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Patients who undergo cardiac surgery have a high risk of significant blood loss and anemia. While allogeneic red blood cell (RBC) transfusions are effective, they are associated with increased morbidity and mortality. Intraoperative cell salvage may reduce reliance on allogeneic transfusions. Although intraoperative RBC salvage is recommended for cardiovascular surgery under cardiopulmonary bypass, there are concerns about increased bleeding due to coagulopathy in patients with a high bleeding risk, and its clinical impact remains unclear. This study aims to evaluate whether salvaged RBC transfusion is noninferior to allogeneic transfusion in terms of postoperative blood loss in patients with a high bleeding risk. This single-center, randomized, two-arm, parallel group, interventional clinical trial will include 142 participants aged ≥ 40 years with a high bleeding risk who undergo elective cardiovascular surgery with cardiopulmonary bypass. Participants will be randomly assigned to receive either salvaged RBC or allogeneic RBC transfusions intraoperatively. The primary outcome is postoperative chest tube blood loss within 12 hours from the end of surgery. Noninferiority will be demonstrated if the upper limit of the 95% confidence interval for the mean difference in blood loss between the salvaged and allogeneic groups is < 200 mL. Secondary outcomes comprise the RBC transfusion volume intraoperatively and for 12 hours from the end of surgery, prevalence of re-thoracotomy within 48 hours from the end of surgery, and prevalence of ≥ 1000 mL postoperative chest tube blood loss within 12 hours from the end of surgery. These outcomes will be analyzed using the modified intention-to-treat set and repeated, for sensitivity reasons, for the per-protocol set. Our trial aims to determine the noninferiority of intraoperative RBC salvage compared with allogeneic blood transfusions regarding postoperative blood loss and to promote its use in surgical procedures with a high bleeding risk. The trial was registered with the Japan Registry of Clinical Trials (jRCT1052240102) on July 30, 2024.

Background Pediatric patients undergoing cardiovascular interventions outside the operating room are at high risk of perioperative hypothermia. We aimed to compare the effects of upper body and full underbody forced-air warming blankets on the time-weighted deviation of esophageal temperature outside the target range (36.5–37.5 °C) during general anesthesia. Methods In this randomized controlled study, 88 children (age < 15 years) scheduled for elective cardiovascular interventions under general anesthesia were randomly assigned to the upper body ( n  = 44) or full underbody ( n  = 44) group. After the induction of anesthesia, warming blankets were applied and heated using a forced-air warmer to maintain an esophageal temperature of 36.5–37.5 °C. The primary outcome was the time-weighted average deviation of esophageal temperature outside the desired range, defined as the total deviation in temperature divided by the duration spent outside the target range. Secondary outcomes included use of additional warming or cooling methods, temperature trends, thermal comfort, and adverse events. Statistical comparisons were performed using t-tests or chi-square tests, with p  < 0.05 considered significant. Results The time-weighted averages of periods out of the desired temperature range were comparable between the two groups (upper body vs. full underbody, 0.213 ± 0.212 °C vs. 0.265 ± 0.277 °C; mean difference, 0.053; 95% confidence interval [CI], − 0.052 to 0.157; p  = 0.318). The incidence of hyperthermia (> 37.5 °C) was 9.09% (upper body) and 0% (full underbody, p  = 0.125). The duration of hypothermia (< 36.5 °C) was 58.82 ± 48.83 min (upper body) and 70.03 ± 53.20 min (full underbody; mean difference, 11.20 min; 95% CI, − 10.44 to 32.85; p  = 0.318). The incidence rates of adverse events were 4.55% (upper body) and 15.91% (full underbody, p  = 0.159). Conclusions Both warming methods showed comparable time-weighted averages of temperatures outside the desired range, suggesting similar effectiveness. However, careful monitoring is essential to mitigate the risks of hyperthermia and skin-related complications and ensure patient safety during pediatric cardiovascular interventions. Trial registration number NCT05349734 (registered at clinicaltrials, principal investigator: Hee-Soo Kim, registration date: April 26,2022).

Choosing between competing treatment options is difficult for patients and clinicians when results from randomized and observational studies are discordant. Observational real-world studies yield more generalizable evidence for decision making than randomized clinical trials, but unmeasured confounding, especially in time-to-event analyses, can limit validity. To compare long-term survival after carotid endarterectomy (CEA) and carotid artery stenting (CAS) in real-world practice using a novel instrumental variable method designed for time-to-event outcomes, and to compare the results with traditional risk-adjustment models used in observational research for survival analyses. A multicenter cohort study was performed. The Vascular Quality Initiative, an observational quality improvement registry, was used to compare long-term mortality after CEA vs CAS. The study included 86 017 patients who underwent CEA (n = 73 312) or CAS (n = 12 705) between January 1, 2003, and December 31, 2016. Patients were followed up for long-term mortality assessment by linking the registry data to Medicare claims. Medicare claims data were available through September 31, 2015. Procedure type (CEA vs CAS). The hazard ratios (HRs) of all-cause mortality using unadjusted, adjusted, propensity-matched, and instrumental variable methods were examined. The instrumental variable was the proportion of CEA among the total carotid procedures (endarterectomy and stenting) performed at each hospital in the 12 months before each patient's index operation and therefore varies over the study period. Participants who underwent CEA had a mean (SD) age of 70.3 (9.4) years compared with 69.1 (10.4) years for CAS, and most were men (44 191 [60.4%] for CEA and 8117 [63.9%] for CAS). The observed 5-year mortality was 12.8% (95% CI, 12.5%-13.2%) for CEA and 17.0% (95% CI, 16.0%-18.1%) for CAS. The unadjusted HR of mortality for CEA vs CAS was 0.67 (95% CI, 0.64-0.71), and Cox-adjusted and propensity-matched HRs were similar (0.69; 95% CI, 0.65-0.74 and 0.71; 95% CI, 0.65-0.77, respectively). These findings are comparable with published observational studies of CEA vs CAS. However, the association between CEA and mortality was more modest when estimated by instrumental variable analysis (HR, 0.83; 95% CI, 0.70-0.98), a finding similar to data reported in randomized clinical trials. The study found a survival advantage associated with CEA over CAS in unadjusted and Cox-adjusted analyses. However, this finding was more modest when using an instrumental variable method designed for time-to-event outcomes for risk adjustment. The instrumental variable-based results were more similar to findings from randomized clinical trials, suggesting this method may provide less biased estimates of time-dependent outcomes in observational analyses.

To evaluate the effect of dexmedetomidine combined with fentanyl on hemodynamics. Prospective, double-blinded, randomized study. Operating room of a university hospital. 30 ASA physical status II and III patients with mild-to-moderate cardiovascular disease. Patients were assigned to one of three groups: Group D-F2 [dexmedetomidine, effect-site concentration (ESC) of fentanyl = two ng/mL]; Group F2 (placebo, ESC of fentanyl = two ng/mL), or Group F4 (placebo, ESC of fentanyl = 4 ng/mL). Dexmedetomidine (an initial dose of 1.0 μg/kg for 10 min, followed by a continuous infusion of 0.7 μg·kg –1·hr –1) or placebo saline was administered 15 minutes before anesthetic induction. Anesthesia was induced with propofol and fentanyl using a target-controlled infusion system. Hemodynamic parameters: systolic (SBP) and diastolic blood pressures (DBP), and heart rate (HR) during anesthetic induction were measured and the percent changes were calculated for both induction and intubation. After inducing anesthesia, SBP was significantly higher in Group D-F2 (127 ± 24 mmHg) than Group F2 (90 ± 20 mmHg) or Group F4 (77 ± 21 mmHg). The SBP in Groups F2 and F4 reached 160 ± 31 mmHg and 123 ± 36 mmHg, respectively, after intubation, but no significant change in SBP was noted in Group D-F2. The percent increase in SBP due to tracheal intubation in Group D-F2 was 3% ± 4% and was significantly lower than that of Group F2 (70% ± 34%) or Group F4 (45% ± 36%). Dexmedetomidine combined with fentanyl during anesthetic induction suppresses the decrease in blood pressure due to anesthetic induction and also blunts the cardiovascular response to tracheal intubation.

Remote ischaemic pre-conditioning and cardiac ischaemic post-conditioning provide myocardial protection in cardiac surgery. However, these two endogenous strategies have not been directly compared in a clinical setting. The purpose of this study was to compare the efficacy of remote ischaemic pre-conditioning and post-conditioning in providing myocardial protection to children undergoing cardiopulmonary bypass for surgical repair of ventricular septal defect. We randomly assigned 60 paediatric patients scheduled for surgical correction of congenital ventricular septal defect to the post-conditioning group (n = 20), remote pre-conditioning group (n = 20), or control group (n = 20). Post-conditioning consisted of 30 seconds of ischaemia and 30 seconds of reperfusion achieved by clamping and unclamping the aorta, repeated three times over 3 minutes immediately after cardioplegic arrest. Remote ischaemic pre-conditioning consisted of 5 minutes of lower limb ischaemia followed by 5 minutes of reperfusion using a blood-pressure cuff inflated to a pressure of 200 millimetres of mercury, also repeated three times over 30 minutes. We assayed creatine kinase-MB, troponin I. Mean age, cardiopulmonary bypass times, and aortic cross-clamp times were matched across groups. Both post-conditioning and remote ischaemic pre-conditioning reduced the peak release of creatine kinase-MB (86.1 plus or minus 24.1 units per litre and 92.8 plus or minus 20.6 units per litre, respectively, versus 111.0 plus or minus 44.6 units per litre in the control, p less than 0.05) and troponin I (0.28 plus or minus 0.10 nanogram per millilitre and 0.26 plus or minus 0.09 nanogram per millilitre, respectively, versus 0.49 plus or minus 0.19 nanogram per millilitre in the control group, p less than 0.05). Our study demonstrates that ischaemic post-conditioning and remote ischaemic pre-conditioning provide comparable myocardial benefit in children undergoing cold blood cardioplegic arrest.

ABSTRACT Objective: To compare the effectiveness of plasma-derived human thrombin and bovine thrombin for achieving hemostasis during surgery. Methods: Adults (N = 305) with ≥ 1 mild or moderate bleeding site not manageable by conventional modalities during elective cardiovascular, neurologic, or general surgical procedures at multiple study centers were randomized to human (n = 153) or bovine (n = 152) thrombin, applied topically with an absorbable gelatin sponge. Bleeding was assessed 3, 6, and 10 min post-application. Other evaluations included laboratory assessments, vital signs, blood loss, blood transfusions, time in specialty-care units, procedure duration, and length of hospital stay. Blood samples for antibody assessment were collected at baseline and postoperative week 5. Results: The proportion of patients achieving hemostasis within 10 min (primary outcome) was equivalent for human and bovine thrombin (97.4 vs. 97.4%, respectively; ratio, 1.00; 95% CI, 0.96-1.05). The proportions of patients achieving hemostasis at 6 min (94.8 vs. 92.8%) and 3 min (73.2 vs. 72.4%) were also equivalent. No clinically meaningful differences were noted for other variables. The products had similar adverse event profiles. More patients (12.7%) who received bovine thrombin demonstrated seroconversion for ≥ 1 of the 4 antibodies assayed than patients who received human thrombin (3.3%). No patients in the human thrombin group developed seroconversion for anti-human thrombin or anti-human factor V/Va antibodies. Limitations of this study include the lack of a placebo-control group, the potential for inter-surgeon variability, and the fact that antibody assessment was not evaluable in all patients. Conclusions: Plasma-derived human thrombin and bovine thrombin were equivalent in achieving hemostasis within 10, 6, and 3 min and had comparable safety profiles. None of the patients receiving human thrombin developed seroconversion for antibodies to any of the human antigens.

Transesophageal echocardiography (TEE) is essential to perioperative cardiac care, providing enhanced cardiac visualization compared to transthoracic echocardiography (TTE), especially in complex cases. While TEE is standard in high-income countries, its utilization in resource-limited settings is not as well-defined. This study aimed to quantify the impact of intraoperative TEE on surgical management at a major tertiary care center in Thailand and to investigate the effects of combining preoperative TTE and TEE on surgical planning. This prospective observational study enrolled 624 adult patients undergoing cardiac surgery from January 2023 to January 2024. All patients received intraoperative TEE, with preoperative assessment conducted via either TTE alone or TTE combined with TEE. The primary outcome was the rate of change in surgical management prompted by new intraoperative TEE findings. Intraoperative TEE findings led to a change in surgical management in 10.58% of all cases (95% CI: 8.28–13.26). The rate of change was higher in patients undergoing preoperative TTE combined with TEE (16.13%) compared to those receiving TTE alone (9.60%); however, after multivariable adjustment, this difference was not statistically significant (adjusted RR 1.18, 95% CI: 0.67–2.09, p = 0.567). The type of surgery was the only independent predictor of management changes, with isolated valve surgery (adjusted RR 2.32, 95% CI: 1.05–5.16) and combined valve with CABG procedures (adjusted RR 3.03, 95% CI: 1.30–7.05) showing the highest likelihood of alteration. Postoperative outcomes, including 30-day mortality and complication rates, were comparable between patients with and without surgical management changes. In this study, intraoperative TEE was associated with changes in surgical decision-making in approximately 10% of cardiac surgeries, suggesting a potential clinical impact, particularly in complex valve-related procedures. The addition of a preoperative TEE, while associated with longer surgical wait times, did not independently associate with the likelihood of intraoperative changes. These findings underscore the crucial role of intraoperative TEE for real-time assessment and support its selective use in high-complexity cases, while also highlighting logistical challenges within resource-limited healthcare systems.

A significant number of surgical patients are at risk of intra- or post-operative complications or both, which are associated with increased lengths of stay, costs, and mortality. Reducing these risks is important for the individual patient but also for health-care planners and managers. Insufficient tissue perfusion and cellular oxygenation due to hypovolemia, heart dysfunction or both is one of the leading causes of perioperative complications. Adequate perioperative management guided by effective and timely hemodynamic monitoring can help reduce the risk of complications and thus potentially improve outcomes. In this review, we describe the various available hemodynamic monitoring systems and how they can best be used to guide cardiovascular and fluid management in the perioperative period in high-risk surgical patients.

ObjectivePatients with repaired tetralogy of Fallot (TOF) are followed serially by cardiac magnetic resonance (CMR) for surveillance of RV dilation and dysfunction. We sought to define the prevalence of progressive RV disease and the optimal time interval between CMR evaluations.MethodsCandidates were selected from a multicentre TOF registry and were included if ≥2 CMR studies performed ≥6 months apart were available without interval cardiovascular interventions. Patients with ‘disease progression’ (defined as increase in RV end-diastolic volume index (RVEDVi) ≥30 mL/m2, decrease in RVEF ≥10% or decrease in LVEF ≥10%) were compared with those with ‘disease non-progression’ (defined as RVEDVi increase ≤5 mL/m2, RVEF decrease ≤3% and LVEF decrease ≤3%).ResultsA total of 849 CMR studies in 339 patients (median age at first CMR 23.6 years) were analysed. Over a median interval of 2.2 years between CMR pairs, RVEDVi increased 4±18 mL/m2 (p<0.001), RV end-systolic volume index increased 3±13 mL/m2 (p<0.001), RVEF decreased 1%±6% (p=0.02) and LVEF decreased 1%±6% (p=0.001). Disease progression was observed in 15% (n=76) and non-progression in 26% (n=133). There were no significant differences between those with and without progression in baseline demographic, anatomic, ECG, exercise or baseline CMR characteristics. The optimal time interval between CMR studies for detection of progression was a 3-year interval (63% sensitivity, 65% specificity, area under the receiver operating characteristic curve 0.65).ConclusionsAlthough progressive RV dilation and decline in biventricular systolic function occur at a slow pace in the majority of adults with repaired TOF, 15% of patients experience rapid disease progression. The results of this study support the practice of serial CMR examinations to identify progressive disease at a time interval of up to 3 years.

Infective endocarditis is a pathology that still presents a high burden of morbidity and mortality. Several observational studies and national and international registries showed that patients undergoing invasive cardiovascular procedures (surgical or percutaneous) are at higher risk of developing infective endocarditis, resulting in increased morbidity, length of hospital stay and mortality related to these procedures. The role of antibiotic prophylaxis is therefore crucial in the prevention of postoperative infections. This is accompanied by new emerging strategies in the pre- and postoperative nursing management of patients.