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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.

This year marked a number of milestones in critical care. As vaccines for the SARS-CoV-2 virus became widely available and were confirmed to be exceptionally effective against severe illness and hospitalization, we were then faced with new variants and the resource-intense responses necessary to combat them. Despite challenges new and old, we have persevered and continued to provide excellent care to our patients while pushing the boundaries of clinical research. This article is a collection of studies published in 2021 relevant to critical care, with a specific focus on cardiothoracic critical care. To ignore the impact of the COVID-19 pandemic would do a disservice to our colleagues, many of whom have made incredible breakthroughs in novel therapies to the coronavirus, and yet we present additional themes of delirium, acute kidney injury, lung transplant, advances in ECMO as well as biomarkers of sepsis.

This year will be forever marked by the drastic changes COVID-19 wrought on our personal and professional lives. New roles and challenges in critical care have forced us to be constantly nimble and flexible in how we approach medicine. The strain of these challenges is apparent throughout the health care community and our society as a whole. Despite this adversity, 2020 will also be remembered for fantastic advances in research. This article is a collection of influential and exciting studies published in 2020 encompassing a broad swath of critical care with a focus on cardiothoracic critical care. Themes include examinations of early extracorporeal membrane oxygenation support for out-of-hospital cardiac arrest patients, the impact of sedation and other risk factors on perioperative mortality, a novel fluid resuscitation strategy following cardiac surgery, and advances in the fields of heart and lung transplantation as well as how they were affected by COVID-19. Given that many cardiothoracic intensivists were redeployed to the care of SARS-CoV-2 patients, we also discuss important advances in therapeutics for the virus.

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.

Introduction Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians’ perceptions of the impact of a multi-disciplinary debrief on OR culture. Methods A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. Results Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. Conclusions Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

Coronavirus disease 2019 (COVID-19) has a clinical course predominated by acute respiratory failure due to viral pneumonia with possible acute respiratory distress syndrome. However, nearly one third of infected patients, especially those with preexisting cardiovascular (CV) disease, are reported to present with some combination of acute cardiac injury, myocarditis, heart failure, cardiogenic shock, or significant dysrhythmias. In addition, COVID-19 infections are also associated with high rates of thromboembolic and disseminated intravascular coagulation complications. Severe myocarditis and heart failure have both been reported as the initial presenting conditions in COVID-19 infection. This review highlights the important considerations related to the CV manifestations of COVID-19 infections, describes the mechanisms and clinical presentation of CV injury, and provides practical management and therapy suggestions. This narrative review is based primarily on the multiple case series and cohorts from the largest initial COVID-19 outbreak centers (ie, Wuhan, China, and Italy); hence, nearly all presented data and findings are retrospective in nature with the attendant limitations of such reports.

This article represents a selective review of literature published in 2019. Initial results from PubMed searching for a combination of terms, including cardiac anesthesiology and anesthesiology outcomes, yielded more than 1400 publications. From there, we manually screened the results and identified 5 major themes for the year of 2019, including transcatheter techniques, delirium and anesthesiology, coagulation management following cardiopulmonary bypass, perfusion management with del Nido cardioplegia, and applied clinical research. The following research accomplishments have expanded what is possible and set ambitious goals for the future.

Objectives Right ventricular (RV) failure is common after left ventricular assist device (LVAD) surgery and is associated with higher mortality. Measurement of longitudinal RV strain using speckle-tracking technology is a novel approach to quantify RV function. The authors hypothesized that depressed peak longitudinal RV strain measured by intraoperative transesophageal echocardiography (TEE) examinations would be associated with adverse outcomes after LVAD surgery. Design Retrospective cohort study. Setting Tertiary academic medical center. Participants Following Institutional Review Board approval, the authors retrospectively identified adult patients who underwent implantation of non-pulsatile LVAD. Exclusion criteria included inadequate TEE images and device explantation within 6 months for heart transplantation. Interventions None. Measurements and Main Results The postoperative adverse event outcome was defined as a composite of one or more of death within 6 months, ≥14 days of inotropes, mechanical RV support, or device thrombosis. Intraoperative TEE images were analyzed for peak RV free wall longitudinal strain by two blinded investigators. Simple logistic regression was used to assess the relationship between adverse outcome and the mean of the strain measurements of the two raters. Agreement between the raters was assessed by intra-class correlation (0.62) and Pearson correlation coefficient (0.63). Of the 57 subjects, 21 (37%) had an adverse outcome. The logistic regression indicated no significant association between RV peak longitudinal strain and adverse events. Conclusions In this retrospective study of patients undergoing non-pulsatile LVAD implantation, peak longitudinal strain of the RV free wall was not associated with adverse outcomes within 6 months after surgery. Additional quantitative echocardiographic measures for intraoperative RV assessment should be explored.

Aortic arch surgery requires meticulous teamwork in the true perioperative sense. Planning and communication at all phases from preoperative evaluation, through intraoperative management, to postoperative care should be well coordinated between surgical, anesthesia, perfusion, and intensive care unit teams. This review discusses intraoperative management from the anesthesiologist’s perspective, with particular emphasis on transesophageal echo evaluation and coagulation management.

Tracheal laceration is a known complication of endotracheal intubation. This rare complication remains a diagnostic and management challenge for today’s practitioners. This clinical challenge report highlights current surgical and anesthetic management strategies.

The Society of Cardiovascular Anesthesiologists (SCA) introduced the FOCUS initiative (Flawless Operative Cardiovascular Unified Systems) in 2005 in response to the need for a rigorous scientific approach to improve quality and safety in the cardiovascular operating room (CVOR). The goal of the project, which is supported by the SCA Foundation, is to identify hazards and develop evidence-based protocols to improve cardiac surgery safety. A hazard is anything that has the potential to cause a preventable adverse event. Specifically, the strategic plan of FOCUS includes 3 goals: (1) identifying hazards in the CVOR, (2) prioritizing hazards and developing risk-reduction interventions, and (3) disseminating these interventions. Collectively, the FOCUS initiative, through the work of several groups composed of members from different disciplines such as clinical medicine, human factors engineering, industrial psychology, and organizational sociology, has identified and documented significant hazards occurring daily in our CVORs. Some examples of frequent occurrences that contribute to reduce the safety and quality of care provided to cardiac surgery patients include deficiencies in teamwork, poor OR design, incompatible technologies, and failure to adhere to best practices. Several projects are currently under way that are aimed at better understanding these hazards and developing interventions to mitigate them. The SCA, through the FOCUS initiative, has begun this journey of science-driven improvement in quality and safety. There is a long and arduous road ahead, but one we need to continue to travel.

Preclinical Research Point of Care testing in the perioperative arena is a high priority topic, specifically in cardiac surgery where a majority of perioperative blood transfusions occur. Platelet function in particular is of interest in cardiac surgery as cardiopulmonary bypass itself creates known platelet dysfunction, but also because more and more patients are on antiplatelet agents due to coronary stenting procedures. This review will focus on presenting current data relating to platelet function in the perioperative setting, along with a brief review of general coagulation concepts.

Purpose Despite recent advancements in the use of thrombelastography (TEG) in the surgical setting, adequate technology to accurately predict bleeding phenotypes for patients undergoing cardiopulmonary bypass on the basis of non-mechanical parameters is lacking. While basic science and translational studies have provided key mechanistic insights about the protein components of coagulation cascades and regulatory mediators of hemostasis and fibrinolysis, targeted protein assays are still missing and the association of protein profiles to bleeding phenotypes and TEG readouts have yet to be discovered. Objective To identify protein biomarkers of bleeding phenotypes of cardiopulmonary bypass patients in pre-operative plasma. Experimental design We applied a targeted proteomics approach to quantify 123 plasma proteins from 23 patients undergoing cardiopulmonary bypass (CPB) and sternotomy. We then correlated these measurements to bleeding outcomes and TEG parameters, associated with speed of clot formation and strength. Results In this pilot study, we demonstrate the feasibility of protein quantitation as a viable strategy to predict low versus high bleeding phenotypes (loss of than 20% of estimated blood volume, calculated as 70 mL/kg for BMI 40. Statistical elaborations highlighted a core set of proteins showing significant correlations to either total blood loss or TEG R/MA parameters. Conclusion and clinical relevance Though prospective verification and validation in larger cohorts will be necessary, this report suggests a potential for targeted quantitative proteomics of pre-operative plasma protein concentrations in the prediction of estimated blood loss following CPB.

The airway is a crucial dynamic structure that spans different anatomical zones, including the intrathoracic, extrathoracic, tracheal, bronchial, and alveolar zones. Because of its vital role as the sole oxygen-conducting pathway to the alveoli, and hence to the human body, surgery involving any portion requires careful and specific planning by both the surgeon and the anesthesiologist. The review covers essential management points for proximal and distal tracheal procedures, including a discussion of tracheal stenting and tracheoplasty.

The platelet-mapping assay of the thromboelastograph was used to measure platelet aggregation and to examine the effect of cardiopulmonary bypass on multiple platelet receptors and the role of altered receptor activity in postoperative bleeding. The percentage platelet aggregation for collagen, adenosine diphosphate and arachidonic acid was measured in 40 patients divided post-hoc into high- or low-bleeding groups depending on postoperative 24-h chest tube output. Platelet aggregation was lower after cardiopulmonary bypass compared to before it using collagen (mean (SD) 45 (25) vs 19 (12)%, p

Objective To determine whether a goal-directed perfusion (GDP) strategy, aimed at maintaining an oxygen delivery above 280 mL . min -1. m -2 reduces the incidence of acute kidney injury. Methods Multicenter randomized trial enrolling 350 patients undergoing cardiac surgery in nine institutions. Patients were randomized to receive either GDP or conventional perfusion. Three hundred and twenty-six patients completed the study and were analyzed. Patients in the treatment arm received a GDP strategy during cardiopulmonary bypass aimed to maintain an oxygen delivery ≥ 280 mL . min -1. m -2 . The perfusion strategy for patients in the control arm was factored on body surface area and temperature. The primary endpoint was acute kidney injury rate. Secondary endpoints were intensive care unit length of stay; major morbidity; red blood cell transfusions; operative mortality. Results Acute Kidney Injury Network (AKIN) stage 1 was reduced in patients treated with GDP (relative risk 0.45, 95% CI 0.25-0.83, P=0.01). AKIN stage 2-3 did not differ between groups (relative risk 1.66, 95% CI 0.46-6.0, P=0.528). There were no significant differences in secondary outcomes. In a pre-specified analysis of patients with a cardiopulmonary bypass time between 1 and 3 hours, the differences in favor of the treatment arm were more pronounced, with a relative risk for acute kidney injury of 0.49 (95% CI 0.27-0.89, P=0.017). Conclusions A GDP strategy is effective in reducing AKIN stage 1 acute kidney injury, further studies are needed to define perfusion interventions that may reduce more severe levels of renal injury (AKIN stage 2 or 3).

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 Early airway management is advocated for patients with penetrating neck trauma who have any signs of airway compromise. This study examined the clinical course of patients with penetrating neck trauma who received prehospital blind nasotracheal intubation, including successful intubation rates, and outcomes. Methods A retrospective review of patients admitted to the emergency department for penetrating neck trauma was conducted from January 1, 1993 to July 1, 2001 at the Denver Health Medical Center. Patients were identified from the trauma registry, and data were collected using standardized inclusion and exclusion criteria. Results The study identified 240 patients with penetrating neck trauma. Overall mortality was 8.3%. Among the 240 patients, 89 (37%) required airway management, and 40 (17%) underwent prehospital management with blind nasotracheal intubation. The success rate for prehospital intubation using the blind nasotracheal method was 90%. The mean number of attempts was 1.16 (range, 1-4), and the mortality in this group was 5%. Conclusion The patients managed with blind nasotracheal intubation did not experience complications related to the choice of airway management. Despite prior warnings in the literature, the results of this study suggest that blind nasotracheal intubation may well be a valuable tool for the management of patients with penetrating neck trauma.