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ObjectivesWe conducted a systematic review and meta-analysis to identify the potential favourable effects of local anaesthesia plus sedation (LAS) compared with general anaesthesia (GA) in transcatheter aortic valve implantation (TAVI).MethodsElectronic databases (PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials) and the reference lists of eligible publications were screened for randomised controlled trials (RCTs) and observational studies published between 1 January 2006 and 26 June 2016 that compare LAS to GA in an adult study population undergoing TAVI. We conducted study quality assessments using the Cochrane risk of bias tool and structured the review according to PRISMA. A meta-analysis calculating the pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) under the assumption of a random-effects model was performed. Statistical heterogeneity was evaluated using the I² statistic and Cochran’s Q-test.ResultsAfter database screening, one RCT and 19 observational studies were included in the review. We found no differences between LAS and GA in terms of 30-day mortality, in-hospital mortality and other endpoints that addressed safety and complication rates. LAS was associated with a shorter ICU and hospital stay and with lower rates of catecholamine administration and red blood cell transfusion. New pacemaker implantations occurred more frequently under LAS. The overall conversion rate from LAS to GA was 6.2%.ConclusionFor TAVI, both LAS and GA are feasible and safe. LAS may have some benefits such as increased haemodynamic stability and shorter hospital and ICU stays, but it does not impact 30-day mortality. Since there is a paucity of randomised trial data and the findings are mainly based on observational study data, this review should be considered as a hypothesis-generating article for subsequent RCTs that are required to confirm the potential favourable effects we detected for LAS.Registration numberCRD42016048398 (PROSPERO).

IntroductionEarly and balanced replacement of blood products appears to be the key factor in improving outcomes of major bleeding patients including acute trauma, cardiac, obstetric and transplant surgery patients. Definitive clinical guidance regarding the optimal ratio of blood products, including those containing fibrinogen, is still lacking. Therefore, we tested the hypothesis that increasing the fibrinogen content to erythrocyte suspension ratio improves the mortality and functional outcomes of patients undergoing surgeries with expected major bleeding.Methods and analysisThe Approximate Dose-Equivalent of Fibrinogen-to-Erythrocyte Suspension (ADEFES) ratio is a multicentre, prospective, observational, cohort study of patients undergoing major surgical procedures with expected major perioperative bleeding (ie, requiring packed red blood cells (PRBC)>4U/24 hours). For 5U of cryoprecipitate and 1.5 U of fresh frozen plasma (FFP), the approximate dose-equivalent for fibrinogen is considered as 1 gram of fibrinogen. Association of the ADEFES ratio at 24 hours will be assessed on the primary objective, which will consist of the composite of 30-day all-cause mortality, 30-day bleeding-specific mortality and the ‘highly-dependent scores’ of Katz index of independence in activities of daily living.Ethics and disseminationThe study protocol was approved by the Ethics Committee of Ankara Bilkent City Hospital (approval no. E2-23-4265, dated 07 June 2023; Chair: Prof. Dr. F.E. Canpolat) and by the institutional review boards of all participating centres. The study will be conducted in accordance with the principles of the Declaration of Helsinki and the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, as well as in compliance with national regulations on data protection and Good Clinical Practice standards. Written informed consent will be obtained from all participants prior to inclusion in the study.The results of this study will be disseminated through peer-reviewed scientific journals, presentations at national and international conferences, and communication with relevant stakeholders including clinical practitioners and healthcare institutions. If applicable, study outcomes will also be shared via institutional newsletters and digital platforms to reach a broader audience in the medical community.Trial registration numberNCT06021184.

ObjectiveTo evaluate the reliability of stroke volume variation (SVV) for predicting responsiveness to fluid therapy in patients undergoing cardiac and thoracic surgery.DesignSystematic review and meta-analysis.Data sourcesPubMed, EMBASE, Cochrane Library, Web of Science up to 9 August 2020.MethodsQuality of included studies were assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We conducted subgroup analysis according to different anaesthesia and surgical methods with Stata V.14.0, Review Manager V.5.3 and R V.3.6.3. We used random-effects model to pool sensitivity, specificity and diagnostic odds ratio with 95% CI. The area under the curve (AUC) of receiver operating characteristic was calculated.ResultsAmong the 20 relevant studies, 7 were conducted during thoracic surgery, 8 were conducted during cardiac surgery and the remaining 5 were conducted in intensive critical unit (ICU) after cardiac surgery. Data from 854 patients accepting mechanical ventilation were included in our systematic review. The pooled sensitivity and specificity were 0.73 (95％ CI: 0.59 to 0.83) and 0.62 (95％ CI: 0.46 to 0.76) in the thoracic surgery group, 0.71 (95％ CI: 0.65 to 0.77) and 0.76 (95％ CI: 0.69 to 0.82) in the cardiac surgery group, 0.85 (95％ CI: 0.60 to 0.96) and 0.85 (95％ CI: 0.74 to 0.92) in cardiac ICU group. The AUC was 0.73 (95% CI: 0.69 to 0.77), 0.80 (95% CI: 0.77 to 0.83) and 0.88 (95% CI: 0.86 to 0.92), respectively. Results of subgroup of FloTrac/Vigileo system (AUC=0.80, Youden index=0.38) and large tidal volume (AUC=0.81, Youden index=0.48) in thoracic surgery, colloid (AUC=0.85, Youden index=0.55) and postoperation (AUC=0.85, Youden index=0.63) in cardiac surgery, passive leg raising (AUC=0.90, Youden index=0.72) in cardiac ICU were reliable.ConclusionSVV had good predictive performance in cardiac surgery or ICU after cardiac surgery and had moderate predictive performance in thoracic surgery. Nevertheless, technical and clinical variables may affect the predictive value potentially.

IntroductionParavertebral blockade (PVB) is a regional anaesthesia technique increasingly used in paediatric cardiothoracic surgery for postoperative pain management. However, its comparative efficacy and safety relative to other analgesic strategies remain inadequately synthesised. This systematic review aims to evaluate the effectiveness, safety and complications of PVB in paediatric patients undergoing cardiothoracic surgery.Methods and analysisThis protocol adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search MEDLINE, EMBASE, Cochrane Library, Web of Science, Scopus, ClinicalTrials.gov and other relevant sources from inception to February 2025. Randomised controlled trials (RCTs) comparing PVB with systemic opioids, epidural analgesia or placebo in patients aged <18 years will be included. Exclusion criteria include non-RCTs, adult populations and non-cardiothoracic surgeries. Primary outcomes include postoperative pain intensity measured using validated scales such as Face, Legs, Activity, Cry, Consolability Scale or Numeric Rating Scale within 24–48 hours. Secondary outcomes include opioid consumption within 24–48 hours, length of hospital stay, haemodynamic stability and complications (eg, pneumothorax, local anaesthetic toxicity). Two reviewers will independently screen studies, extract data and assess the risk of bias using the Cochrane Risk of Bias-2 tool. A meta-analysis using a random-effects model or a narrative synthesis will be conducted based on heterogeneity (I²≥75%). Subgroup analyses will explore variations by age group, surgical type and PVB technique.Ethics and disseminationAs this study involves secondary analysis of existing data, ethical approval is not required. The completed review will be submitted for open-access publication in a peer-reviewed journal to ensure accessibility for clinicians, researchers and policymakers.PROSPERO registration numberCRD42025644837.

BackgroundAccurate arterial pressure monitoring is critical in cardiac surgery to guide haemodynamic management and vasopressor therapy. Radial arterial pressure monitoring may systematically underestimate central aortic pressure compared with femoral monitoring, potentially leading to inappropriate vasopressor escalation and associated complications. Recent evidence demonstrates that excessive norepinephrine exposure is associated with acute kidney injury and increased mortality in cardiac surgery patients.ObjectiveTo determine whether femoral arterial pressure monitoring reduces norepinephrine use compared with radial monitoring in cardiac surgery patients.Methods and analysisThis is a prospective, randomised, controlled, single-blind, superiority trial conducted at two French university hospitals (CHU Besançon and CHU Dijon). Adult patients undergoing cardiac surgery with cardiopulmonary bypass will be randomised 1:1 to receive either femoral or radial arterial pressure monitoring. The primary endpoint is the proportion of patients treated with norepinephrine from anaesthetic induction to postoperative day 7. Secondary endpoints include acute kidney injury according to KDIGO criteria, cardiac complications, vasoactive-inotropic scores, duration of vasopressor therapy, vascular complications, and 7-day and 30-day mortality. Sample size calculation indicates 340 patients (170 per group) are needed to detect a 15% absolute reduction in norepinephrine use with 90% power and α=0.05, and an anticipated loss to follow-up rate of 5%.Ethics and disseminationThe study has been approved by the French Ethics Committee (Comité de Protection des Personnes Nord-Ouest II, no. 2024/897) and will be conducted according to the Declaration of Helsinki and Good Clinical Practice guidelines. Results will be submitted for publication in peer-reviewed journals and presented at international conferences.Trial registration numberNCT06952907.

IntroductionPostoperative cardiac injury, encompassing myocardial infarction (MI) and myocardial injury after non-cardiac surgery (MINS), is a major perioperative complication associated with substantial morbidity and mortality. While numerous prediction models have been developed using traditional statistical and machine learning approaches, their comparative performance, calibration quality and methodological rigour remain unclear. This protocol outlines a systematic review and meta-analysis to comprehensively evaluate multivariable risk prediction models for postoperative cardiac injury in adults undergoing non-cardiac surgery.Methods and analysisFollowing Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, this PROSPERO-registered systematic review will search PubMed, Embase, Web of Science, Cochrane Library, Scopus, grey literature and trial registries for studies developing, validating or updating multivariable prediction models for postoperative cardiac injury (MI or MINS) occurring within 72 hours of non-cardiac surgery. Two reviewers will independently extract data and assess quality using CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) and PROBAST (Prediction Model Risk of Bias Assessment Tool) tools. The primary outcome is discriminative performance (area under the receiver operating characteristic curve), with calibration metrics and diagnostic accuracy measures as secondary outcomes. Random-effects meta-analyses will pool performance estimates for models validated in multiple cohorts. Heterogeneity will be explored through subgroup analyses and meta-regression, examining factors including model methodology (regression-based vs machine learning), predictor types and validation contexts. Sensitivity analyses will test the robustness of findings.Ethics and disseminationEthical approval is not required for this study, as it is a systematic review and meta-analysis based on previously published data.PROSPERO registration numberCRD420251041628.

IntroductionPostoperative atrial fibrillation (POAF) affects approximately 20% of patients undergoing thoracic surgery and is associated with severe complications such as stroke, myocardial infarction, heart failure, and increased mortality. Early diagnosis is critical to mitigate these risks, but conventional monitoring is limited in detecting asymptomatic episodes. Smartwatches equipped with single-lead ECG and atrial fibrillation (AF) detection algorithms offer a novel approach for early POAF detection. This study aims to evaluate the effectiveness of smartwatch-based monitoring compared with standard care in identifying POAF following thoracic surgery.Methods and analysisThe THOFAWATCH trial is a randomised, bicentric open-label study enrolling 302 adult patients undergoing major thoracic surgery (pneumonectomy or lobectomy) with one-lung ventilation. Eligible patients will be randomised into two groups: (1) the ‘Smartwatch Monitoring’ group, where participants will undergo rhythm monitoring using a smartwatch and (2) the ‘Conventional Monitoring’ group, receiving standard care without smartwatch monitoring. In the intervention group, any smartwatch-detected POAF episodes will be confirmed by 12-lead ECG. The primary outcome is the incidence of POAF within 7-day postsurgery. Secondary outcomes include the rate of asymptomatic POAF, cardiovascular prognosis evaluated at 2 and 6 months (composite major adverse cardiovascular events outcome), feasibility of smartwatch usage (device usage time and success rate of single-lead ECGs) and recurrence or management of AF at follow-up. Inclusion criteria include adults (>18 years) undergoing scheduled thoracic surgery and able to use the smartwatch device. Exclusion criteria encompass patients with prior AF, those requiring telemetry, or undergoing reoperations. Statistical analysis will assess the primary outcome using χ2 or Fisher’s exact test (α=5%), while secondary outcomes will include descriptive and inferential statistics, with analysis conducted using SAS V.9.4.Ethics and disseminationEthical approval for this bicentric study has been granted by the institutional review board (IRB) of the University Hospital of Amiens (Comité de Protection des Personnes sud-ouest et outre-mer 1, 21050 Toulouse, France, registration number ID RDB: 2022-A02028-27 in November 2024). The trial is registered under ClinicalTrials.gov (ID: (NCT06724718)). Results will be disseminated through peer-reviewed publications and scientific conferences to inform clinical practice regarding POAF detection and management following thoracic surgery.Trial registration numberNCT06724718; clinical trial.

IntroductionPostoperative arrhythmias are common and clinically significant complications. They are a cause of increased morbidity and mortality rates in surgical patients. Although various pharmacological and procedural strategies have been explored for preventing postoperative arrhythmia, evidence regarding their effectiveness remains inconsistent. The stellate ganglion block (SGB) has emerged as a promising alternative to reduce the occurrence of postoperative arrhythmias. By summarising the existing evidence, this meta-analysis aims to assess the effectiveness of SGB in preventing postoperative arrhythmias.Methods and analysisWe will review literature from January 1970 to April 2025 using MEDLINE, Cochrane CENTRAL and Embase. Studies eligible for inclusion will be randomised controlled trials and observational studies reporting postoperative arrhythmia incidence in surgical patients who received preoperative or intraoperative SGB. We will include articles in the following languages: English, Spanish, Chinese or Portuguese. Secondary outcomes are SGB-related complications. The risk of bias will be determined by Rob-2 and ROBINS-I tools. Meta-analyses, reporting relative risks or ORs with 95% confidence intervals will be performed when at least three studies report the same outcome under comparable conditions. Quality of evidence will be evaluated using GRADE guidelines.Ethics and disseminationWe will use information from previously published manuscripts found in reputable databases, and ethical approval is not necessary.PROSPERO registration numberCRD420251029643.

ObjectivesTo examine whether the use of a venous access-site closure device is associated with the occurrence of postoperative nausea and vomiting (PONV) after atrial fibrillation (AF) ablation under propofol sedation.DesignObservational study.SettingA single-centre retrospective observational study in Okayama, Japan.ParticipantsWe retrospectively analysed consecutive patients who underwent AF ablation under deep propofol sedation with adaptive servo-ventilation. A total of 686 patients were included. Patients were managed using a standardised sedation protocol with or without low-dose pentazocine. Patients treated with conventional manual compression for haemostasis (n=383) were compared with those treated using a venous access-site closure device (n=303).InterventionsPostprocedural bed rest duration and the incidence and timing of PONV were compared between groups. Associations between closure device use and PONV were evaluated using logistic regression analysis.Primary outcome measureThe primary outcome was the occurrence of PONV following AF ablation.ResultsAll procedures were completed under propofol sedation without conversion to general anaesthesia. The duration of postprocedural bed rest was shorter in the device group than in the conventional-compression group (mean difference −14.7 hours, 95% CI −15.2 to −14.0).PONV occurred in 6/303 patients (2.0%) in the device group and 20/383 patients (5.2%) in the conventional-compression group, corresponding to a relative risk of 0.38 (95% CI 0.15 to 0.93), an OR 0.25 (95% CI 0.10 to 0.62) and a risk difference of −3.2% (95% CI −6.0% to −0.5%).In multivariable analysis, use of a venous closure device was associated with a lower likelihood of PONV.ConclusionsIn this single-centre observational study, use of a venous access-site closure device was associated with a lower occurrence of PONV after AF ablation under propofol sedation. These findings suggest that postprocedural management strategies enabling earlier mobilisation may be associated with improved patient comfort; however, causal inference is limited by the observational design.

BackgroundCurrent indicators for monitoring intraoperative organ function remain predominantly indirect, delayed and non-specific, particularly in paediatric populations undergoing congenital heart surgery, where multifactorial influences further complicate functional assessments. Emerging evidence suggests that the use of near-infrared spectroscopy (NIRS) technology to continuously monitor the regional oxygen saturation (rSO₂) of intraoperative organs can predict the postoperative organ functional status. This study aims to investigate the associations between intraoperative cerebral/renal rSO₂ fluctuations monitored by NIRS and postoperative neurological injury or acute kidney injury (AKI) in paediatric congenital heart disease (CHD) surgery.Methods and analysisIn this prospective observational cohort study, patients ≤18 years, scheduled for CHD surgery under cardiopulmonary bypass (CPB), will be enrolled after obtaining written informed consent. Exclusion criteria include pre-existing neuropsychiatric disorders, chronic kidney disease or other related disorders. Dual-channel NIRS probes will be applied to simultaneously monitor cerebral and renal rSO₂ from anaesthesia induction until the patient is transferred to the cardiac care unit. Serum S100 calcium-binding protein B (S100B) levels will be measured before CPB, at the end of the surgery and on postoperative day 1 to quantify cerebral injury. AKI will be diagnosed using the paediatric risk, injury, failure, loss, end-stage renal disease (pRIFLE) criteria based on dynamic creatinine changes. Health-related quality of life will be assessed through the paediatric quality of life (PedsQL) inventory at preoperative baseline and postoperative day 30.Ethics and disseminationThis study has been approved by the Institutional Review Board of Beijing Children’s Hospital (approval number: [2024]-Y-093-D). Prior to enrolment, written informed consent will be obtained from the parents or legal guardians of all participating minors. The findings of this research will be disseminated through peer-reviewed publications and presentations at relevant conferences and shared with participating communities via lay summaries and social media platforms.Trial registration numberThe study was registered with the Chinese Clinical Trial Registry on 18 April 2024 (ChiCTR2400083225).