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In 2021, progress in clinical science related to Cardiac Anesthesiology continued, but at a slower rate due to the ongoing pandemic and disruptions to clinical research. Most progress was incremental and addressed persistent questions related to our field. To identify articles for this review, we completed a structured review using our previously reported methods (1). Specifically, we used the search terms: “cardiac anesthesiology and outcomes” (n = 177), “cardiothoracic anesthesiology” (n = 34), “cardiac anesthesia,” and “clinical outcomes” (n = 42) filtered on clinical trials and the year 2021 in PubMed. We also reviewed clinical trials from the most prominent clinical journals to identify additional studies for a narrative review. We then selected the most noteworthy publications for inclusion in this review and identified key themes.

The year 2020 was marred by the emergence of a deadly pandemic that disrupted every aspect of life. Despite the disruption, notable research accomplishments in the practice of cardiothoracic anesthesiology occurred in 2020 with an emphasis on optimizing care, improving outcomes, and expanding what is possible for patients undergoing cardiac surgery. This year’s edition of Noteworthy Literature Review will focus on specific themes in cardiac anesthesiology that include preoperative anemia, predictors of acute kidney injury following cardiac surgery, pain management modalities, anticoagulation strategies after transcatheter aortic valve replacement, mechanical circulatory support, and future directions in research.

Objectives The aim of this study was to evaluate the utility of transesophageal echocardiography (TEE) during transvenous lead extraction (TLE) involving both conventional and laser lead removal. Background TLE carries a small but measurable risk of serious adverse events. Few studies have examined the potential benefit of continuous monitoring with TEE during this procedure. Methods Continuous TEE monitoring was performed in 100 consecutive patients (67% male; average age, 57 ± 17 years) who underwent TLE in the past 5 years. Lead extraction was attempted for 193 leads. The average time since lead implant was 78 ± 55 months (range, 1.4 to 274.4 months). Indications for extraction were device endocarditis (n = 28), lead fracture (n = 28), recalled lead (n = 21), pocket infection (n = 17), and other (n = 6). Results Complete success occurred in 181 leads (94%), partial success in 4 leads (2%), and failure in 8 leads (4%). Eighty patients required laser lead extraction (80%). Major complications included 1 right ventricular and 2 right atrial/superior vena cava lacerations, which were detected and localized within 1 to 2 min with the use of TEE and resulted in prompt surgical repair. There was 1 upper gastrointestinal bleed caused by the TEE probe. TEE prevented premature termination and unnecessary surgery in 4 patients with hypotension but no intracardiac abnormalities seen on TEE. In-hospital mortality rate was 0%. In total, TEE provided immediately useful clinical information in 7 patients (7%). Conclusions Continuous monitoring with TEE facilitates prompt diagnosis and treatment of intracardiac damage and prevents premature termination of cases with hypotension but no abnormalities on TEE.

We describe a 43-year-old male presenting for hemiarch replacement and possible aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) demonstrated an atypical coronary vessel, enabling proper diagnosis of an anomalous circumflex artery and appropriate operative planning.

Background: Transvenous lead extraction (TLE) carries a small but measurable risk of serious adverse events. Few studies have examined the potential benefit of continuous monitoring with transesophageal echocardiography (TEE) during this procedure. Objective: Evaluate the utility of TEE during TLE involving both conventional and laser lead removal. Methods: TEE was performed in 100 consecutive patients undergoing TLE. All patients underwent TLE in the operating room with general anesthesia and continuous TEE monitoring. TLE was attempted for 193 leads in 100 patients. Eighty patients required laser lead extraction (80%). Indications for extraction were device endocarditis (28), lead fracture (28), recalled lead (21), pocket infection (17), and other (6). Results: Sixty-seven patients were male and the average age was 56.96 +- 17.01 years. The average length since lead implant was 78±55.19 (1.4-274.43) months. Complete success occurred in 181 leads (94%), partial success in 4 leads (2%), and failure in 8 leads (4%). Major complications included right ventricle laceration (1) and right atrium/superior vena cava laceration (2) which resulted in detection and localization within 1-2 minutes and prompt surgical repair. Premature termination and unnecessary surgery were prevented in 4 patients with hypotension but no intracardiac abnormalities seen on TEE (Figure 1). There was one upper gastrointestinal bleed from the TEE probe (1). In-hospital mortality was 0%. Conclusion: In total the clinical management was changed in 7 patients (7%) based on real-time TEE monitoring helping to decrease the TLE related mortality and premature termination of the procedure. Figure 1 Monitoring with real time TEE prevented premature termination of cases with severe hypotension showing RV obstruction due to invagination of the free wall. RA: right atrium; RV: right ventricle.

DESPITE ITS LONGSTANDING RECOGNITION, esophageal carcinoma remains a highly lethal disease that affects thousands of patients annually. The United States Centers for Disease Control and Prevention reports heterogenous development of mortality from esophageal cancer over time (Fig 1). Although improvements over time have been made in the mortality rates of black women and men, the mortality for white men actually has increased in the last decade of the 20th century. In 2010, death rates from esophageal cancer were approximately 40/100,000 for men Z 65 years of age and about 10/100,000 for women Z 65 years of age. In 1990, death rates were significantly higher for black than for white patients; in 2010 the death rates were similar (Fig 1). Perioperative mortality for esophagectomy is the highest among elective procedures, and has been reported from 1% to 3% in contemporary single-center studies and between 3.4% high-volume hospitals and 17.3% in low-volume hospitals in a large multicenter retrospective study assessing cancer outcomes from 1984 to 1993 in patients older than 65. A recent study looking at trends and outcomes of esophageal surgery in the United States examined the national inpatient sample database to analyze results for patients with esophageal cancer treated with either total or partial esophagectomy. Between 2001 and 2010 in the United States, 15,190 esophagectomies were performed. Although numbers increased progressively during this period, mortality decreased from 8.3% to 4.2%.

We describe a 43-year-old male presenting for hemiarch replacement and possible aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) demonstrated an atypical coronary vessel, enabling proper diagnosis of an anomalous circumflex artery and appropriate operative planning.

We present a rare and unique case of calcific constrictive pericarditis with a calcified pericardial mass invading the right ventricular myocardium. Perioperative two-dimensional and three-dimensional transesophageal echocardiography revealed the extent and structure of the pericardial mass and led to the repair of the right ventricular free wall as a surgical intervention.

Objectives. Ischemia time is a risk factor for mortality and right ventricular (RV) failure after heart transplantation. The purpose of this study was to determine the effect of ischemia time on known transesophageal echocardiography (TEE) parameters of RV function and on a novel quantitative measurement of RV circumferential shortening. Methods. Right and left ventricular (LV) function was evaluated retrospectively in 20 consecutive patients after heart transplant using known TEE parameters as well as a quantitative measurement of circumferential contraction. The control group consisted of 20 patients undergoing coronary artery bypass grafting (CABG) with no documented RV dysfunction. Results. Posttransplant TEE parameters of RV function were depressed compared with post–cardiopulmonary bypass CABG patients. Significant correlation was observed between tricuspid annular planar systolic excursion, basal, mid, and global circumferential shortening and total ischemia time. Conclusion. Total ischemia time of the transplanted heart may play a role in deterioration of longitudinal and circumferential shortening of the RV.