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Objective: The study objective was to determine whether targeted therapy to optimize cerebral oxygenation is associated with improved neurocognitive and perioperative outcomes., Methods: In a prospective trial, intraoperative cerebral oximetry monitoring using bilateral forehead probes was performed in cardiac surgical patients who were randomly assigned to an intervention group in which episodes of cerebral oxygen desaturation (<60% for >60 consecutive seconds at either probe) triggered an intervention protocol or a control group in which the cerebral oximetry data were hidden from the clinical team, and no intervention protocol was applied. Cognitive testing was performed preoperatively and at postoperative months 3 and 6; domains studied were response speed, processing speed, attention, and memory. Perioperative outcomes studied were death, hospital length of stay, intensive care unit length of stay, postoperative day of extubation, time on mechanical ventilation, intensive care unit delirium, Sequential Organ Failure Assessment on intensive care unit admission, and intensive care unit blood transfusion., Results: Group mean memory change scores were significantly better in the intervention group at 6 months (0.60 [standard error, 0.30] vs -0.17 [standard error, 0.33], adjusted P = .008). However, presence, duration, and severity of cerebral desaturation were not associated with cognitive change scores. Perioperative outcomes did not differ between the intervention and control groups., Conclusions: Targeted therapy to optimize cerebral oxygenation was associated with better memory outcome in a group of cardiac surgical patients. Some aspects of the protocol other than desaturation duration and severity contributed to the observed neuroprotective effect., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Low bispectral index (BIS) and low mean arterial pressure (MAP) are associated with worse outcomes after surgery. We tested the hypothesis that a combination of these risk factors, a 'double low', is associated with death and major complications after cardiac surgery., Methods: We used data from 8239 cardiac surgical patients from two US hospitals. The primary outcomes were 30-day mortality and a composite of in-hospital mortality and morbidity. We examined whether patients who had a case-averaged double low, defined as time-weighted average BIS and MAP (calculated over an entire case) below the sample mean but not in the reference group, had increased risk of the primary outcomes compared with patients whose BIS and/or MAP were at or higher than the sample mean. We also examined whether a prolonged cumulative duration of a concurrent double low (simultaneous low MAP and BIS) increased the risk of the primary outcomes., Results: Case-averaged double low was not associated with increased risk of 30-day mortality {odds ratio [OR] 1.73 [95% confidence interval (CI) 0.94-3.18] vs reference; P =0.01} or the composite of in-hospital mortality and morbidity [OR 1.47 (95% CI 0.98-2.20); P =0.01] after correction for multiple outcomes. A prolonged concurrent double low was associated with 30-day mortality [OR 1.06 (95% CI 1.01-1.11) per 10-min increase; P =0.001] and the composite of in-hospital mortality and morbidity [OR 1.04 (95% CI 1.01-1.07), P =0.004]., Conclusions: A prolonged concurrent double low, but not a case-averaged double low, was associated with higher morbidity and mortality after cardiac surgery., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Objectives: The purpose of this study was to investigate whether patients with an elevated left ventricular mass index undergoing cardiac surgery were more likely to experience postoperative atrial and ventricular arrhythmias., Design: A retrospective analysis., Setting: A single tertiary care university hospital., Participants: One thousand consecutive patients undergoing all types of adult cardiac surgery., Interventions: With institutional review board approval, intraoperative transesophageal echocardiographic images were reviewed by a single reviewer. The left ventricular mass index was calculated using the American Society of Echocardiography-recommended formula. Medical charts were reviewed for the occurrence and type of clinically significant postoperative arrhythmias., Measurements and Results: Of the patients who had an elevated left ventricular mass index, 47.6% (225/473) developed clinically significant postoperative arrhythmias compared with 38.3% (142/371) of patients with a normal left ventricular mass index (odds ratio [OR] = 1.46; 95% confidence interval [CI], 1.11-1.93; p = 0.007). In the multivariate analysis, this finding remained statistically significant, controlling for the effects of age, weight, sex, surgery type, left ventricular function, functional status, left atrial dimensions, and a history of atrial fibrillation (OR = 1.40; 95% CI, 1.03-1.90 per 100-g/m(2) increase in the left ventricular mass index). An increased left ventricular mass index was also an independent predictor of the separate or combined occurrence of atrial or ventricular arrhythmias., Conclusions: An elevated left ventricular mass index was a strong independent predictor of clinically significant postoperative atrial and ventricular arrhythmias after adult cardiac surgery. Although prospective validation is required, targeting patients for arrhythmia prophylaxis therapy may be justified in patients with a left ventricular mass index >188 g/m(2)., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Increased left ventricular mass (LVM) is a well-recognized predictor of cardiovascular morbidity and mortality in epidemiological studies, but its impact on mortality after cardiac surgery is poorly defined. We hypothesized that patients with increased LVM index (LVMI) were more likely to have greater 30 day and 1 yr mortality., Methods: With IRB approval, intraoperative transoesophageal echocardiography images of 844 cardiac surgical patients were reviewed. LVMI was calculated using the American Society of Echocardiography recommended formula. Outcome variables studied were 30 day and 1 yr mortality., Results: Mortality within 30 days occurred in 28 patients (3.3%) and within 1 yr in 91 patients (10.8%). An almost linear relationship was found between increasing LVMI and the risk of mortality within 30 days of cardiac surgery. The odds ratio (OR) of dying within 30 days of surgery was 1.15 (95% confidence interval 1.01-1.31) per 20 g m(-2) increase in LVMI. This finding remained statistically significant in multivariate analysis controlling for the effects of age, weight, gender, surgery type, LV function, and functional status [OR=1.36 (1.11-1.66) per 20 g m(-2) increase]. Increased LVMI was not found to be a statistically significant predictor of 1 yr mortality., Conclusions: Increased LVMI, but not LV systolic function as measured by the fractional area of contraction (FAC) was identified as a strong independent predictor of perioperative mortality after adult cardiac surgery. The relationship between LVMI and risk of 30 day mortality was nearly linear. Furthermore, decreased FAC, and not LVMI, was a strong independent predictor of 1 yr mortality.

Objective: The primary purpose of this study was to determine the practicality of long-term, postoperative neurocognitive assessment via remote Internet-based testing in a cohort of patients who had undergone cardiac or thoracic aortic surgery within the previous 6 years. The secondary aim of this study was to examine the relationships among hypothermic circulatory arrest time, cardiopulmonary bypass time, and selective cerebral perfusion time with long-term postoperative neurocognitive function, as assessed by this novel testing method., Methods: Three hundred patients who had undergone cardiac and/or proximal aortic surgery with cardiopulmonary bypass (n = 207), thoracic aortic surgery with hypothermic circulatory arrest (n = 67), or thoracic aortic surgery with hypothermic circulatory arrest and selective cerebral perfusion (n = 26) within the previous 6 years underwent Internet-based neurocognitive assessment., Results: The duration of hypothermic circulatory arrest was negatively associated with processing speed scores and memory scores; arrest duration greater than 21 to 24 minutes was negatively associated with response speed scores. These associations were independent of time since surgery, age at testing, and educational level. Neither cardiopulmonary bypass duration nor selective cerebral perfusion duration was associated with test score results., Conclusions: This study demonstrated the practicality of long-term neurocognitive assessment of patients who have undergone cardiac and thoracic aortic surgery by means of Internet-based computerized testing. Furthermore, there was a negative association between the duration of intraoperative hypothermic circulatory arrest and long-term postoperative neurocognitive function that needs further examination in prospective studies., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To investigate the incidence of preanesthesia hypertension, case cancellation for hypertension, and association with postoperative outcomes., Design: Retrospective descriptive, univariate, and multivariate analyses of electronic anesthesia and hospital records., Setting: A large urban academic medical center., Participants: Adult elective surgical patients with preinduction blood pressure (BP) >140/90 mmHg during calendar years 2002 to 2008., Interventions: None., Measurements and Main Results: Preinduction hypertension was present in 21,126 of 209,985 (10%) patients, and the incidence of adverse outcomes (elevated troponin or in-hospital death) was 1.3% overall and 2.8% for the subset of patients with baseline systolic BP >200 mmHg. Independent predictors of adverse outcome included increased baseline systolic BP, intraoperative diastolic BP <85 mmHg, increased intraoperative heart rate, blood transfusion, and anesthetic technique, controlling for standard risk factors. A total of 69 hypertensive patients (0.3%) had surgery cancelled before the induction of anesthesia; 29 of these cancellations occurred among the 1,330 patients with baseline SBP >200 mmHg (2.2%). Among 42 "cancelled" patients who returned for surgery hours to years later, the average preinduction BP was 192/102 mmHg, and adverse cardiovascular outcomes occurred in 4.8%., Conclusions: The increasing severity of preinduction hypertension was an independent risk factor for postoperative myocardial injury/infarction or in-hospital death. Only a small percentage of cases with patients presenting with severe hypertension were cancelled, and the delay of surgery did not result in interval normalization of blood pressure., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Neurological dysfunction and stroke following cardiac surgery and thoracic surgery requiring hypothermic circulatory arrest is a well-defined problem. The original studies in CABG patients identified risk factors, such as prior stroke and lower educational level. There is older evidence suggesting that higher perfusion pressures during cardiopulmonary bypass are helpful. Hyperthermia during rewarming on cardiopulmonary bypass and postoperative hyperthermia have been associated with adverse cognitive outcomes. Glucose management intraoperatively remains controversial, but most now advocate for moderate glucose control using insulin, if required. The subset of patients having thoracic aortic surgery requiring periods of aortic discontinuity are particularly problematic. A cerebral protection strategy should be determined, and this may include hypothermic circulatory arrest, selective cerebral perfusion, or retrograde cerebral perfusion. All of these techniques have been associated with good surgical outcomes, but there is little information on cognitive outcomes of thoracic aortic surgery.

The influence of anesthetic choices and techniques upon outcomes in cardiac surgery is difficult to ascertain because of the low incidence of morbid and fatal outcomes that are attributable to anesthetic management. This discussion summarizes several areas that have been addressed in clinical trials, including temperature management, intraoperative hemodynamics, and glucose control.

Background: Neonates and infants often require extended periods of mechanical ventilation facilitated by sedation and neuromuscular blockade., Methods: Twenty-three patients aged younger than 2 yr were randomly assigned to receive either cisatracurium or vecuronium infusions postoperatively in a double-blinded fashion after undergoing congenital heart surgery. The infusion was titrated to maintain one twitch of a train-of-four. The times to full spontaneous recovery of train-of-four without fade, extubation, intensive care unit discharge, and hospital discharge were documented after drug discontinuation. Sparse sampling after termination of the infusion and a one-compartment model were used for pharmacokinetic analysis. The Mann-Whitney U test and Student t test were used to compare data between groups., Results: There were no significant differences between groups with respect to demographic data or duration of postoperative neuromuscular blockade infusion. The median recovery time for train-of-four for cisatracurium (30 min) was less than that for vecuronium (180 min) (P < 0.05). Three patients in the vecuronium group had prolonged train-of-four recovery: Two had long elimination half-lives for vecuronium, and one had a high concentration of 3-OH vecuronium. There were no differences in extubation times, intensive care unit stays, or hospital stays between groups., Conclusions: Our results parallel data from adults demonstrating a markedly shorter recovery of neuromuscular transmission after cisatracurium compared with vecuronium. Decreased clearance of vecuronium and the accumulation of 3-OH vecuronium may contribute to prolonged spontaneous recovery times. Cisatracurium is associated with faster spontaneous recovery of neuromuscular function compared with vecuronium but not with any differences in intermediate outcome measures in neonates and infants.

Unlabelled: We sought to determine how frequently intraoperative transesophageal echocardiography (TEE) altered the planned surgical procedure and to assess the potential cost implications associated with these changes. A retrospective chart review was conducted at one university hospital. Cardiac surgical operative notes from July 1999 through June 2000 were reviewed. We interrogated all adult cardiac surgical records for patients scheduled for repair of coronary artery disease or valvular disease requiring the use of cardiopulmonary bypass. Cancellations based on TEE findings were included in the analysis. Of the 430 patient records reviewed, 24 procedures were ether canceled or changed on the basis of the intraoperative TEE examination (5.6%; 95% confidence interval, 3.6%-8.2%). Six of these cases involved valvular heart disease, and the remaining 18 involved the intraoperative diagnosis and repair of a patent foramen ovale. A cost-benefit analysis based on the 6 valvular diagnoses revealed a saving of $230 per patient. Assuming that unnecessary present or future operations may be avoided by altering the surgical plan on the basis of TEE findings, these preliminary data suggest that routine intraoperative TEE in cardiac surgery is beneficial and cost-effective., Implications: A review of 430 adult cardiac surgical records indicates that routine transesophageal echocardiography during cardiac surgery, including coronary artery surgery, is beneficial and cost-effective.

Purpose: Weight-based heparin and protamine dosing strategies for cardiopulmonary bypass (CPB) do not take into account interpatient variability in drug sensitivity and may result in bleeding complications. We compared the Hemochron RxDx heparin and protamine titration system with standard weight based management with regard to heparin dose, protamine dose, and perioperative bleeding., Methods: One hundred and thirty-five cardiac surgical patients were randomised into four groups. Group 1 received standard heparin and protamine management: Group 2 received heparin and protamine by in vitro titration. Group 3 had the heparin dose titrated, and group 4 had the protamine dose titrated. Coagulation tests, bleeding, and transfusion requirements were measured., Results: The initial heparin bolus predicted by the titration was < 300 U.kg-1 in all patients. Group 2 received a lower heparin bolus for the initiation of bypass but total heparin doses were not different among groups (group 1 = 365 +/- 43, group 2 = 348 +/- 73 U.kg-1, group 3 = 394 +/- 86 U.kg-1, group 4 = 376 +/- 60; P = 0.06). Groups 2 and 4 received a lower initial and a lower total protamine dose (total dose group 1 = 4.03 +/- 0.65 mg.kg-1, group 2 = 3.56 +/- 1.11 mg.kg-1, group 3 = 4.22 +/- 0.90 mg.kg-1, group 4 = 3.38 +/- 0.98 mg.kg-1, P = 0.001). The incidences of incomplete heparin neutralisation (P = 0.14) and heparin rebound (P = 0.1) were not different among groups. Postoperative bleeding and transfusion requirements did not differ., Conclusion: In cardiac surgical patients, heparin and protamine titration did predict a lower protamine dose but did not result in a measurable improvement in haemostasis during the perioperative period.

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.

We compared portable bedside tests of whole blood coagulation with standard laboratory plasma coagulation tests to assess the accuracy and precision of the bedside tests in a clinical setting (postcardiac surgery). The Ciba Corning 512 Coagulation Monitor (Ciba Corning Diagnostics Corp., Medfield, MA) and the Hemochron 801 (International Technidyne Corp., Edison, NJ) were tested. One hundred forty-one patients who underwent cardiac surgery requiring cardiopulmonary bypass were evaluated upon arrival in the intensive care unit. Nine milliliters of fresh whole blood were used to obtain the prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT), and the heparin-neutralized thrombin time (HNTT) that were measured by bedside coagulation monitors. TT and HNTT were only measured by the Hemochron method. Blood from the same sample was also sent to the Hospital Stat Laboratory for simultaneous comparison of bedside results and standard coagulation tests. For PT and aPTT testing, an accuracy of +/- 10% and a precision of +/- 25% were considered clinically acceptable. Both of the PT tests met the dual criteria for clinical acceptability, but the aPTT tests did not meet either criterion. The difference between Hemochron TT and Hemochron HNTT correlated weakly, but significantly, with laboratory aPTT ratio (r = 0.52, P < 0.001). The slope of the regression line indicated that a TT-HNTT difference > 30 s correlated with an aPTT > 1.5 x control. We conclude that, in the postoperative cardiac surgical patient, PT was both accurate and precise in two commercially available tests, but aPTT was not.(ABSTRACT TRUNCATED AT 250 WORDS)

The activated clotting time (ACT) is a commonly used method for assessing the degree of anticoagulation during cardiac surgery. Two automated ACT monitors were evaluated in 29 adult patients undergoing cardiac surgery. The HemoTec ACT monitor (HTC; HemoTec, Inc., Englewood, CO) was evaluated using 0.8 ml of whole blood in dual-chamber, high range kaolin cartridges. The Hemochron ACT monitor (HCH; International Technidyne, Inc, Edison, NJ) was evaluated using 2.0 ml of whole blood in glass tubes with diatomaceous earth activator. Following sternotomy, a coagulation profile consisting of HTC, HCH, and a partial thromboplastin time (PTT) was obtained (T0). Beef lung heparin was administered in 3 consecutive doses: 40 units/kg (T1), 80 units/kg (T2), and 180 units/kg (T3). Coagulation profiles were drawn 5 minutes after each dose. Following cardiopulmonary bypass (CPB), coagulation profiles were drawn 15 minutes (T4), 2 hours (T5), and 24 hours (T6) after the protamine dose. HTC and HCH ACT values differed significantly at T1, T2, and T4 (p less than 0.001). In the pre-CPB period, the HCH ACT correlation with PTT divided by its control value (PTT/CTL) (r = 0.73) was significantly better (p = 0.02) than the correlation of HTC ACT with PTT/CTL (r = 0.41). In the post-CPB period, both HCH ACT (r = 0.45) and HTC ACT (r = 0.30) correlated weakly with PTT/CTL. In the bias analysis, the limits of agreement (of all HCH and HTC ACT values) showed that HTC ACT is between 61% and 133% of the HCH ACT value in 95% of determinations.(ABSTRACT TRUNCATED AT 250 WORDS)