Cardiothoracic Anesthesia
Review: Management of Atrial Fibrillation
18 Dec, 2024 | 14:22h | UTCIntroduction: This summary of a comprehensive review on atrial fibrillation (AF) focuses on an increasingly prevalent arrhythmia affecting more than 10 million adults in the United States. AF significantly elevates the risks of stroke, heart failure (HF), cognitive decline, and mortality. This guideline-based overview examines the pathophysiology, detection, prevention, and treatment strategies for AF, emphasizing risk factor modification, appropriate anticoagulation, and early rhythm control interventions to improve clinical outcomes and quality of life.
Key Recommendations:
- Risk Factor and Lifestyle Modification: Implement weight reduction, regular exercise, optimal blood pressure control, smoking cessation, and reduced alcohol intake at all AF stages to prevent new-onset AF, reduce recurrences, and mitigate complications.
- Screening and Diagnosis: Consider AF screening in high-risk patients using wearable devices or implantable loop recorders. Confirm suspected AF with electrocardiography and extended rhythm monitoring in those with cryptogenic stroke.
- Stroke Prevention: Assess stroke risk using CHA2DS2-VASc. For patients with annual stroke risk ≥2%, initiate oral anticoagulation (preferably direct oral anticoagulants over warfarin) to lower stroke risk by up to 80%. Avoid aspirin monotherapy for AF-related stroke prevention due to inferior efficacy.
- Early Rhythm Control: Begin rhythm control within one year of AF diagnosis, particularly in symptomatic patients or those with HF and reduced ejection fraction (HFrEF). Early use of antiarrhythmic drugs or catheter ablation can improve symptoms, cardiac function, and reduce hospitalizations.
- Catheter Ablation: Utilize ablation as a first-line therapy in symptomatic paroxysmal AF to maintain sinus rhythm and prevent progression. In patients with AF and HFrEF, ablation enhances quality of life, improves left ventricular function, and lowers mortality and HF hospitalization rates.
- Rate Control Strategies: For patients who are not candidates for rhythm control, use beta-blockers or nondihydropyridine calcium channel blockers to achieve satisfactory ventricular rate control. Consider atrioventricular nodal ablation plus pacemaker implantation if pharmacologic therapy is inadequate.
- Staging and Long-Term Management: Recognize four AF stages (at risk, pre-AF, clinically apparent AF, and permanent AF) to tailor management. After ablation, continue anticoagulation for at least three months, then reassess stroke risk before considering discontinuation.
- Addressing Inequities: Improve access to guideline-directed AF therapies, including ablation and specialized care, and address social determinants of health that influence disparities in diagnosis, treatment, and outcomes.
Conclusion: Guideline-directed AF management, encompassing comprehensive risk factor modification, appropriate anticoagulation, and timely rhythm control strategies, can reduce stroke incidence, improve HF outcomes, and prolong life. Catheter ablation is a key intervention for appropriate patients, especially those with symptomatic paroxysmal AF or HFrEF, while striving for equitable and evidence-based care across diverse populations remains a critical priority.
Meta-analysis: Perioperative Colchicine Reduced Postoperative Atrial Fibrillation After CABG
18 Sep, 2024 | 13:33h | UTCBackground: Coronary artery disease (CAD) remains a leading cause of mortality worldwide. Inflammation is a key factor in the development and progression of CAD, and anti-inflammatory therapies have shown potential in improving cardiovascular outcomes. Colchicine, traditionally used to treat gout, has demonstrated efficacy in reducing cardiovascular events in patients with chronic CAD. Previous individual studies have suggested that perioperative colchicine may decrease the incidence of postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting (CABG), but a comprehensive analysis is needed to confirm these findings.
Objective: To evaluate the effect of perioperative colchicine administration on the incidence of POAF in patients undergoing isolated CABG surgery through a meta-analysis of randomized controlled trials (RCTs).
Methods: A systematic search was conducted across MEDLINE, Web of Science, and The Cochrane Library to identify RCTs comparing perioperative colchicine administration with standard care in patients undergoing CABG. Inclusion criteria encompassed studies involving isolated CABG patients randomized to receive colchicine or standard care without colchicine. The primary outcome was the incidence of POAF during short-term follow-up.
Results: Five RCTs published between 2014 and 2022 met the inclusion criteria, including a total of 839 patients undergoing isolated CABG. Perioperative colchicine administration was associated with a significant reduction in POAF rates compared to standard care (relative risk [RR], 0.54; 95% confidence interval [CI], 0.40–0.73; p < 0.01). Other outcomes, such as graft patency, myocardial infarction, or long-term mortality, were not uniformly reported and, therefore, not analyzed.
Conclusions: Perioperative administration of colchicine is associated with a significant reduction in the incidence of POAF in patients undergoing CABG surgery.
Implications for Practice: Colchicine may be considered as a prophylactic strategy to reduce POAF in patients undergoing CABG, potentially improving both short- and long-term outcomes. Given the association of POAF with increased perioperative morbidity and long-term adverse events, implementing colchicine could have substantial clinical benefits in this high-risk population.
Study Strengths and Limitations: Strengths of this meta-analysis include the exclusive inclusion of randomized controlled trials and the use of rigorous statistical methods, including sensitivity analysis, which confirmed the robustness of the results. Limitations involve the small number of studies (five RCTs), potential variability in colchicine dosing regimens, and the lack of data on other clinically relevant outcomes.
Future Research: Large-scale, multicenter RCTs are warranted to further assess the effects of colchicine on other important outcomes in CABG patients, such as graft patency, myocardial infarction rates, and long-term mortality. Future studies should also evaluate the risk-benefit profile of colchicine in this patient population to establish its full role in clinical practice.
Reference: Kirov H., Caldonazo T., Runkel A., et al. (2024). Colchicine in Patients with Coronary Disease Undergoing Coronary Artery Bypass Surgery – A Meta-Analysis of Randomized Controlled Trials. The American Journal of Cardiology. DOI: http://doi.org/10.1016/j.amjcard.2024.09.003
RCT: Interruption of Oral Anticoagulation during TAVI Reduces Bleeding Without Increasing Thromboembolic Events
7 Sep, 2024 | 12:43h | UTCStudy Design and Population: This international, open-label, randomized noninferiority trial examined 858 patients undergoing transcatheter aortic-valve implantation (TAVI) who had an indication for oral anticoagulation due to concomitant diseases. Patients were randomized 1:1 to either continue or interrupt their oral anticoagulation during the procedure, with the primary outcome being a composite of cardiovascular death, stroke, myocardial infarction, major vascular complications, or major bleeding within 30 days.
Main Findings: Primary outcome events occurred in 16.5% of the continuation group and 14.8% of the interruption group, showing a non-significant risk difference of 1.7 percentage points (95% CI, -3.1 to 6.6). Thromboembolic events were similar between groups (8.8% in continuation vs. 8.2% in interruption). However, bleeding events were significantly higher in the continuation group (31.1% vs. 21.3%; risk difference, 9.8 percentage points; 95% CI, 3.9 to 15.6).
Implications for Practice: Interrupting oral anticoagulation during TAVI significantly reduces bleeding without increasing thromboembolic risks, suggesting it may be a safer strategy for patients undergoing TAVI. These findings could influence clinical decision-making regarding anticoagulation management in this population.
Reference: van Ginkel, D.J. et al. (2024). Continuation versus Interruption of Oral Anticoagulation during TAVI. The New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2407794
News Release: SCOFF Trial Confirms Fasting Not Necessary Before Cardiac Catheterisation Procedures
7 Sep, 2024 | 10:10h | UTC1 September 2024 – London, United Kingdom – New findings from the SCOFF trial, presented at ESC Congress 2024, suggest that fasting prior to minimally invasive cardiac catheterisation procedures under conscious sedation does not increase the risk of complications. The trial supports reconsidering current guidelines on pre-procedural fasting.
Key Points for Physicians:
– No increased complications: The SCOFF trial found no significant difference in adverse outcomes, such as aspiration pneumonia or hypoglycemia, between patients who fasted and those who ate normally before cardiac catheterisation.
– Improved patient satisfaction: Patients who did not fast reported higher satisfaction, with fewer complaints of discomfort and hunger.
– Potential guideline change: These findings, in line with previous studies like CHOW-NOW and TONIC, challenge the necessity of fasting before such procedures.
The trial’s lead investigator, Dr. David Ferreira (John Hunter Hospital, Australia), emphasized that avoiding fasting may improve patient experience without increasing risks, making it time to reconsider fasting guidelines for these procedures.
Study Overview:
– Trial design: Prospective, randomized, open-label, with blinded endpoint assessment.
– Participants: 716 patients undergoing coronary angiography, coronary intervention, or cardiac implantable electronic device procedures.
– Primary endpoint: Composite of hypotension, aspiration pneumonia, hyperglycemia, and hypoglycemia, showing a lower event rate in the non-fasting group (12.0%) compared to the fasting group (19.1%).
These results are likely to influence future clinical practice, providing greater flexibility for both patients and healthcare systems.
RCT: Hypothermic Oxygenated Perfusion Trends Toward Lower Primary Graft Dysfunction in Heart Transplantation – The Lancet
17 Aug, 2024 | 19:38h | UTCStudy Design and Population: This randomized, controlled, open-label, multicenter clinical trial evaluated the safety and efficacy of hypothermic oxygenated machine perfusion (HOPE) compared to static cold storage (SCS) in preserving donor hearts for transplantation. Conducted across 15 transplant centers in eight European countries, the study enrolled 229 adult heart transplant candidates between November 2020 and May 2023. The trial included 204 patients who received a transplant and met the study’s inclusion and exclusion criteria.
Main Findings: The primary composite endpoint, including cardiac-related death, graft dysfunction, and rejection within 30 days post-transplant, occurred in 19% of patients in the HOPE group compared to 30% in the SCS group, reflecting a 44% risk reduction (HR 0.56, 95% CI 0.32–0.99, p=0.059). Notably, primary graft dysfunction was significantly lower in the HOPE group (11% vs. 28%, RR 0.39, 95% CI 0.20–0.73). The incidence of major adverse cardiac transplant events was also reduced with HOPE (18% vs. 32%, RR 0.56, 95% CI 0.34–0.92).
Implications for Practice: HOPE showed a potential clinical benefit by reducing the incidence of primary graft dysfunction and major adverse cardiac events after heart transplantation. Although the primary endpoint was not statistically significant, the observed risk reductions suggest that HOPE could improve outcomes in heart transplantation. Further research is needed to confirm these findings and optimize donor heart preservation strategies.
RCT: Routine Protamine Administration Enhances Hemostasis and Reduces Vascular Complications in TAVI – JAMA Cardiol
17 Aug, 2024 | 19:09h | UTCStudy Design and Population: The ACE-PROTAVI trial was a double-blind, placebo-controlled randomized clinical trial conducted at three Australian hospitals. It involved 410 patients (median age 81 years) undergoing transfemoral transcatheter aortic valve implantation (TAVI). The trial evaluated the efficacy and safety of routine protamine administration versus placebo.
Main Findings: Patients receiving protamine showed a higher rate of successful hemostasis (97.9% vs. 91.6%) and a significantly shorter time to hemostasis (median 181 vs. 279 seconds). Protamine administration also led to a reduced risk of composite vascular complications (5.2% vs. 12.8%), primarily due to fewer minor vascular events. No adverse events were associated with protamine.
Implications for Practice: Routine protamine administration after TAVI improves hemostasis, reduces minor vascular complications, and shortens procedural and postprocedural recovery times, suggesting it should be considered in standard TAVI protocols.
RCT: Intravenous Amino Acids Reduce AKI Incidence in Cardiac Surgery Patients – N Engl J Med
3 Aug, 2024 | 19:12h | UTCStudy Design and Population: In this multinational, double-blind, randomized clinical trial, 3511 adult patients scheduled for cardiac surgery with cardiopulmonary bypass were recruited from 22 centers across three countries. Patients were randomly assigned to receive an intravenous infusion of either a balanced mixture of amino acids (2 g/kg/day) or a placebo (Ringer’s solution) for up to three days.
Main Findings: The primary outcome, occurrence of acute kidney injury (AKI), was significantly lower in the amino acid group (26.9%) compared to the placebo group (31.7%) with a relative risk of 0.85 (95% CI, 0.77 to 0.94; P=0.002). The incidence of severe AKI (stage 3) was also reduced in the amino acid group (1.6% vs. 3.0%; relative risk, 0.56; 95% CI, 0.35 to 0.87). There were no substantial differences between the groups regarding secondary outcomes such as the use and duration of kidney-replacement therapy or all-cause 30-day mortality.
Implications for Practice: The infusion of amino acids in adult patients undergoing cardiac surgery appears to reduce the incidence of AKI, indicating a potential protective renal effect. However, this intervention did not significantly impact other secondary outcomes, including mortality and the use of kidney-replacement therapy. These findings suggest that amino acids could be considered as a strategy to mitigate AKI risk in this patient population, although further research is needed to explore long-term benefits and other clinical outcomes.
RCT: Serratus anterior plane block reduces pain and opioid use in rib fracture patients – JAMA Surgery
2 May, 2024 | 23:20h | UTCStudy Design and Population:
This study was a multicenter, open-label, pragmatic randomized clinical trial conducted across eight emergency departments in New South Wales, Australia. The trial included 210 patients aged 16 years or older who had clinically suspected or radiologically confirmed rib fractures. Patients intubated, transferred for urgent surgical intervention, or with major concomitant nonthoracic injuries were excluded.
Main Findings:
In the trial, patients were randomized to receive either a serratus anterior plane block (SAPB) along with standard rib fracture management or standard care alone. The primary outcome was a composite pain score measured 4 hours post-enrollment. The SAPB group showed a significant increase in patients achieving the desired pain score reduction (41% in SAPB group vs. 19.6% in control; RR 0.73, 95% CI 0.60-0.89, P = 0.001). Additionally, SAPB recipients had significantly lower opioid consumption at 24 hours compared to the control group.
Implications for Practice:
The trial’s results support the addition of a serratus anterior plane block (SAPB) to standard rib fracture management for providing effective early pain relief and reducing opioid use. However, it’s important to note that this study did not include a sham group, and patients were aware of whether they received the intervention. This lack of blinding could influence patient-reported outcomes due to placebo effects. Despite this limitation, the reduction in pain and opioid consumption suggests that SAPB is a beneficial component of care for patients with rib fractures.
Reference (link to abstract – $ for full-text):
Review | Regional analgesia for acute pain relief after open thoracotomy and video-assisted thoracoscopic surgery
31 Jul, 2023 | 14:03h | UTC
Practice advisory for preoperative and intraoperative pain management of thoracic surgical patients
19 Jun, 2023 | 14:05h | UTCPart 1: Practice Advisory for Preoperative and Intraoperative Pain Management of Thoracic Surgical Patients – Anesthesia and Analgesia (free for a limited period)
Part 2: Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients – Anesthesia and Analgesia (free for a limited period)
See also: Prevalence and Characteristics of Persistent Postoperative Pain After Thoracic Surgery: A Systematic Review and Meta-Analysis – Anesthesia and Analgesia (free for a limited period)
Infographic: Persistent Pain After Thoracic Surgery—What Works, What Doesn’t – Anesthesia and Analgesia (free for a limited period)
M-A | Comparison of intercostal block and epidural analgesia for post-thoracotomy
5 Jun, 2023 | 13:04h | UTC
ISHLT Guidelines for the care of heart transplant recipients
3 May, 2023 | 15:09h | UTC
RCT | Ventilation approaches in one-lung ventilation and pulmonary complications after major lung resection surgery
2 May, 2023 | 13:23h | UTC
Commentary on Twitter
One of the largest #RCTs on the management of one lung ventilation in #thoracicanesthesia (880 pts). https://t.co/ZVhTP5sv4o pic.twitter.com/KyLu4BE2yd
— Journal of Cardiothoracic and Vascular Anesthesia (@JCVAonline) April 30, 2023
Review | Enhanced recovery after surgery and chest tube management
21 Mar, 2023 | 13:26h | UTCEnhanced recovery after surgery and chest tube management – Journal of Thoracic Disease
Related:
Consensus Paper | Pain management and opioid stewardship in adult cardiac surgery
8 Mar, 2023 | 14:22h | UTC
Regional anesthesia for thoracic surgery: a narrative review of indications and clinical considerations
23 Feb, 2023 | 13:11h | UTC
RCT | Intraoperative intravenous infusion of esmketamine in patients undergoing thoracic surgery
16 Feb, 2023 | 14:56h | UTC
Review | Postoperative atrial fibrillation: from mechanisms to treatment
15 Feb, 2023 | 15:54h | UTCPostoperative atrial fibrillation: from mechanisms to treatment – European Journal of Cardiology
Commentary on Twitter
Postoperative atrial fibrillation: from mechanisms to treatment https://t.co/Alpb9eFRGb @escardio #EHJ #ESCYoung #cardiotwitter @ehj_ed @rladeiraslopes pic.twitter.com/s27PGkS49X
— European Society of Cardiology Journals (@ESC_Journals) February 14, 2023
Review | Perioperative cardiovascular pathophysiology in patients undergoing lung resection surgery
8 Feb, 2023 | 12:19h | UTC
Review | Advanced diagnostic and therapeutic techniques for anesthetists in thoracic trauma
8 Feb, 2023 | 12:18h | UTC
M-A | Colchicine for prevention of post-operative atrial fibrillation
27 Jan, 2023 | 12:03h | UTC
M-A | Effects of ultrasound-guided regional anesthesia in cardiac surgery
20 Jan, 2023 | 14:35h | UTC
RCT | In patients undergoing cardiac surgery, intravenous high-dose selenium did not reduce morbidity or mortality
15 Jan, 2023 | 20:00h | UTC
Commentary on Twitter
In this study, high-dose sodium selenite was not effective in reducing the development of organ dysfunction and death in high-risk cardiac surgery patients. @CStoppe @CriticalCa https://t.co/H3HR1u1HhU
— JAMA Surgery (@JAMASurgery) January 12, 2023
RCT | Anterior quadratus lumborum block at lateral supra-arcuate ligament vs. thoracic epidural analgesia after open liver surgery
13 Jan, 2023 | 13:03h | UTCUltrasound-Guided Anterior Quadratus Lumborum Block at Lateral Supra-Arcuate Ligament vs Thoracic Epidural Analgesia after Open Liver Surgery: A Randomized, Controlled, Noninferiority Trial – Journal of the American College of Surgeons (link to abstract – $ for full-text)
Commentary on Twitter
https://twitter.com/acsJACS/status/1594420458413527040
Consensus Document | The use of mechanical circulatory support in lung transplantation
11 Jan, 2023 | 14:18h | UTC
Commentary on Twitter
https://twitter.com/AATSJournals/status/1585645197639450624