The Effect of Sugammadex on Prothrombin and Activated Partial Thromboplastin Time.

Sugammadex is routinely used as an effective neuromuscular blockade reversal agent. Several studies have indicated that it may prolong the prothrombin time (PT) and the activated partial thromboplastin time (aPTT). This review gathers the relevant in vivo studies to accumulate knowledge on the subject. Nine studies were included. According to the results, sugammadex seems to lead to a transient increase in aPTT and PT values, compared to standard care. However, the clinical impact seems to be trivial. Nevertheless, the trials' findings reveal great heterogeneity, preventing a meta-analysis. Therefore, more well-designed studies are needed to lead to prudent conclusions.

Analysis of risk factors for in-hospital mortality in 177 patients who underwent isolated coronary bypass grafting and received intra aortic balloon pump.

BACKGROUND AND AIM OF THE STUDY: Intra-aortic balloon pump (IABP) is the most commonly used device for circulatory support of patients with heart disease. The aim of this study evaluated the risk factors for outcomes of patients who underwent isolated coronary bypass grafting and received IABP. METHODS: One hundred-seventy-seven patients underwent isolated coronary bypass grafting and received intraoperative IABP. All perioperative data were recorded. The primary end-point was in-hospital mortality, while the secondary end-points were the length of intensive care unit (ICU) stay and hospital length of stay (LOS). RESULTS: In-hospital mortality was 5.6% (10 patients). Multivariable logistic regression analysis showed that the risk factors for in-hospital mortality were preoperative plasma creatinine level and cardiopulmonary bypass (CPB) time (for both p < .05). Multivariable linear regression analysis showed that postoperative acute kidney injury (AKI), immediate plasma troponin after operation, numbers of grafts, and CPB time were predicted the hospital LOS, while postoperative AKI, preoperative left ventricular ejection fraction, and immediate plasma troponin after operation were predicted the lengths of ICU stay. CONCLUSION: Our analysis showed that increased preoperative plasma creatinine, postoperative renal dysfunction, and CPB time negatively affected the outcomes of patients who received intraoperative IABP insertion.

Antegrade and Retrograde Cerebral Perfusion During Acute Type A Aortic Dissection Repair in 290 Patients.

AIM: Hypothermia and selective brain perfusion is used for brain protection during an acute type A aortic dissection (ATAAD) correction. We compared the outcomes between antegrade and retrograde cerebral perfusion techniques after ATAAD surgery. METHOD: Between January 1995 and August 2017, 290 patients underwent ATAAD repair under deep hypothermic circulatory arrest/retrograde cerebral perfusion (DHCA/RCP) in 173 patients and moderate hypothermic circulatory arrest/antegrade cerebral perfusion (MHCA/ACP) in 117 patients. Outcomes of interest were: 30-day mortality, new-onset postoperative neurological complications, and length of intensive care unit (ICU) and in-hospital stays. RESULTS: No differences were observed between the preoperative details of both groups (p>0.05). Thirty-day (30-day) mortality did not differ between groups (RCP vs ACP, 22% vs 21.4%; p=0.90). New-onset postoperative permanent neurological dysfunctions and coma was similar in two group in 6.9% versus 10.3% of patients and 3.8% versus 6.8% patients of patients, respectively (p=0.69). The incidence of 30-day mortality and new postoperative neurological complications were similar in the RCP and ACP groups (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.39-2.83 [p=0.91] and OR, 1.7; 95% CI, 0.87-3.23 [p=0.11], respectively). There was no difference between length of stay in the ICU and overall stay in hospital between the RCP and ACP groups (p=0.31 and p=0.14, respectively). No difference in survival rate was observed between the RCP and ACP groups (hazard ratio, 1.2; 95% CI, 0.76-2.01 [p=0.39]). CONCLUSIONS: Thirty-day (30-day) mortality rate, new-onset postoperative neurological dysfunctions, ICU stay, and in-hospital stay did not differ between the MHCA/ACP and DHCA/RCP groups after ATAAD correction. Although the rates of 30-day mortality and postoperative neurological complications were high after ATAAD repair, ACP had no advantages over the RCP technique.

Current Anesthetic Care of Patients Undergoing Transcatheter Aortic Valve Replacement in Europe: Results of an Online Survey.

OBJECTIVES: Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe. DESIGN: Structured web-based, anonymized, voluntary survey. SETTING: Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018. PARTICIPANTS: Physicians. MEASUREMENTS AND MAIN RESULTS: The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only ≤30%. Postprocedurally, patients were transferred to an intensive care unit by 51.43% of the respondents with a reported nurse-to-patient ratio of 1:2 or 1:3, to a post-anesthesia care unit by 27.14%, to a postoperative recovery room by 11.43%, and to a peripheral ward by 10%. CONCLUSION: The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe.

Current challenges in the diagnosis and treatment of cardiac myxoma.

Cardiac myxoma is the most common benign cardiac tumor. It is located in the left atrium and typically arises from the foramen ovale in approximately 75% of the general patient population, in the right atrium in 23%, and in the ventricles in only 2%. Symptoms depend on its size, mobility, and relation to surrounding cardiac structures. Neurological complications resulting from cardiac myxoma are seen in 20% to 25% of patients. Molecular genetic studies show that the condition can be inherited in Carney complex due to mutations of the PRKAR1A gene. Cardiac myxoma resection is a cardiac surgery with a low complication rate and the 30­day mortality of up to 10%. Recurrence may be observed months or years after surgery, and its rate is approximately 5%. Long­term follow­up with transthoracic echocardiography is needed in all patients after tumor resection. This review summarizes the available data on cardiac myxoma and, in particular, issues relating to diagnosis and treatment.

Tying the knot: An uncommon complication.

Cardiothoracic procedures require continuous hemodynamic monitoring and a fair proportion of these require the insertion of a pulmonary artery catheter, known also as Swan-Ganz catheter. Given, however, the invasive nature of these procedures, unforeseen complications may ensue. Early recognition and appropriate handling are essential to minimize adverse outcomes.

Four-year clinical results of transcatheter self-expanding Medtronic CoreValve implantation in high-risk patients with severe aortic stenosis.

BACKGROUND: transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with severe aortic stenosis considered inoperable or at high operative risk, but the long-term outcome remains unknown. HYPOTHESIS: we assessed the 4-year clinical and echocardiographic outcomes of patients undergoing TAVI with the self-expanding Medtronic CoreValve prosthesis. METHODS: sixty-three patients (mean age 80 ± 6 years) with severe aortic stenosis (AS) at high risk for surgical aortic valve replacement (Logistic EuroSCORE 28.8 ± 10.9%) were included in this study. RESULTS: all-cause cumulative mortality at 1, 2, 3 and 4 years was 14.3, 25.4, 28.6 and 36.5%, respectively. The cumulative incidence of documented major stroke at 4 years was 6.3%. In survivors, there was a significant improvement in functional status at 4 years. Paravalvular leak (trivial/mild to moderate) was observed in the majority of patients post-TAVI with no case of progression to severe regurgitation at 4-year follow-up. In multivariate analysis, independent predictor for increased all-cause mortality was left ventricular ejection fraction <40% (HR: 5.347, 95% CI: 1.126-25.381, P = 0.035). CONCLUSION: our study demonstrated favourable long-term (4 years) outcomes after successful TAVI using the third-generation Medtronic CoreValve device.

NT-proBNP in the mitral valve surgery.

BACKGROUND: Prognosis and severity of mitral valve disease in patients are reflected in their natriuretic peptide levels. Patients in the upper margin of this range with severe mitral valve dysfunction also present with a range of myocardial dysfunction and symptomatic progression. We investigated whether serial pre- and immediate postoperative measurements of N-terminal probrain natriuretic peptide (NT-proBNP) can serve as surrogate markers of these surgical patients' severity status and predictors of their immediate postoperative progress. METHODS: Clinical characteristics, echocardiographic indices, and preoperative and postoperative day 1, 5, 7 values of NT-proBNP were retrospectively recorded in a cohort of 75 patients who underwent mitral valve surgery. They were analyzed as a whole and separately for those suffering from severe mitral regurgitation. Correlations, multiple linear regression, logistic regression, and nonparametric receiver operating characteristic curve analyses were implemented. RESULTS: The patients' preoperative New York Heart Association class, presence of atrial fibrillation, and left ventricular function were strongly correlated with the preoperative NT-proBNP level. Specifically for those with severe mitral regurgitation, preoperative NT-proBNP was also correlated to their left ventricular end-diastolic diameter. NT-proBNP values increased respectively postoperatively in all patients and were related to the preoperative values, the patients' preoperative characteristics, and the operative times. Logistic regression analysis identified preoperative NT-proBNP as a predictor of postoperative optimal clinical outcome (P < 0.001). CONCLUSIONS: NT-proBNP is a valuable biomarker of the clinical presentation and immediate postoperative outcome in patients undergoing mitral valve surgery. The preoperative measurement of NT-proBNP can be used to predict an optimal postoperative clinical outcome.

Anesthetic management of patients undergoing transcatheter aortic valve implantation.

OBJECTIVE: To compare 2 anesthetic techniques, general anesthesia or monitored anesthesia care, performed by the same cardiac anesthesiologists for transcatheter aortic valve implantation in the authors' institution. DESIGN: A retrospective study. SETTING: A single specialized cardiac surgery center. PARTICIPANTS: Ninety-eight patients with severe aortic valve stenosis and a high logistic EuroSCORE considered not eligible to undergo conventional aortic valve replacement. INTERVENTION: General anesthesia or monitored anesthesia care. MEASUREMENTS AND MAIN RESULTS: General anesthesia was used in 57 and monitored anesthesia care in 41 patients. The authors compared the following parameters: Duration of procedure, transfusion requirements, cardiac indices, superior vena cava saturation (ScVO2) before and after the aortic valve implantation, hospital length of stay and 30-day mortality. The only significant differences between the groups concerned were the duration of anesthesia (p<0.001) and ScVO2 values. Anesthesia duration was prolonged significantly when general anesthesia was administered, and ScVO2 was significantly higher both before and after the valve implantation in the general anesthesia group. Thirty-day mortality was 5.3% in the general anesthesia group and 4.9% in the monitored anesthesia group. CONCLUSIONS: It would appear that both anesthetic techniques may be used for patients with a high logistic EuroSCORE undergoing transcatheter aortic valve implantation.

Outcomes after ascending aorta and proximal aortic arch repair using deep hypothermic circulatory arrest with retrograde cerebral perfusion: analysis of 207 patients.

OBJECTIVES: Correction of ascending aorta and proximal aortic arch pathology with numerous surgical techniques having been proposed over the years remains a surgical challenge. This study was undertaken to identify risk factors influencing outcome after aortic arch operations, requiring deep hypothermic circulatory arrest (DHCA). METHODS: Between 1993 and 2010, 207 consecutive patients were operated for ascending aorta and proximal arch correction with the use of deep hypothermic circulatory arrest with retrograde cerebral perfusion. All patients were followed up with regular out-patient clinics, transthoracic echocardiography and, when required, chest computed tomography. RESULTS: There were 102 (49.3%) emergencies (acute type A dissection) and 105 (50.7%) elective cases. Mean age: 63.5 ± 12 years. Mean circulatory arrest time was 25.4 ± 13 min. Unadjusted analysis of factors associated with 30-day mortality revealed emergency status, preoperative hemodynamic instability, acute dissection, reoperation, increased circulatory arrest time, postoperative bleeding, postoperative creatinine levels and presence of neurological dysfunction. Multi-adjusted analysis revealed duration of circulatory arrest as the only and main factor related to death. Thirty-day mortality was 2.4% for the elective and 7.2% for emergencies cases. Survival during long-term follow-up was 93, 82 and 53% at 1, 5 and 10 years, respectively. CONCLUSIONS: Ascending aorta and proximal aortic arch replacement with brief duration of deep hypothermic circulatory arrest combined with retrograde cerebral perfusion is a safe method with acceptable short- and long-tem results.

The predictive value and evolution of N-terminal pro-B-type natriuretic peptide levels following transcutaneous aortic valve implantation.

AIMS: We sought to define the predictive value and evolution of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels following transcutaneous aortic valve implantation (TAVI). METHODS AND RESULTS: We investigated 91 consecutive patients who underwent TAVI (59 transfemoral [TF], 32 transapical [TA]) in our institution. The balloon-expandable valve was implanted in 75 and the self-expanding in 16 patients. The baseline (within 48 hours prior to procedure), early (24-74 hours), and late (3-12 months) postprocedural NT-proBNP levels were determined. The mortality status of all patients was ascertained as of September 2010. The 30-day and 1.3(mean)-year mortality was 3% and 12% (2%, 9% in the TF and 6%, 19% in the TA group). Increased baseline (χ(2) = 5.9, P = 0.016) and early (χ(2) = 4.9, P = 0.028) NT-proBNP levels were predictive of mortality. All decrements of the NT-proBNP levels in the TF patients were significant (baseline 4,984 ± 8,106 vs. early 3,912 ± 6,551 pg/mL, P = 0.016; late 633 ± 606 pg/mL, P = 0.003). In contrast, there was a trend for the early levels to increase in the TA patients (6,423 ± 8,897 vs. 8,100 ± 10,178 pg/mL, P = 0.090), and a significant decline in the late levels as compared to baseline (1,704 ± 3,417 pg/mL, P = 0.005). CONCLUSION: NT-proBNP levels are predictive of mortality following TAVI. There is a differential early evolution of their levels between the TF and TA patients and a significant decline later in both groups.

Surgical treatment of primary intracardiac myxoma: 19 years of experience.

Cardiac myxoma is the most common benign tumor of the heart. It presents with a variety of clinical signs and symptomatology making diagnosis frequently quite a challenge. We review our experience with 41 patients who underwent surgical intervention for cardiac myxoma between 1994 and 2011. All patients' preoperative, intraoperative and postoperative characteristics were recorded. They all had a standard sternotomy and cardiopulmonary bypass with cardioplegic cardiac arrest and were followed up with clinical examination and echocardiography. The surgical goal was to remove not only the tumor but the whole area of attachment to prevent recurrence. Biatrial approach facilitated the complete excision of the tumor. Surgical excision of cardiac myxoma carries a low-operative risk and gives excellent short- and long-term results.

Transcatheter aortic valve implantation, patient selection process and procedure: two centres' experience of the intervention without general anaesthesia.

INTRODUCTION: transcatheter aortic valve implantation (TAVI) is an emerging technique for the treatment of aortic stenosis. With the advent of percutaneous suture devices for the access point and prosthesis delivery systems of smaller diameter, TAVI has become a truly percutaneous procedure: percutaneous aortic valve replacement (PAVR). Thus, PAVR may be conducted without general anaesthesia (GA). METHODS: We report two centres' experience from PAVR without GA. CoreValve aortic bioprostheses were utilised. The patient selection process and PAVR procedure are described in detail. RESULTS: a total of 30 patients (pts) were treated with PAVR. In 4 pts correction of the initial malposition of the prosthesis required a special technique (2 pts: "snare"; 2 pts: "removing and reinserting"). At 1-month follow up, haemodynamic and clinical improvements were observed: left ventricular ejection fraction increased from 50.8 ± 9.3% to 54.3 ± 8.3% (p=0.02); peak aortic valve gradient decreased from 90.3 ± 26.4 mmHg to 14.8 ± 9.7 mmHg, (p<0.001); NYHA functional class decreased from 3.53 ± 0.93 to 1.45 ± 0.94 (p<0.001). Overall 1-month mortality was 3.3% (1 patient died). CONCLUSION: PAVR without general anaesthesia is a feasible technique, however the role of anaesthesiologists is still important.

Percutaneous aortic valve implantation of the Medtronic CoreValve self-expanding valve prosthesis via left subclavian artery access: the first case report in Greece.

This case report describes a percutaneous aortic valve implantation with the Medtronic CoreValve selfexpanding valve prosthesis in a patient with severe aortic stenosis. The approach was made via the left subclavian artery because of the lack of femoral vessel access. The patient was a 78-year-old female with breathlessness on minimal effort, a recent hospitalisation due to pulmonary oedema, and frequent episodes of pre-syncope; surgical valve replacement had been ruled out. The prosthetic valve was successfully implanted with mild paravalvular aortic regurgitation. At 30 days, the patient's clinical condition had significantly improved, with excellent functioning of the aortic valve prosthesis.

Transcatheter aortic valve implantation: first Greek experience.

INTRODUCTION: Percutaneous aortic valve replacement represents an alternative to conventional open-heart surgery for selected high-risk patients without the need for sternotomy, aortotomy, or cardiopulmonary bypass. We present the first Greek series of transcatheter prosthetic aortic valve implantation procedures, performed in our centre. METHODS: All 12 patients (age 81 +/- 5 years) had severe, symptomatic, calcific aortic stenosis and were judged not to have a reasonable surgical option by a medical team including experienced cardiac surgeons. The patients' mean logistic EuroSCORE was 34 +/- 15% (min 11%, max 61%). Eight (8) of them underwent transfemoral (SAPIEN, Edwards 23 mm valve in 7 and 26 mm in 1 patient) and 4 transapical (26 mm in 2 and 23 mm in 2 patients) prosthetic aortic valve implantation, all in the cardiac catheterisation laboratory under general anaesthesia. RESULTS: The procedural, in-hospital and 2-month (mean follow up 50 days, min 17, max 122 days) mortality was 0%. The length of hospital stay was 8 +/- 2 days (min 5, max 12 days). The aortic valve area increased from 0.64 +/- 0.14 cm2 to 1.83 +/- 0.14 cm2 and the mean pressure gradient decreased from 57 +/- 23 mmHg to 10 +/- 3 mmHg post-implantation (p<0.001 for both). The patients' mean NYHA functional status improved from 2.8 +/- 0.7 to 1.3 +/- 0.5 at follow-up (p<0.001). CONCLUSIONS: Our initial experience with transcatheter prosthetic aortic valve implantation demonstrates that it can be performed safely and with excellent short and mid-term clinical outcomes.