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In this article, we focus on the important role of robot-assisted coronary surgery by reporting the successful case of a morbidly obese male (body mass index = 58 kg/m2) who presented to our center with severe coronary disease. A 54-year-old morbidly obese male presented with acute chest pain and was diagnosed with coronary artery disease. The culprit lesion was the left anterior descending (LAD) coronary artery. A percutaneous coronary intervention angiography attempted in a university hospital was not successful. Our heart team chose a hybrid robot-assisted revascularization (HCR) strategy based on the patient’s body size. The patient underwent left internal thoracic mammary artery to LAD bypass with uneventful postoperative recovery. Robotic HCR is a valuable strategy in morbidly obese patients undergoing coronary artery bypass grafting.

Background and aim of the study Although abundant biological, clinical, and scientific evidence exists on the superiority of multi-arterial (MAR) and total-arterial revascularization (TAR) over the conventional strategy with a single internal thoracic artery, only 10% of patients undergoing coronary artery bypass grafting (CABG) in the United States receives a second arterial conduit, and only 5% of patients receives TAR. Methods and results In January 2020, the authors performed comprehensive search to identify studies that evaluated MAR and TAR strategies through the MEDLINE database. Conclusions In this paper, the authors reviewed the literature on the historical and current evidence in favor of MAR and TAR, thus underlying why current CABG practice needs qualitative improvement.

The development of new transcatheter and percutaneous solutions for mitral valve regurgitation have originated postoperative concerns that intensivists and cardiologists need to be familiar with, recognize, and manage accordingly. Each device has its own postoperative management considerations, which we have presented in detail.

Nitrous oxide (N2O) is an anesthetic and analgesic gas with a long history of medical applications. It acts on multiple supraspinal and spinal targets and has utility in a wide range of clinical situations. The relative safety, low incidence, and acuity of adverse effects of N2O, along with the ability to be administered by trained medical providers with varying clinical backgrounds, as well as self-administered by patients, assure its persistent and expanding role in clinical practice.

Background: Chronic kidney disease (CKD) is associated with a high prevalence of atrial fibrillation (AF), but in this population the risk/benefit ratio of anticoagulant therapy with vitamin K antagonists (VKA) for thromboprophylaxis is uncertain. Summary: In end-stage renal disease (ESRD) patients undergoing hemodialysis, VKA seem less effective in stroke prevention than in the general population, with an increased risk of major bleeding. Recently, novel oral anticoagulant agents (NOACs) have proven to be effective for stroke prevention in AF and have demonstrated an improved safety profile compared to VKA. Limited data from post hoc analyses of controlled clinical trials suggest the safe and effective use of NOACs in patients with moderate renal impairment (i.e., estimated glomerular filtration rate, eGFR, between 30 and 50 mL/min). The question still remains whether NOACs can be used in patients with an eGFR Key Messages: Stroke prevention in patients with ESRD and AF represents a clinical challenge with poor evidence. LAA occlusion may become the standard of care for stroke prevention in patients with ESRD and AF.

Chronic kidney disease (CKD) is associated with a high prevalence of atrial fibrillation (AF), but in patients with severe renal impairment, the risk/benefit ratio of anticoagulant therapy with vitamin K antagonists (VKA) for thromboprophylaxis is uncertain. In end-stage renal disease (ESRD) patients undergoing hemodialysis, VKA seem less effective in stroke prevention than in the general population, with an increased risk of major bleeding. Recently, novel oral anticoagulant agents (NOACs) have proven to be effective for stroke prevention in AF and have demonstrated an improved safety profile compared with VKA. Limited data from posthoc analyses of controlled clinical trials suggest the safe and effective use of NOACs in patients with moderate renal impairment (i.e., estimated glomerular filtration rate [eGFR] between 30 and 50 mL/min). The question still remains whether NOACs can be used in patients with an eGFR less than 30 mL/min, because there are no studies addressing this subject. In fact, patients with CKD stage 4 and 5 were excluded from controlled clinical trials on anticoagulation therapy for stroke prevention in AF. Left atrial appendage (LAA) occlusion represents a nonpharmacologic alternative for stroke prevention in patients with AF who are difficult to manage medically. Preliminary data indicate a similar efficacy and safety profile in patients with CKD compared with patients with normal renal function. Stroke prevention in patients with ESRD and AF represents a clinical challenge with poor evidence. LAA occlusion may become the standard of care for stroke prevention in patients with ESRD and AF.

ITHIN THE SPECIALTY of critical care medicine, a new subspecialty of cardiothoracic surgical critical care has emerged as a result of the unique physiologic changes and complications associated with cardiothoracic surgery. The demand for cardiovascular critical care is increasing with the aging of the population and is projected to increase markedly over the next 15 years worldwide. 1 New paradigms of nutritional and metabolic support have been introduced in the last decade in critically ill patients, focusing on early, combined enteral nutrition (EN) and parenteral nutrition (PN), intensive insulin therapy for tight glucose control, and specific nutrients to modulate system and organ functions. 2 Although most cardiac surgical patients stay in the intensive care unit (ICU) for 1 to 2 days and do not require nutritional support, a small percentage progress to a more complicated and prolonged course and are at higher risk for complications from catabolism related to their illness. In addition, more patients with advanced heart failure are being admitted to the cardiac surgical ICU for prolonged periods and are malnourished at baseline. 3 This article reviews the current evidence regarding nutrition and metabolic support in cardiac surgical patients in the ICU and provides a framework for a structured approach to improve outcomes in this high-risk population.

Mechanical circulatory support devices have been increasingly used for long-term support. We reviewed outcomes in all patients supported with a SynCardia total artificial heart (TAH) for more than 1 year to assess its safety in long-term support. As of December 2011, all 47 patients who received the TAH from 10 centers worldwide were included in this retrospective study. Clinical data were collected on survival, infections, thromboembolic and hemorrhagic events, device failures, and antithrombotic therapy. The mean age of patients was 50 ± 1.57 years, the median support time was 554 days (range 365-1373 days). The primary diagnosis was dilated cardiomiopathy in 23 patients, ischemic in 15, and "other" in 9. After a minimum of 1 year of support, 34 patients (72%) were successfully transplanted, 12 patients (24%) died while on device support, and 1 patient (2%) is still supported. Five patients (10%) had a device failure reported. Major complications were as follows: systemic infections in 25 patients (53%), driveline infections in 13 patients (27%), thromboembolic events in 9 patients (19%), and hemorrhagic events in 7 patients (14%). SynCardia TAH has proven to be a reliable and effective device in replacing the entire heart. In patients who reached a minimum of 1 year of support, device failure rate is acceptable and only in two cases was the leading cause of death. Infections and hemorrhagic events were the major causes of death. Patients who remain supported beyond 1 year are still likely to survive to transplantation.

Background Anaesthetists have traditionally ventilated patients' lungs with tidal volumes (TVs) between 10 and 15 ml kg−1 of ideal body weight (IBW), without the use of PEEP. Over the past decade, influenced by the results of the Acute Respiratory Distress Syndrome Network trial, many anaesthetists have begun using lower TVs during surgery. It is unclear whether the benefits of low TV ventilation can be extended into the perioperative period. Methods We reviewed the records of 29 343 patients who underwent general anaesthesia with mechanical ventilation between January 1, 2008 and December 31, 2011. We calculated TV kg−1 IBW, PEEP, peak inspiratory pressure (PIP), and dynamic compliance. Cox regression analysis with propensity score matching was performed to examine the association between TV and 30-day mortality. Results Median TV was 8.6 [7.7–9.6] ml kg−1 IBW with minimal PEEP [4.0 (2.2–5.0) cm H2O]. A significant reduction in TV occurred over the study period, from 9 ml kg−1 IBW in 2008 to 8.3 ml kg−1 IBW in 2011 (P=0.01). Low TV 6–8 ml kg−1 IBW was associated with a significant increase in 30-day mortality vs TV 8–10 ml kg−1 IBW: hazard ratio (HR) 1.6 [95% confidence interval (CI) [1.25–2.08], P=0.0002]. The association remained significant after matching: HR 1.63 [95% CI (1.22–2.18), P Conclusions Use of low intraoperative TV with minimal PEEP is associated with an increased risk of 30-day mortality.

Right ventricular failure after cardiac surgery is a difficult clinical dilemma. We review the physiology of right ventricular failure in addition to current management strategies to address it.

Methylene blue (MB) has received much attention in the perioperative and critical care literature because of its ability to antagonize the profound vasodilation seen in distributive (also referred to as vasodilatory or vasoplegic) shock states. This review will discuss the pharmacologic properties of MB and review the critical care, liver transplantation, and cardiac anesthesia literature with respect to the efficacy and safety of MB for the treatment of shock. Although improved blood pressure has consistently been demonstrated with the use of MB in small trials and case reports, better oxygen delivery or decreased mortality with MB use has not been demonstrated. Large randomized controlled trials are still necessary to identify the role of MB in hemodynamic resuscitation of the critically ill.

OBJECTIVES The Total Artificial Heart (Syncardia, Tucson, AZ) is approved for use as a bridge-to-transplant or destination therapy in patients who have irreversible end-stage biventricular heart failure. We present a unique case, in which the inferior vena cava compression by a total artificial heart was initially masked for days by the concurrent placement of an extracorporeal membrane oxygenation cannula. PATIENT This is the case of a 33-year-old man admitted to our institution with recurrent episodes of ventricular tachycardia requiring emergent total artificial heart and venovenous extracorporeal membrane oxygenation placement. CONCLUSION This interesting scenario highlights the importance for critical care physicians to have an understanding of exact anatomical localization of a total artificial heart, extracorporeal membrane oxygenation, and their potential interactions. In total artificial heart patients with hemodynamic compromise or reduced device filling, consideration should always be given to venous inflow compression, particularly in those with smaller body surface area. Transesophageal echocardiogram is a readily available diagnostic tool that must be considered standard of care, not only in the operating room but also in the ICU, when dealing with this complex subpopulation of cardiac patients.

The aim of this study was to determine the effect of pulmonary artery catheterization on clinical outcomes after cardiac surgery in higher-risk patients.Retrospective national database analysis.U.S. hospitals.A weighted sample of 2,063,337 patients undergoing cardiac surgery identified from the Nationwide Inpatient Sample (NIS) from January 1, 2000 to December 31, 2010.Pulmonary artery catheterization.Compared to patients who did not receive a pulmonary artery catheter, those who did on the whole were on average slightly older (66.6±11.9 years v 65.5±12.8 years, p0.001), more likely to have pulmonary hypertension (7.5% v 5.1%, p0.001), chronic obstructive pulmonary disease (24.6% v 20.7%, p0.001), obesity (15.0% v 13.1%, p0.001), and chronic renal failure (10.9% v 9.2%, p0.001). In multivariate analysis, the risk of operative mortality in patients who underwent pulmonary artery catheterization was significantly higher than in those who did not (4.6% v 3.1%, p0.001), adjusted OR 1.34 (95% CI 1.26-1.43, p0.001). In propensity matched subgroup analysis operative mortality risk was higher in octogenarian patients (OR 1.24, p = 0.24), and patients with congestive heart failure (OR 1.39, p = 0.023) who underwent pulmonary artery catheterization. No significant difference in operative mortality was observed in low-risk patients according to whether or not they underwent pulmonary artery catheterization. The incidence of prolonged mechanical ventilation and length of stay30 days was higher in patients who underwent pulmonary artery catheterization in all subgroups.In contemporary practice pulmonary artery catheters do not appear to be associated with reductions in operative mortality or morbidity and are associated with increases in duration of ventilation and length of stay in the intensive care unit.

HE PERIOPERATIVE MANAGEMENT of patients with pulmonary hypertension (PH) is a growing concern for anesthesiologists worldwide as more patients with PH are presenting for elective noncardiac surgery. As a direct result of increased awareness and discovery of new medical therapies, patients with PH not only have a longer life expectancy, but also an improved quality of life. 1 Despite these recent advances, surgery still poses a significant risk for patients with PH. 2–5 A considerable amount of data already have been published showing increased mortality and morbidity in patients undergoing cardiac surgery with PH. 6–9 There are, however, much less data investigating the outcomes of patients with PH in the setting of noncardiac surgery. In a retrospective study by Ramakrishna et al, 42% of PH patients who underwent noncardiac surgery had 1 or more short-term morbid events, and 7% of patients had early death, which was due primarily to respiratory or right ventricular (RV) failure. 4 These outcomes have been compared to other high-risk populations undergoing noncardiac surgery such as elderly patients older than 80 years of age who experienced a mortality of 4.6%, 10 or those older than 65 years who experienced a mortality of 3.4%. 11 This review will discuss the classifications, pathophysiology, and the anesthetic management of patients with PH for noncardiac surgery.

Objectives The objective of this study was to evaluate the impact of timing of tracheostomy on outcomes of patients with respiratory failure after cardiac surgery. Design Retrospective analysis of national database. Setting United States hospitals. Participants A weighted estimate of 2,063,227 patients (475,773 case records) undergoing cardiac surgery identified from the Nationwide Inpatient Sample between 2002-2010 Interventions Early versus late tracheostomy. Measurements and Main Results The incidence of postoperative respiratory failure was 7.8%. The strongest independent predictors of respiratory failure included female gender (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.28-1.31), age (OR 1.13 for each decade, 95% CI 1.12-1.13), chronic obstructive airways disease (OR 2.16, 95% CI 2.13-2.19), chronic renal insufficiency (OR 2.28, 95% CI 2.25-2.31), and valve surgery (OR 1.62, 95% CI 1.6-1.64). Tracheostomy was performed in 22.9% of patients with respiratory failure; 13.6% of tracheostomies were performed within 5 days of surgery (or within 5 days of intubation in patients who underwent reintubation), and 20.5% were performed on postoperative day 21 or later. Compared with tracheostomy performed within 5 days of intubation, there was a near-stepwise increase in risk of mortality with delayed tracheostomy performed between days 11-15 (OR 1.29, 95% CI 1.16-1.43), days 16-20 (OR 1.25, 95% CI 1.11-1.41), and day 21 or later (OR 1.53, 95% CI 1.37-1.71). Conclusions In this analysis of outcomes of patients with respiratory failure after cardiac surgery in the United States, deferring tracheostomy did not appear to improve patient outcomes after cardiac surgery.

The purpose of this study was to investigate whether patients who received methylene blue as treatment for vasoplegia during cardiac surgery with cardiopulmonary bypass had decreased morbidity and mortality.Retrospective analysis.Single tertiary care university hospital.Adult patients who suffered from vasoplegia and underwent all types of cardiac surgery with cardiopulmonary bypass at this institution between 2007 and 2008.With IRB approval, the authors reviewed the charts of the identified patients and divided them into 2 groups based on whether they had received methylene blue. Two hundred twenty-six patients were identified who met the inclusion criteria for the study. Fifty-seven of these patients had received methylene blue for vasoplegia. The authors collected data on preoperative and intraoperative variables as well as outcomes.The patients who received methylene blue had higher rates of in-hospital mortality, a compilation of morbidities, as well as renal failure and hyperbilirubinemia. A multiple logistic regression model demonstrated that receiving methylene blue was an independent predictor of in-hospital mortality (p value: 0.007, OR 4.26, 95% CI: 1.49-12.12), compilation of morbidities (p value: 0.001, OR 4.80, 95% CI: 1.85-12.43), and hyperbilirubinemia (p value:0.001, OR 6.58, 95% CI: 2.91-14.89). Using propensity score matching, the association with morbidity was again seen but the association with mortality was not found.The current study identified the use of methylene blue as treatment for vasoplegia to be independently associated with poor outcomes. While further studies are required, a thorough risk-benefit analysis should be applied before using methylene blue and, perhaps, it should be relegated to rescue use and not as first-line therapy.