Selected 2023 Highlights in Congenital Cardiac Anesthesia.

This article reviews the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist published in 2023. After a search of the US National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2023. The authors of this article considered the following topics noteworthy to be included in this review: (1) advancements in percutaneous mechanical support in children with congenital heart disease, (2) children with pulmonary hypertension undergoing surgery for congenital heart disease, (3) dexmedetomidine in pediatric cardiac surgery, and (4) recommendations for pediatric heart surgery in the United States: Implications for pediatric cardiac anesthesia.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2020.

THIS SPECIAL article is the 13th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology.1 The major themes selected for 2020 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2020 begin with an update on valvular disease, with a focus on updates in management of aortic and mitral valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and surgical management. The third major theme is focused on the perioperative management of patients with coronavirus disease 2019 (COVID-19), with the authors highlighting literature discussing medical, surgical, and anesthetic considerations for their cardiac care. The fourth major theme is an update in heart failure, with discussion of medical, psychosocial, and procedural aspects of this complicated disease process. The fifth and final theme focuses on the latest analyses regarding survival in heart transplantation. The themes selected for this 13th special article are only a few of the diverse advances in the specialty during 2020. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Opioid-Sparing Cardiac Anesthesia: Secondary Analysis of an Enhanced Recovery Program for Cardiac Surgery.

BACKGROUND: Cardiac anesthetics rely heavily on opioids, with the standard patient receiving between 70 and 105 morphine sulfate equivalents (MSE; 10-15 µg/kg of fentanyl). A central tenet of Enhanced Recovery Programs (ERP) is the use of multimodal analgesia. This study was performed to assess the association between nonopioid interventions employed as part of an ERP for cardiac surgery and intraoperative opioid administration. METHODS: This study represents a post hoc secondary analysis of data obtained from an institutional ERP for cardiac surgery. Consecutive patients undergoing cardiac surgery received 5 nonopioid interventions, including preoperative gabapentin and acetaminophen, intraoperative dexmedetomidine and ketamine infusions, and regional analgesia via serratus anterior plane block. The primary objective, the association between intraoperative opioid administration and the number of interventions provided, was assessed via a linear mixed-effects regression model. To assess the association between intraoperative opioid administration and postoperative outcomes, patients were stratified into high (>50 MSE) and low (≤50 MSE) opioids, 1:1 propensity matched based on 15 patients and procedure covariables and assessed for associations with postoperative outcomes of interest. To investigate the impact of further opioid restriction, ultralow (≤25 MSE) opioid participants were then identified, 1:3 propensity matched to high opioid patients, and similarly compared. RESULTS: A total of 451 patients were included in the overall analysis. Analysis of the primary objective revealed that intraoperative opioid administration was inversely related to the number of interventions employed (estimated -7.96 MSE per intervention, 95% confidence interval [CI], -9.82 to -6.10, P < .001). No differences were detected between low (n = 136) and high (n = 136) opioid patients in postoperative complications, postoperative pain scores, time to extubation, or length of stay. No differences were found in outcomes between ultralow (n = 63) and high (n = 132) opioid participants. CONCLUSIONS: Nonopioid interventions employed as part of an ERP for cardiac surgery were associated with a reduction of intraoperative opioid administration. Low and ultralow opioid use was not associated with significant differences in postoperative outcomes. These findings are hypothesis-generating, and future prospective studies are necessary to establish the role of opioid-sparing strategies in the setting of cardiac surgery.

Interruption of the European Association of Cardiothoracic Anaesthesiology (EACTA) Fellowship Program During the Coronavirus Disease 2019 Pandemic: Consequences and Solutions.

This article discusses the impact of the COVID-19 pandemic on the EACTA fellowship program. The authors present three points that in their view are important and give cause for concern because they could make it difficult or impossible to achieve the original goals of the fellowship program. Corresponding points are discussed and possible solutions are presented. An implementation in the fellowship curriculum is planned.

The Future Directions of Research in Cardiac Anesthesiology.

This article provides an overview of knowledge gaps that need to be addressed in cardiac anesthesia, including mitigating the inflammatory effects of cardiopulmonary bypass, defining myocardial infarction after cardiac surgery, improving perioperative neurologic outcomes, and the optimal management of patients undergoing valve replacement. In addition, emerging approaches to research conduct are discussed, including the use of new analytical techniques like machine learning, pragmatic trials, and adaptive designs.

Selected 2018 Highlights in Congenital Cardiac Anesthesia.

THIS ARTICLE IS a review of the highlights of pertinent literature published during the 12 months of 2018 that is of interest to the congenital cardiac anesthesiologist. During a search of the US National Library of Medicine PubMed database, several topics that displayed significant contributions to the field in 2018 emerged. The authors of the present review consider the following topics noteworthy: the patient with high-risk congenital heart disease (CHD) presenting for noncardiac surgery, cardiopulmonary resuscitation in infants and children with CHD, dexmedetomidine use in pediatric patients, point-of-care lung ultrasound, and regional anesthesia in pediatric cardiac surgery.

Preparing for a Fellowship in Adult Cardiothoracic Anesthesiology: Resources and Approaches for the Anesthesiology Trainee.

Adult cardiothoracic anesthesiology (ACTA) is a competitive fellowship. Despite increases in both the number of programs offering cardiothoracic fellowships and the number of residents applying each year, there is little direction or advice for prospective candidates. This review aims to educate anesthesiology residents who are hoping to pursue cardiothoracic anesthesiology, by examining a brief history of the advanced perioperative echocardiography qualification, the credentialing goals of ACTA fellowships, and the current status of ACTA fellowships. The second part of the review covers the ACTA fellowship application and aims to assist the candidate in navigating this process. The review examines the qualifications that fellowship programs look for in a candidate, including a discussion on professional behavior, and what an applicant can look for in a program. Finally, there is a brief discussion on post-match preparation.

Gender Differences in Authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-Year Analysis of Publications Originating From the United States, 1990-2017.

OBJECTIVE: Gender-based differences in scholarship among cardiothoracic anesthesiologists have not been studied. The authors examined the gender distribution of authorship of original research articles, case reports, review articles, and editorials in the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) originating from the United States during four 3-year intervals to determine temporal changes in productivity of women in cardiothoracic anesthesiology. The authors tested the hypothesis that scholarly output of women has increased progressively in JCVA over time concomitant with greater participation in first, last, and corresponding author roles. DESIGN: Observational study. SETTING: Internet analysis. PARTICIPANTS: Authors of research articles, case reports, review articles, and editorials published in JCVA in 1990-92, 1999-2001, 2008-10, and 2015-17. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The gender of each author was determined by inspection of the first name. If gender could not be established easily, the author's institutional website was examined or an internet search using the Google search engine was conducted. First, last, and corresponding authors as well as coauthors were noted for each article. A total of 1,195 publications with 4,982 authors (1,032 women; 20.7%) were examined. Gender was identified positively in 98.5% of authors. Women were first, last, and corresponding authors on 22.4%, 10.3%, and 14.6% of publications, respectively. The percentage of women who were authors increased from 12.1% in 1990-92 to 20.9% in 1999-2001 (p < 0.05), but plateaued in 2008 to 2010 (22.3%) and 2015 to 2017 (22.9%). Greater percentages of women were first authors (26.2%), senior authors (11.8%), and corresponding authors (16.6%) in 2015 to 2017 compared with 1990 to 1992 (9.6%, 7.0%, and 8.7%, respectively; p < 0.05 for each). The contributions of women to research articles and case reports were primarily responsible for these observed increases, although women also made a substantial impact with review articles in 2015 to 2017. The percentage of publications that included at least 1 female author in any capacity increased in a time-dependent manner (p < 0.05) from 31.0% (1990-1992) to 74.4% (2015-2017). The proportion of female first or last authors (35.0%) appearing in JCVA during 2015 to 2017 was modestly higher than the current percentage of female cardiothoracic anesthesiologists practicing in departments with accredited fellowship programs (29.1%). CONCLUSION: The results indicate that scholarly output of women rose in JCVA over time, but gains in productivity have plateaued more recently. These findings are encouraging, but women continue to be underrepresented in corresponding and last author roles.

Financial Considerations of an Anesthesia Consult Service.

Surgical patients with complex cardiac disease often require noncardiac surgery. There have been recent articles written concerning the role of the cardiothoracic anesthesiologist as a consultant in the operating room as well as outside the operating theatre.1,2 With the evolution of the cardiothoracic anesthesia consult service (CACS), there are many issues regarding medical billing, financial reimbursement, and Medicare rules that anesthesiologists may not be familiar with. This paper will discuss the financial implications of starting a CACS.

Fellowship Training in Pediatric Cardiac Anesthesia: History, Maturation, and Current Status.

Pediatric cardiac anesthesia as a discipline has evolved over the years to become a well recognized sub-specialty. Education and training in the field has also continued to change and develop. In this review, the author outline the changes in the field over the years and suggest a structure for an organized fellowship training process.

Myasthenia Gravis and Thymoma Surgery: A Clinical Update for the Cardiothoracic Anesthesiologist.

Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended.

How Cardiac Anesthesiology Can Help "STEM" the Tide of Under-representation of Minorities in Science and Medicine.

The field of medicine is built upon science, technology, engineering, and math (STEM), yet the United States is rapidly falling behind when it comes to educating the next generation in these disciplines, especially under-represented populations. The authors reflect on existing educational literature surrounding efforts to promote interest in STEM among students and under-represented populations. The authors advocate for greater efforts toward the development of youth programing. Cardiac anesthesia is uniquely positioned as a subspecialty to advance the goal of promoting interest in STEM in diverse groups of young students. The authors describe their development and implementation of a community outreach program to enhance interest in medicine through a cardiac dissection experience.

Use of Dexmedetomidine in Cardiothoracic and Vascular Anesthesia.

Dexmedetomidine is a highly selective α2-adrenergic agonist with analgesic and sedative properties. In the United States, the Food and Drug Administration approved the use of the drug for short-lasting sedation (24 h) in intensive care units (ICUs) in patients undergoing mechanical ventilation and endotracheal intubation. In October 2008, the Food and Drug Administration extended use of the drug for the sedation of nonintubated patients before and during surgical and nonsurgical procedures. In the European Union, the European Medicine Agency approved the use of dexmedetomidine in September 2011 with a single recognized indication: ICU adult patients requiring mild sedation and awakening in response to verbal stimulus. At present, the use of dexmedetomidine for sedation outside the ICU remains an off-label indication. The benefits of dexmedetomidine in critically ill patients and in cardiac, electrophysiology-related, vascular, and thoracic procedures are discussed.