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Introduction: The objective of this study was to investigate the effect of mivacurium in the application of fast-track anesthesia for transthoracic device closure of ventricular septal defects (VSDs) in children. Methods: The data of 108 children who underwent transthoracic device closure of VSDs from December 2018 to June 2020 were recorded and analyzed. All children were divided into group M (mivacurium group, n=55) and group C (cisatracurium group, n=53) according to the different muscle relaxant drug used. Results: No statistically significant differences in general preoperative data, intraoperative hemodynamic changes, or the incidence of adverse reactions were noted between the two groups (P>0.05). However, the intubation condition rating of children in group M was better than that in group C. The onset time, duration of clinical action and recovery index of the muscle relaxant, postoperative mechanical ventilation duration, and length of intensive care unit stay in group M were significantly lower than those in group C (P

Purpose of review The number of complex procedures performed in the cardiac catheterization laboratory (CCL) is rapidly increasing. Because of their complexity, they frequently require the assistance of an anesthesiologist. The CCL is primarily designed to facilitate a percutaneous cardiac intervention; therefore, it might be a challenging workplace for an anesthesiologist. The aim of this review is to briefly present tasks and challenges of providing anesthesia in the CCL and to provide a concise description of common cardiac procedures performed there. Recent findings Recent literature indicates that many complicated cardiac procedures can be performed in CCL under monitored anesthesia care. At the same time several of them (e.g. transcatheter aortic valve replacement) are quickly becoming a viable alternative for surgical valve replacement. The most recent expansion of CCL procedures is related to rapidly growing population of grown-ups with congenital heart disease. All aforementioned developments present new challenges to an anesthesiologist. Summary New and fast development of percutaneous cardiac interventions has created a new working place for the anesthesiologist - the CCL. Our expertise in complex cardiac pathophysiology allows conduct of complicated procedures outside of the operating theater. For the same reasons, there is ongoing discussion whether anesthesia support in CCL should be provided by a general or cardiac anesthesiologist.

Cardiac rehabilitation (CR) is considered as a cornerstone in improving physical function in older people after cardiac procedures; however, its effects in patients aged more than 75 years are still debated. To assess the effectiveness of early CR in improving functional outcomes and reducing the length of stay (LOS) and sanitary costs in patients aged ≥ 75 years. We retrospectively analysed data from medical records of patients aged ≥ 75 years performed CR after cardiac procedures. Patients were divided into two groups according to the median timing lasting from the cardiac procedure and CR start: ‘early rehabilitation’ (

Purpose: The impact of cardiology fellows (CFs) and interventional cardiology fellows (ICFs) on patient radiation and contrast exposure during diagnostic coronary angiography and percutaneous coronary intervention is unknown. Methods: Between 2011 and 2014, 16,175 cases were retrospectively assessed involving 27 CFs, 22 ICFs and 24 staff as primary operators. Results: During diagnostic coronary angiography, ICFs administered the lowest radiation dose (5,648±5,523 cGy*cm2; 1.30 ± 1.27 mSv)—achieving 22% less radiation than the staff (6,889±4,294 cGy*cm2; 1.58 ± 0.99 mSv) and 36% less than CFs (7,700±6,751 cGy*cm2; 1.77 ± 1.55 mSv) (p

Background Despite the proven benefit of transradial access over transfemoral access in cardiac procedures, the transition for cerebrovascular procedures has only been slowly enforced. We present our experience with transradial access in cerebral diagnostic angiographies and neurointerventional procedures. Methods We performed a retrospective analysis of patients who underwent transradial access for cerebrovascular procedures in 3 German centers between February 2017 and May 2019. Demographics, technical features, and complications were evaluated. Results Transradial access was successful in 40/45 endovascular procedures (89%). Selected catheterization of the intended vessels was obtained in 95% of cases (40/42). The rate of procedure-related vascular complications was 2% (1/45). Conclusions In this small retrospective series, transradial access proved to be safe and efficient. In the future, it is planned to further promote it as a standard access alternative for more patients.

The use of transradial access for cardiac procedures has increased worldwide over the past two decades. Despite the many advantages this technique offers, there remains some concern that radial artery occlusion, a potential complication of radial cannulation, might lead to significant ischemic sequelae in the hand. This paper reviews the major causes, its possible consequences and the strategies for its prevention and treatment. It appears however from multiple studies that there is little or no correlation between radial occlusion and symptomatic hand ischemia.

Summary Background Cardiac catheterization is one of the most widely performed cardiac interventional procedures worldwide. The Austrian National Catheterization Laboratory Registry (ANCALAR), started in 1992, collects annual data on cardiac catheterization in Austria. The registry enables in-depth understanding of the dynamics of cardiac catheterization procedures and their use across 34 cardiac catheterization laboratories in Austria. Methods Data from ANCALAR on cardiac catheterization including the latest data for 2017, voluntarily provided by centers with cardiac catheterization laboratories, were analyzed. Where possible, international comparisons in therapeutic and interventional cardiac procedures are made with Switzerland and Germany. Results Internationally, Austria ranks alongside the top countries in Europe. Whilst the number of people undergoing routine percutaneous coronary interventions (PCI) remains stable, complex and acute interventions are increasing year by year in Austria. Conclusion Evidence from ANCALAR revealed that Austria is another example of the difficulties of weighing current guidelines with new emerging evidence and resulting real-life clinical practice in the dynamic world of interventional cardiology.

Medical and surgical approaches to children with trisomy 13 and 18 are evolving, and an increasing number of patients are being considered for simple and complex cardiac procedures. This review describes how the shifts in medical and social considerations for children with trisomy 13 and 18 mirror the shifts that occurred 50 years ago for children with trisomy 21. Yet the variability in cardiac lesions, and variability in non-cardiac comorbidities, is much greater for patients with trisomy 13 and 18 than for those with trisomy 21. That variability, combined with the severe neurologic impairment in survivors, complicates the current risk: benefit balance of surgical intervention. Consistent approaches to care for these patients should be built on an evidence base, and should include contributions from specialists in medical ethics and palliative care.

The purpose of this report is to provide an updated description of the technique of bilateral sequential lung transplant via median sternotomy. A sternotomy provides the advantage of less morbidity than the clamshell incision, as well as exposure to perform mechanical circulatory support and concurrent cardiac procedures. Our experience shows that lung transplantation via a midline sternotomy can be done with equivalent to better short-term outcomes than a clamshell incision, including earlier extubation and fewer transfusions. Familiarity with this technique is important for all surgeons managing end-stage lung disease.

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.

There is a large variation in the factors used to estimate effective doses from kerma area product (KAP) for interventional cardiology. These factors are required to estimate population doses. This paper presents the results for this conversion factor for cardiac procedures using tissue weighting factors of ICRP-103 and the impact of the added copper filtration in the X-ray beam. The data from 925 cardiac procedures and 75,347 radiation events were collected from two angiography laboratories using the DICOM Radiation Dose Structured Reports (RDSR). Effective doses were calculated with Monte Carlo software and the dosimetric, technical and geometrical information included in the RDSR. In one laboratory, with an X-ray system without Cu filtration for the cine runs, a factor of 0.21 ± 0.05 mSv/(Gy·cm2) was obtained. In other laboratory, incorporating a patient dose reduction technique, and 0.4 mm of Cu filtration for cine runs, the conversion factor was 0.29 ± 0.05 mSv/(Gy·cm2). The analysis of the radiation events for the different Cu filtrations (0.0; 0.1; 0.4 and 0.9 mm) resulted in conversion factors of: 0.16; 0.27; 0.34 and 0.40 mSv/(Gy·cm2) respectively. The estimation of effective and population doses from KAP should take into account the Cu filtration in the X-ray beam. For the X-ray system with patient dose reduction technique, using 0.4 mm Cu for cine runs, the global conversion factor increased by 38%, from 0.21 to 0.29 mSv/(Gy·cm2) in comparison to the standard X-ray system with a protocol that did not include copper filtration for cine acquisitions.

Intravascular lithotripsy facilitates percutaneous coronary intervention of lesions with severe calcification by using high-pressure ultrasonic energy. It is the newest adjunctive tool for calcium modification and is showing promise as its users gather more experience and it becomes readily available worldwide. This article reviews intravascular lithotripsy technology, the evidence in the literature, and the advantages and disadvantages compared with other forms of calcium modification, and discusses its role in specific subsets of coronary lesions. It concludes with a discussion about the future direction of research involving this new technology as its role within percutaneous cardiac procedures becomes more defined.

BackgroundThe repercussions of the COVID-19 pandemic concern care in many clinical areas, including cardiology. We aim to assess the impact of the COVID-19 pandemic on hospital care for cardiac patients.MethodsScoping review. Performance indicators were extracted and collated to inform on changes in the use of health services and care provided during January - June 2020.ResultsDatabase searches yielded 6277 articles, of which 838 articles met the inclusion criteria during initial screening. After full-text screening, 94 articles were considered for data extraction. In total, 1637 indicators were retrieved, showing large variation in the indicators and their definitions. Most of the indicators that provided information on changes in number of admissions (n=118, 88%) signalled a decrease in admissions; 88% (n=15) of the indicators showed patients’ delayed presentation and 40% (n=54) showed patients in a worse clinical condition. A reduction in diagnostic and treatment procedures was signalled by 95% (n=18) and 81% (n=64) of the indicators reporting on cardiac procedures, respectively. Length of stay decreased in 58% (n=21) of the indicators and acute coronary syndromes treatment times increased in 61% (n=65) of the indicators. Outpatient activity decreased in 94% (n=17) of the indicators related with outpatient care, whereas telehealth utilization increased in 100% (n=6). Outcomes worsened in 40% (n=35) of the indicators, and mortality rates increased in 52% (n=31).ConclusionAll phases of the hospital cardiac care pathway were affected. This information could support the planning of care during the ongoing pandemic and in future events.

The intricate nature of congenital heart disease requires understanding of the complex, patient-specific three-dimensional dynamic anatomy of the heart, from imaging data such as three-dimensional echocardiography for successful outcomes from surgical and interventional procedures. Conventional clinical systems use flat screens, and therefore, display remains two-dimensional, which undermines the full understanding of the three-dimensional dynamic data. Additionally, the control of three-dimensional visualisation with two-dimensional tools is often difficult, so used only by imaging specialists. In this paper, we describe a virtual reality system for immersive surgery planning using dynamic three-dimensional echocardiography, which enables fast prototyping for visualisation such as volume rendering, multiplanar reformatting, flow visualisation and advanced interaction such as three-dimensional cropping, windowing, measurement, haptic feedback, automatic image orientation and multiuser interactions. The available features were evaluated by imaging and nonimaging clinicians, showing that the virtual reality system can help improve the understanding and communication of three-dimensional echocardiography imaging and potentially benefit congenital heart disease treatment.

The interest in percutaneous high-tech cardiac procedures has increased in recent years together with its safety and efficacy. In fragile patients, procedural sedation and analgesia are used to perform most of the procedures. General anesthesia remains the technique of choice during the team learning curve and might be required in selected patients or in emergent situations. Despite the high costs of percutaneous high-tech cardiac procedures, the decrease in length of hospital stays, rate of intensive care admission and complications, balance the increase in devices costs. In fragile patients who undergo percutaneous high tech cardiac procedures, the primary role of the anesthesiologist is to prevent the need for postprocedural intensive care unit and complications rate. Starting from the experience of a large university third level hospital we identified the eight most commonly performed contemporary percutaneous high tech cardiac procedures (ventricular tachycardia and atrial fibrillation ablation, protected percutaneous coronary intervention, transcatheter aortic valve implantation, MitraClip® (Abbott Laboratories; Abbott Park, IL, USA), percutaneous patent foramen ovale closure, left atrial appendage closure, and dysfunctional lead extraction), discuss the role of procedural sedation and analgesia in this setting, and explore future perspectives.

The number of patients with complex congenital heart disease (CHD) presenting for non-cardiac procedures is steadily increasing and more and more anaesthesiologists will be asked to participate in their care. This can be a very challenging task and will require adequate planning and preparation, but also some basic scientific inquiries.

Neurological complications after cardiac surgery and percutaneous cardiac interventions are not uncommon. These include periprocedural stroke, postoperative cognitive dysfunction after cardiac surgery, contrast-induced encephalopathy after percutaneous interventions, and seizures. In this article, we review the incidence, pathophysiology, diagnosis, and management of these complications. Improved understanding of these complications could lead to their prevention, faster detection, and facilitation of diagnostic workup and appropriate treatment.

The advance of technology in the recent era of surgery has outpaced the ability of the medical community to adequately interrogate the true utility of certain techniques prior to their widespread adoption. Often hospitals and patients within a community seeking the latest technology become a driving force for surgeons to adopt new techniques. Ideally, the benefit of these measures are examined and discussed within the surgical community prior to their establishment as "common practice." Many surgeons would argue that the true role for robotics in surgery is yet to be properly defined. Certainly there is an appeal for hospitals in marketing themselves as centers offering robotic surgery, and for surgeons to be promoted as regional experts in robotics and minimally invasive surgery. Although they may not know why, patients request robotic surgery in the hopes that they are receiving the most advanced care possible. We as surgeons, however, must decide when the application of robotics is truly advantageous. There is no doubt that the robot enhances the technical ability of the surgeon in ways that common laparoscopic techniques currently do not. The wristed instruments increase the maneuverability of the operating instruments with two more degrees of freedom than traditional laparoscopic instruments. The robot adds internal pitch and yaw to the pitch, yaw, grasp, rotation, and in-and-out motions of the laparoscopic instruments. The end result is that the instruments mimic the motion of a surgeon's hands with the added benefits of tremor reduction and motion scaling. Confined spaces such as the pelvis and mediastinum provide arenas where these benefits are best realized. The visualization offered by the da Vinci system also serves as an enhancement to traditional laparoscopy. A stereoscopic camera allows for representation in both twodimensional and three-dimensional views. The three-dimensional view provides a clarity and depth of field which further improves the surgeon's ability to discriminate among tissue planes. Furthermore, the surgeon has the added benefit of control over the camera with one of the robot arms. This eliminates the frustration that can be met with inexperienced or fatigued camera operators and enhances the ability of the surgeon to complete difficult maneuvers in an efficient fashion. Another benefit of robotics not to be overlooked is the reduction of surgeon fatigue. The long term toll of laparoscopy on an individual surgeon may still not be fully realized given the fairly recent adoption of laparoscopy into the every day practice of many surgeons. Over the course of a twenty to thirty year career, the stresses of awkward positioning and maneuvering may prove to be detrimental to the health of many operating surgeons. During a robotic procedure, the surgeon is sitting comfortably with arms and head resting against padded surfaces. Recentering of hand controls eliminates the cumbersome task of maintaining positions beyond the normal range of comfort and convenience. Control of the visual field with the head comfortably supported reduces the neck strain often encountered during many laparoscopic procedures. Although the immediate benefit to any given patient is difficult to demonstrate, the pending dilemma of physician shortage reminds us that

Purpose - There is a paucity of literature comparing patient and staff dose during coronary angiography (CA), implantable cardiac devices, permanent pacemakers (PPM) and electrophysiology (EP) procedures and little noting dose to staff other than cardiologists. This study sought to compare patient and occupational dose to staff during a range of fluoroscopically guided cardiac procedures. Methods - Radiation dose levels for the patients (n=1651), cardiologists (n=24), scrub (n=32) and scout nurses (n=35) were measured in a prospective single-centre study between February 2017 and August 2019. A comparison of dose during CA, device implantation, PPM insertion and EP studies was performed. Three Philips angiographic units were used, and DoseAware badges were worn on the temple of staff. Results - Results indicated that occupational dose during PPM was (statistically) significantly higher than other procedures. The cardiologist had the highest measured mean dose during biventricular implantable cardioverter defibrillators; levels were approximately five times that of ‘normal’ pacemaker insertions. Transcatheter aortic valve implantations (TAVI) were associated with relatively high mean doses for both staff and patients and had a statistically significant higher (>2 times) mean patient dose area product than all other categories. TAVI workups were also related to higher mean cardiologist and scrub nurse dose. It was observed that the mean scrub nurse dose can exceed that of the cardiologist. Scout nurses had the highest mean staff dose during EP studies. Conclusions - Given the significantly higher temple dose associated with PPM insertion, cardiologists should consider utilizing ceiling mounted lead shields, lead glasses and/or skull caps where possible. Efforts should also be made to minimize the use of DSA during TAVI and TAVI workups to reduce cardiologist, nurse and patient dose.

Complications of minimally invasive cardiac procedures range from self-limiting to life-threatening. This review article will highlight the incidence, risk factors, and imaging features of acute thoracic complications of three of the most common minimally invasive cardiac procedures encountered in practice: transcatheter aortic valve replacement, cardiac implantable electronic devices, and pulmonary vein isolation. Most minimally invasive cardiac procedures have a relatively low risk profile. Acute thoracic complications are usually detected during the procedure; however, delayed presentations are not uncommon, and therefore imaging with computed tomography or x-ray, in conjunction with echocardiography, plays an important role. As most of the imaging-relevant acute thoracic complications are secondary to catheter and device deployment within a vessel or cardiac chamber, the highlighted complications in this article can be extrapolated to a majority of the several other minimally invasive techniques not discussed here. Radiography and computed tomography demonstrate readily recognizable abnormalities that confirm or suggest procedure related complications and guide further management.

Background: This retrospective study investigates the efficacy and safety of the novel Celt ACD® vascular closure device (VCD) following antegrade and retrograde common femoral artery (CFA) punctures for the treatment of peripheral artery disease in a challenging patient collective (e.g. calcifications, obesity, and anticoagulation). Methods: A total of 208 VCDs (i.e. 100 antegrade and 108 retrograde) were deployed between October 2019 and December 2020 in a tertiary referral interventional radiology department. Fifty-two devices were undersized in relation to the introducer sheath (up to 2 Fr). Technical success and VCD related complications were evaluated in the immediate post procedure period and the following 24 h clinically. In 68% of cases, additional duplex ultrasound was performed prior to discharge. Results: The overall technical success rate was 97%. Technical failures following antegrade approach were due to a too acute access angle (⩾60°), rendering it impossible to pass the applicator tip through the sheath lumen. A subgroup analysis of technical success pinpoints severe calcification as another key limiting factor in VCD use ( p = 0.004). Comparing equally sized with undersized device selection ( p = 0.196), direction of approach ( p = 0.265), and body mass index ( p = 0.184) proved to be insignificant. Five (2%, 5/208) major complications occurred: Four antegrade (i.e. one false aneurysm, one vessel laceration with retroperitoneal hemorrhage, two device migrations; 4%, 4/100) and one following retrograde access (i.e. >6 cm hematoma, 1%, 1/108)). Complications were successfully managed with manual compression or interventional procedures. Conclusions: The novel clip-based VCD proved to be effective with a low VCD related complication rate.

A man in his 20s with Down syndrome presented to cardiology clinic for evaluation of a murmur. He denied symptoms. He had no prior history of invasive cardiac procedures or cardiac surgery. His examination revealed a murmur. An echocardiogram was performed and a diagnostic image is shown in figure 1. Figure 1 Colour M-mode echocardiographic image of the mitral valve. 1. Based on the colour Doppler M-mode echocardiographic image (figure 1), what is the most likely cause …

Mechanical circulatory support (MCS) devices, especially veno-arterial extracorporeal membrane oxygenation (VA-ECMO) devices, are increasingly used to shore complex cardiac procedures in high-risk patients. We are reporting two cases where patients underwent coronary artery bypass grafting (CABG) under support of VA-ECMO in the setting of cardiogenic shock complicating acute myocardial infarction. The patients had different courses, but both survived the initial insult and were weaned successively from VA-ECMO. Our report indicates that VA-ECMO can be used instead of the cardiopulmonary bypass machine (CPB) to support the circulation during CABG surgery in patients with complex coronary anatomy and unstable haemodynamics. Future studies focusing on the long-term outcomes of such patients will probably help to establish the optimal management of this type of patients.

Until 2019, guidelines for procedural sedation emphasized a detailed process most applicable for elective procedures scheduled well in advance. These guidelines provided by the American Society of Anesthesiologists were adopted by many specialties and institutions, and they have historically served the medical field well. However, cardiologists and other specialists often encounter urgent situations that demand unscheduled sedation. Physicians have been concerned about performing procedures in a fashion that "departs from the guidelines." In response, the American College of Emergency Physicians (ACEP) has developed a set of guidelines for patients requiring urgent unscheduled sedation. Many of the recommendations made within the novel ACEP guidelines are appropriate for cardiology, but there remain fundamental differences between trauma and other emergencies encountered in the emergency department and urgent cardiac procedures. This paper examines the differences between the American Society of Anesthesiologists and ACEP guidelines and provides some points to consider regarding best practices for cardiologists.

Background: Minimal invasive extracorporeal circulation (MiECC) circuits are an established alternative to conventional extracorporeal circulation (CECC). Based on the positive effects and improved perioperative outcomes of MiECC in adult cardiac surgery, this perfusion concept appears particularly attractive to pediatric cardiac surgery. So far, there are no reports on the clinical application of a MiECC system for corrective surgery in neonates and children. We report our initial experiences by using a MiECC system in pediatric cardiac surgery. Methods: A total of 38 pediatric patients underwent surgical interventions for a variety of congenital heart disease from March 2017 until August 2018 with a MiECC. Following the classification of MiECC circuits by the Minimal invasive Extra-Corporeal Technologies International Society (MiECTIS), type I and type III perfusion circuits were assembled depending on the planned intervention: type I for closed heart interventions and type III for open heart procedures. Primary outcome was conversion to CECC, secondary endpoints included major adverse cardiac or cerebrovascular events (MACCE). Results: MiECC perfusion was successfully performed in all patients (100%). Median patient age was 9.5 months (range, 0.2–176 months) with a median weight of 8.1 kg (range, 2.3–49 kg). For both MiECC types no system related technical complications were encountered. Beating heart procedures were performed in 23 cases (60%) at normothermia, while in 15 (40%) interventions cardioplegic cardiac arrest was induced at mild hypothermia. All patients had an uneventful perioperative course with no in-hospital mortality. MACCE did not occur during the hospitalization period. Conclusions: MiECC can be performed by using standard techniques for closed and open cardiac procedures for the correction of a variety of malformations in neonates and children with good results and uneventful postoperative course.

The aims of the present study were to present the frequency of multiple interventional cardiac procedures for a certain group of patients obtained at one of the largest paediatric hospitals in Chile. In addition it has been analysed cumulative kerma area product (KAP) and cumulative air kerma (CAK), and calculated organ doses for the patient groups undergoing 2, 3 and ≥ 4 procedures, using Monte Carlo software. Effective doses were also estimated for epidemiological purposes and to permit comparison with other imaging procedures. The sample used corresponds to the last 9 years and refers to a total of 1521 paediatric patients and 1824 interventional cardiac procedures. The results for frequency were: 13.7% of patients underwent 2 procedures, 4.1% underwent 3 procedures and 1.4% underwent 4 or more procedures. The median KAP and CAK values measured for the cumulative procedures in these three groups of patients were 3.7, 5.4 and 10.8 Gy·cm2 and 59.9, 83.2 and 147.6 mGy, respectively. In terms of the most irradiated organs during interventional cardiac procedures, the highest median values (for the group of ≥4 procedures) were: active bone marrow 5.0 mGy, lungs 23.5 mGy, oesophagus 15.2 mGy, thyroid 7.8 mGy and breast 11.0 mGy. Median dose value to the heart (for the group of ≥4 procedures) was 12.7 mGy. Median values in terms of calculated effective dose for the three patient groups (with 2, 3 and ≥4 procedures) were 3.4, 5.9 and 8.7 mSv, respectively.

Background The radial approach to cardiac procedures has become increasingly common. Although previous studies have suggested a favorable risk profile, serious complications can occur. The purpose of this study is to examine the incidence, subsequent treatment, and outcome of all suspected significant neurovascular complications following transradial cardiac procedures at a large US hospital. Methods We reviewed all patients who underwent a left heart catheterization, coronary angiogram, or percutaneous coronary intervention via the transradial approach at a single large academic medical center in the United States between 2010 and 2016. Consultations to the vascular and hand surgery services were examined to assess demographic variables, risk factors, presenting symptoms, subsequent treatment, and outcome of all serious complications. Results A total of 9,681 radial access cardiac procedures were performed during the study period. Twenty-four cases (0.25%) were suspected to have major complications and subsequently received consults. A total of 18 complications were diagnosed, including 8 vascular injuries or perforations, 4 hematomas, 4 radial artery occlusions, 1 case of compartment syndrome, and 1 severe radial artery spasm. Of the complications noted, 3 (16.7%) required operative interventions, but all recovered neurovascular function. Conclusions Radial artery access for cardiac procedures has become increasingly common and has been associated with a low rate of major peripheral neurovascular complications. The majority (83.3%) of complications were successfully treated with a nonoperative management algorithm.

AimThe primary goal of the study was to perform retrospective analysis of fast-track coronary artery bypass grafting at our institute to identify risk factors for prolonged hospital stay. A secondary goal was to identify and compare survival statistics with those published in literature.MethodWe performed a retrospective analysis of patients enrolled in our fast-track coronary artery bypass protocol. There were 709 patients with a mean age of 58.85 ± 8.9 years; 572 were men. The mean EuroSCORE II was 2.02% ± 2.64%. Of these 709 patients, 538 (76%) met the requirements for discharge within 100 hours.ResultsProlonged ventilation or reintubation, major pulmonary complications, gastrointestinal and neurological complications were the strongest predictors of fast-track failure. Persistent atrial fibrillation, postoperative transient renal impairment, requirement for noninvasive ventilation > 3 times, sternal wound infection, insulin-dependent diabetes mellitus, preoperative intraaortic balloon pump for chest pain or ST changes, preoperative severe left ventricular dysfunction, preoperative severe renal impairment, and peripheral arterial disease were also found to be significant risk factors for fast-track failure. Cumulative survival at 66 months of follow-up was 90.2% ± 0.02%.ConclusionThe risk factors listed above were associated with fast-track failure. Smoking cessation helps to nullify the factor of chronic obstructive pulmonary disease. Intraoperative elective insertion of a balloon pump does not affect the fast-track protocol. Survival was comparable to that described in the literature.

Percutaneous coronary intervention for the treatment of coronary artery disease is most commonly performed in the UK through the radial artery, as this is safer than the femoral approach. However, despite improvements in technology and techniques, complications can occur. The most common complication, arterial spasm, can cause intense pain and, in some cases, procedural failure. The incidence of spasm is dependent on several variables, including operator experience, artery size, and equipment used. An anti-spasmolytic cocktail can be applied to reduce spasm, which usually includes an exogenous nitric oxide (NO) donor (glyceryl trinitrate). NO is an endogenous local vasodilator and therefore is a potential target for anti-spasm intervention. However, systemic administration can result in unwanted side-effects, such as hypotension. A method that adopts local delivery of NO might be advantageous. This review article describes the mechanisms involved in radial artery spasm, discusses the advantages and disadvantages of current strategies to reduce spasm, and highlight the potential of NO-loaded nanoporous materials for use in this setting.

This article presents technical aspects of the arterial switch procedure. The arterial switch procedure is a technically reproducible operation that involves less three-dimensional judgment and fewer difficult sequencing decisions than many other complex cardiac procedures. Hemostasis is the most important principal that must be adhered to mainly through meticulous surgical technique. Meticulous technique will also lead to successful transfer of the coronary arteries. Teaching a surgical trainee how to manage a child who requires an arterial switch procedure requires instruction in the technical aspects of the procedure. However, this is just one component of the overall management of babies requiring this procedure. Attention and training should be directed at all areas of competence that have been emphasized by bodies such as the American College of Surgeons. Simulation is playing an increasingly important role in the instruction of surgical trainees within the domain of congenital heart disease.

Aims A global outbreak of Mycobacterium chimaera infections following cardiac surgery and linked to contaminated heater-cooler units (HCUs) is currently ongoing. Neither the status of this outbreak in Italy nor the mitigation strategies adopted by adult cardiac surgery units (ACSUs) are currently known. In 2017, the Italian Society of Cardiac Surgery launched a national survey among the Italian ACSU to shed some light on this issue. Methods In Italy, there are 90 ACSUs across 20 regions. From May to November 2017, these ACSUs were surveyed collecting data on patients diagnosed with MC infections, ACSU workload, HCU models in use and control measures adopted in the operatory room. Results The response rate was 87.8%. The median number of cardiac procedures at each ACSU was 450/year [interquartile range (IQR) 350-650 procedures/year], and nationally, the number of procedures/year exceeded 40k. In Italy, seven patients with M. chimaera infections following cardiac procedures have been reported since 2015: all had aortic or valvular surgery as the first procedure; the median latency between the first operation and the infection was 2 years (IQR 2-3.25). Mortality for patients requiring redo cardiac surgery was 50%. M. chimaera infections risk was 0.4-1 patient every 1000 cardiac procedures. The most common HCU model in Italy is the 3T HCU (70.9%). The most common control measures adopted included implementing new HCU disinfection protocols, using sterile or filtrated water in the HCU and displacing HCU fans away from the patient: HCU replacement and microbiology testing were instead infrequent. Conclusion In Italy, the risk of contracting M. chimaera infections and the mortality reported are in line with other European countries, but significant heterogeneity exists on the mitigation strategies adopted to prevent further M. chimaera inoculations, suggesting the development of national guidelines.

Objectives Although rare, incidents of broken/dislodged fragment of various angioplasty hardwares, including catheters, guidewires, angioplasty balloons, and stents, are being increasingly reported in recent years. Since these broken fragments may cause life-threatening consequences for a patient, it is vital for an interventional cardiologist to be acquainted with different retrieval techniques. Here, we are reporting our observations of several incidents of device dislodgement/fracture during cardiac interventions and their retrieval using simple balloon method. Methods We present a study of eight patients in whom we attempted to retrieve dislodged/fractured cath-lab hardwares during cardiac interventions, using simple balloon method. These cases include two cases of balloon, three cases of stent, and three cases of guidewire dislodgement/fracture. Results Fractured/dislodged cath-lab hardwares were successfully retrieved using a simple balloon method in six out of eight cases (75%), without any need of other retrieval hardwares. We observed no major complications in any patient. Conclusions The balloon-assisted retrieval method is a simple, safe, and cost-effective way to avoid complications of endothelial injury, myocardial infarction, emergency coronary artery bypass graft, and sudden cardiac death. This study, particularly the context of retrieval technique used in each case, will offer valuable information to fellow interventional cardiologists.

Objective Transcatheter cardiac procedures have generated increasing interest in trainees and training programs alike. Using the modified Delphi method, we sought to clarify the transcatheter competencies that cardiac surgery residents should be expected to attain by the completion of training. Methods Individuals with expertise in transcatheter structural heart and aortic procedures were recruited across Canada. A questionnaire was prepared using a 5-point Likert scale. During 2 rounds, participants rated the competencies that they thought cardiac surgery residents should be required to achieve to perform transcatheter procedures. Data were analyzed and presented to participants between rounds. Competencies rated 4 or higher by at least 80% of respondents after the second round were considered fundamental to transcatheter cardiac surgical training. Results A total of 46 individuals participated in the study, including 23 cardiac surgeons, 17 interventional cardiologists, and 6 vascular surgeons. Participants with relevant experience performed a median of 75 (interquartile range, 40-100) transcatheter aortic valve implantations in the prior year as primary or secondary operator and 15 (interquartile range, 11-35) thoracic endovascular aortic repairs in the prior 2 years as primary operator. Median clinical and teaching experience consisted of 13 (interquartile range, 7-19.5) years in practice and 8.5 (interquartile range, 5-15) residents taught per year, respectively. Of the included competencies, 53 were considered fundamental to transcatheter cardiac surgical training. Conclusions The identified fundamental competencies can be used to develop educational strategies during transcatheter cardiac surgery training. Future efforts should focus on collecting evidence for their validity.

BACKGROUND Transfemoral venous access (TFV) is the cornerstone of minimally invasive cardiac procedures. Although the presence of inferior vena cava filters (IVCFs) was considered a relative contraindication to TFV procedures, small experiences have suggested safety. We conducted a systematic review of the available literature on cardiac procedural success of TFV with IVCF in-situ. METHODS Two independent reviewers searched PubMed, EMBASE, SCOPUS, and Google Scholar from inception to October 2020 for studies that reported outcomes in patients with IVCFs undergoing TFV for invasive cardiac procedures. We investigated a primary outcome of acute procedural success and reviewed the pooled data for patient demographics, procedural complications, types of IVCF, IVCF dwell time, and procedural specifics. RESULTS Out of the 120 studies initially screened, 8 studies were used in the final analysis with a total of 100 patients who underwent 110 procedures. The most common IVCF was the Greenfield Filter (36%), 60% of patients were males and the mean age was 67.8 years. The overall pooled incidence of acute procedural success was 95.45% (95% confidence interval = 89.54-98.1) with no heterogeneity (I2 = 0%, p = 1) and there were no reported filter-related complications. CONCLUSION This systematic review is the largest study of its kind to demonstrate the safety and feasibility of TFV access in a variety of cardiac procedures in the presence of IVCF.

Purpose: An important factor when considering the use of interventional cone beam computed tomography (CBCT) imaging during cardiac procedures is the trade-off between imaging dose and image quality. Accordingly, Adaptive CaRdiac cOne BEAm computed Tomography (ACROBEAT) presents an alternative acquisition method, adapting the gantry velocity and projection rate of CBCT imaging systems in accordance with a patient's electrocardiogram (ECG) signal in real-time. The aim of this study was to experimentally investigate that ACROBEAT acquisitions deliver improved image quality compared to conventional cardiac CBCT imaging protocols with fewer projections acquired. Methods: The Siemens ARTIS pheno (Siemens Healthcare, GmbH, Germany), a robotic CBCT C-arm system, was used to compare ACROBEAT with a commercially available conventional cardiac imaging protocol that utilizes multisweep retrospective ECG-gated acquisition. For ACROBEAT, real-time control of the gantry position was enabled through the Siemens Test Automation Control system. ACROBEAT and conventional image acquisitions of the CIRS Dynamic Cardiac Phantom were performed, using five patient-measured ECG traces. The traces had average heart rates of 56, 64, 76, 86, and 100 bpm. The total number of acquired projections was compared between the ACROBEAT and conventional acquisition methods. The image quality was assessed via the contrast-to-noise ratio (CNR), structural similarity index (SSIM), and root-mean square error (RMSE). Results: Compared to the conventional protocol, ACROBEAT reduced the total number of projections acquired by 90%. The visual image quality provided by the ACROBEAT acquisitions, across all traces, matched or improved compared to conventional acquisition and was independent of the patient's heart rate. Across all traces, ACROBEAT averaged 1.4 times increase in the CNR, a 23% increase in the SSIM and a 29% decrease in the RMSE compared to conventional and was independent of the patient's heart rate. Conclusion: Adaptive patient imaging is feasible on a clinical robotic CBCT system, delivering higher quality images while reducing the number of projections acquired by 90% compared to conventional cardiac imaging protocols.

Composite performance measures for the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database participants (typically hospital departments or practice groups) are currently available only for individual procedures. To assess overall participant performance, STS has developed a composite metric encompassing the most common adult cardiac procedures.Analyses included 1-year (July 1, 2018 to June 30, 2019) and 3-year (July 1, 2016 to June 30, 2019) time windows. Operations included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve repair (MVr) or replacement (MVR), AVR + CABG, MVr or MVR + CABG, AVR + MVr or MVR, and AVR + (MVr or MVR) + CABG. The composite was estimated using Bayesian hierarchical models with risk-adjusted mortality and morbidity end points. Star ratings were based upon whether the 95% credible interval of a participant's score was entirely lower than (1 star), overlapping (2 star), or higher than (3 star) the STS average composite score.The North American procedural mix in the 3-year study cohort was as follows: 448 569 CABG, 72 067 AVR, 35 708 MVr, 29 953 MVR, 45 254 AVR + CABG, 12 247 MVr + CABG, 10 118 MVR + CABG, 3743 AVR + MVr, 6846 AVR + MVR, and 3765 AVR + (MVr or MVR) + CABG. Mortality and morbidity weightings were similar for 1- and 3-year analyses (76% and 24% [3-year]), as were composite score distributions (median, 94.7%; interquartile range, 93.6% to 95.6% [3-year]). The 3-year time frame was selected for operational use because of higher model reliability (0.81 [0.78-0.83]) and better outlier discrimination (26%, 3 star; 16%, 1 star). Risk-adjusted outcomes for 1-, 2-, and 3-star programs were 4.3%, 3.0%, and 1.8% mortality and 18.4%, 13.4%, and 9.7% morbidity, respectively.The STS participant-level, multiprocedural composite measure provides comprehensive, highly reliable, overall quality assessment of adult cardiac surgery practices.

Background: COVID-19 has changed the world as we know it, and the United States continues to accumulate the largest number of COVID-related deaths worldwide at the time of publication. There exists a paucity of data regarding the effect of COVID-19 on adult cardiac surgery trends and outcomes on a national level. Methods: The STS Adult Cardiac Surgery Database was queried and analyzed from January 1, 2018 to June 30, 2020. The Johns Hopkins COVID-19 database was queried from February 1, 2020 to January 1, 2021. Surgical and COVID-19 volumes, trends, and outcomes were analyzed on a national and regional level. Observed-to-expected ratios were used to analyze mortality for all risk-adjustable cardiac procedures. Findings: A total of 717,103 adult cardiac surgery patients and more than 20 million COVID-19 patients were included for analysis. The South Atlantic (21.1%) and Great Lakes (17.4%) regions contributed the most patients during the study period. Nationally, there was a 52.7% reduction in overall adult cardiac surgery volume, and a 65.5% reduction in elective cases. The Mid-Atlantic region was most affected by the first COVID-19 surge, with a 69.7% reduction in overall case volume and 80.0% reduction in elective cases. In the Mid-Atlantic and New England regions, the observed-to-expected mortality for isolated coronary bypass increased as much as 1.48 times (148% increase) pre-COVID rates. After the first COVID-19 surge, nationwide cardiac surgical case volumes increased but did not return to baseline, indicating a COVID-associated deficit of cardiac surgery patients. Interpretation: This study is the largest analysis of COVID-19 related impact on adult cardiac surgery volume, trends, and outcomes. During the COVID-19 pandemic, cardiac surgery volume suffered dramatically, particularly in the Mid-Atlantic and New England regions during the first surge of COVID-19 cases, with a concurrent significant increase in observed-to-expected 30-day mortality. Funding: None. Conflict of Interest: TCN – Consultant, Edwards LifeSciences, Abbott, LivaNova, CryoLife. VHT – Consultant/research, Abbott, Boston Scientific, Edwards LifeSciences, W. L. Gore & Associates, Jenavalve. APN – None. RHH – None. JAD – None. JAC – None. AR – None. HM – None.DMS – None. JPJ – None. VB – Consultant, Abbott.

First introduced in 1987, transesophageal echocardiography (TEE) has become an essential imaging tool for the diagnosis of many cardiac conditions. In addition, TEE is routinely used during many surgical and percutaneous cardiac procedures for immediate assessment of cardiac function and structures. There are 20 standard TEE views that are acquired from esophageal and transgastric levels. This chapter orients the reader to the basic operations of the TEE device and highlights the necessary views to perform a comprehensive TEE exam.

Anesthesia for electrophysiology (EP) procedures has many complex challenges for the anesthesia provider. The EP suite has several unique challenges because of its remote location, room layout, and the types of cardiac procedures performed. The anesthesia provider must be familiar with the procedures so he/she can participate in the management of problems during critical steps. A good working relationship between the anesthesia provider and the invasive cardiologist is crucial to minimizing complications and ensuring a good outcome. With proper planning and close communication, EP procedures should be routinely safe and uneventful. The total number of procedures performed in EP suites is increasing yearly as new techniques are being introduced and refined. It is more important than ever for the anesthesia provider to fully understand cardioversion and cardiac ablation procedures and the related anesthesia considerations. In this chapter, we present a brief description of anesthesia considerations for cardioversion and cardiac ablation procedures.