we conducted a systemic review. Our hypothesis was that levosimendan improves cardiac function, but also triggers a systemic vasodilatation. Methods Systematic review with meta-analysis. English-language literature with access to full texts and supplements in US National Library of Medicine (PUBMED), MEDLINE, EMBASE, and CENTRAL was searched systematically from 2006 until July 2018. Included randomized controlled trials, case-matched or retrospective studies providing at least two sequentially measured haemodynamic variables in adult patients undergoing cardiac surgery with cardio pulmonary bypass and treated with levosimendan in comparison to alternative drugs or devices. Results Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardised mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference (SMD) at baseline by a multivariate mixed effects meta-analysis model. With the correction for baseline differences, other haemodynamic variables, especially the systemic vascular resistance did not significantly differ until POD 1 [-0.17 (-0.64 to 0.30), p=0.48] and POD 7 [-0.13 (-0.61 to 0.34), p=0.58] between the levosimendan and the comparator group. Discussion Levosimendan increased cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome. Hypotension seems not to be statistically relevant.

Levosimendan is a potent non-adrenergic inodilator agent. The net effect of hemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. We conducted a systematic review and meta-analysis assessing hemodynamics in cardiac surgery patients treated with levosimendan. English-language literature was searched systematically from 2006 until October 2018, including randomized controlled trials and case-matched or retrospective studies providing at least two sequentially measured hemodynamic variables in adult patients who underwent cardiac surgery with cardiopulmonary bypass and were treated with levosimendan in comparison to alternative drugs or devices. Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardized mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference at baseline by a multivariate mixed effects meta-analysis model. With this correction for baseline differences, other hemodynamic variables including systemic vascular resistance did not significantly differ until POD 1 [−0.17 (−0.64 to 0.30), p = 0.48] and POD 7 [−0.13 (−0.61 to 0.34), p = 0.58] between the levosimendan and the comparator group. Levosimendan increases cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome.

We present the case of a patient with infective endocarditis anesthetized for replacement of severely regurgitant aortic valve. Intraoperative transesophageal echocardiography revealed a new diagnosis of severe secondary mitral regurgitation. After aortic valve replacement and tricuspid valve repair, severe mitral regurgitation resolved rapidly without any intervention. In multivalvular disease, instant spontaneous resolution of secondary mitral regurgitation is possible after surgical correction of an aortic regurgitation causing left ventricular volume overload.

Current guidelines on postcardiotomy veno-arterial extracorporeal oxygenation ECMO (vaECMO) do not mention the assessment of pulmonary function, especially prior to the weaning procedure in the operation room (OR). Mucociliary dysfunction, a nearly ubiquitous finding among mechanically ventilated patients, might put these patients at risk for potential airway problems and associated weaning failure at the time of vaECMO weaning in the OR. In conformity to veno-venous ECMO management, we suggest routine bronchoscopy with bronchial hygiene in the ICU prior to vaECMO weaning in the OR. Likewise, an assessment of patient pleura for effusions should be routinely performed. Although cardiac and respiratory failure often co-exist and there are multiple causes of respiratory failure in patients who require vaECMO, we anticipate that vaECMO patients would significantly benefit from an expanded focus on the pulmonary function and possible respiratory mucous congestion. A routine preweaning bronchoscopy would reduce the frequency of weaning failures in this particular setting, especially in those patients with successfully restored cardiac function.

Introduction Hypothermic circulatory arrest (HCA) in conjunction with selective antegrade cerebral perfusion (sACP) is frequently used for neuroprotection.(1) Nonetheless optimal sACP has only been investigated in animal studies.(2) The objective of this study was to determine sACP during HCA necessary to reach baseline tissue oxygenation as measured by near infrared spectroscopy (NIRS). Methods With local ethics committee approval, consecutive patients scheduled for elective aortic arch surgery in HCA were included in this prospective observational single center study. Bilateral sACP was institued by introducing perfusion catheters in the innominate and left carotid artery. The quality of sACP was monitored by bifrontal NIRS. Baseline NIRS were measured before anesthesia induction in the awake patient. NIRS values were recorded after initiation of HCA at sACP of 6, 8 and 10 milliliters (ml) per ideal body weight (kg) per minute (min). For comparison the mean of bifrontal NIRS in each patient was calculated for this interim analysis. Differences in NIRS between sACP flow rates were assessed by one-way ANOVA and Bonferroni t-test. A p Results Fifteen patients had complete datasets (4 female). NIRS was 62 (8) at baseline; 56 (11) at 6; 62 (11) at 8 and 63 (9) at 10 ml/kg/min sACP, respectively. ANOVA showed no significant differences between baseline and the three distinct sACP (p = 0.223). Bonferroni t-test indicated no differences between the different sACP and the baseline (all p>0.05). Duration of HCA was 12 (15) minutes. All patients were discharged after a length of hospital stay of 10 +/- 4 days. Three patients had new onset focal neurological deficits before discharge and three patients had postoperative delirium. Discussion SACP of 6-10ml is the range often used in centers of aortic arch surgery. (1) In an animal-model, the lower threshold of 6ml/kg/min was confirmed recently, since venous saturation decreased markedly when sACP was lowered below this sACP.(2) Our data support this finding in humans as sACP f of 6 ml/kg/min is sufficient to reach baseline NIRS values. A further increase, e.g., to 8 or 10 ml/kg/min, is not associated with an even better NIRS. The data suggest that sufficient frontal brain oxygenation can be achieved with a relatively low sACP flow rate in HCA.

Current guidelines on postcardiotomy veno-arterial extracorporeal oxygenation ECMO (vaECMO) do not mention the assessment of pulmonary function, especially prior to the weaning procedure in the operation room (OR). Mucociliary dysfunction, a nearly ubiquitous finding among mechanically ventilated patients, might put these patients at risk for potential airway problems and associated weaning failure at the time of vaECMO weaning in the OR. In conformity to veno-venous ECMO management, we suggest routine bronchoscopy with bronchial hygiene in the ICU prior to vaECMO weaning in the OR. Likewise, an assessment of patient pleura for effusions should be routinely performed. Although cardiac and respiratory failure often co-exist and there are multiple causes of respiratory failure in patients who require vaECMO, we anticipate that vaECMO patients would significantly benefit from an expanded focus on the pulmonary function and possible respiratory mucous congestion. A routine preweaning bronchoscopy would reduce the frequency of weaning failures in this particular setting, especially in those patients with successfully restored cardiac function.