共找到 20 条结果
暂无摘要（点击查看详情）
Accurate echocardiographic assessment of mitral valve (MV) anatomy and function is essential for guiding therapeutic decision making in patients with mitral regurgitation. This is particularly critical for transcatheter mitral edge-to-edge repair, in which open surgical inspection is not feasible and procedural success is heavily dependent on periprocedural echocardiographic imaging. Measurements on the order of millimeters determine procedure feasibility and risk of complications. The authors hypothesized that 3-dimensional (3D) imaging with multiplanar reconstruction (MPR) would improve quantitative assessment of the MV leaflet lengths. A retrospective analysis of patients scheduled for elective cardiac surgery with adequate transesophageal echocardiographic 2-dimensional (2D) mid-esophageal views and full-volume 3D datasets was performed at a single institution. Seventy-five adult patients participated in this study. Two- and three-dimensional diastolic leaflet lengths of the middle segment of the anterior leaflet (A2), anterior-lateral scallop of the posterior leaflet (P1), middle scallop of the posterior leaflet (P2), and posterior-medial scallop of the posterior leaflet (P3) were measured and compared using Bland-Altman and Pearson correlation statistics. Interobserver variability was evaluated in a subset of 15 patients. Correlations between 2D and 3D imaging were moderate (r = 0.41-0.74, p < 0.0001 for all). While the mean biases (differences) between 2D and 3D measures of A2 and P2 were small (0.03 and -0.07 cm, respectively), the coefficients of variation (CoVs) ranged from 19.4% to 23.7% for A2 and from 41.4% to 44.3% for P2. The mean biases between 2D and 3D measures of P1 and P3 were 0.05 and 0.04 cm, respectively, with CoVs of 59.9% and 49.6%, respectively. Interobserver variability analysis showed that 3D MPR measures of A2 (CoV, 7.3%) and P2 (CoV, 17.3%) were significantly lower (p = 0.004 and p = 0.02, respectively) than 2D measures from the mid-esophageal 4-/5-chamber and mid-esophageal long-axis windows of A2 (20.4% and 38.2%, respectively) and P2 (43.6% and 53.6%, respectively). There were significant differences between 2D and 3D measurements of diastolic mitral leaflet lengths. While this study did not define the gold-standard measurement technique, it showed that 3D MPR with 3D feedback for precise leaflet identification of A2 and P2 resulted in improved precision based on interobserver variability and significantly lower CoV. Overall, the variability reported in this study indicates the need for well-defined standardized methods of image acquisition, image interpretation, and analysis of the MV.
Perioperative cardiovascular complications and frailty are major drivers of morbidity, mortality, and loss of functional independence after noncardiac surgery, particularly in older adults. Updated European and American guidelines published between 2022 and 2025 address these challenges with differing approaches. This review provides a comparative analysis of contemporary European (European Society of Cardiology 2022, European Society of Anaesthesiology and Intensive Care 2025) and American (American Heart Association 2024) guidelines on preoperative cardiovascular risk and frailty assessment and optimization, highlighting clinically relevant differences for anesthesiologists managing adult patients undergoing elective noncardiac surgery. All guideline sets aim to improve perioperative risk stratification but differ in key domains. European guidelines discourage subjective estimation of functional capacity using metabolic equivalents and emphasize validated tools and objective assessment of cardiorespiratory fitness, whereas American guidelines retain a contextual role for subjective assessment. Recommendations regarding measuring natriuretic peptides, use of cardiac imaging, and thresholds for further evaluation also differ. A major innovation of the 2025 European guidelines is routine preoperative frailty screening, recognizing frailty as an independent predictor of postoperative complications, disability, and mortality. Furthermore, increasing emphasis is placed on multimodal prehabilitation and comprehensive geriatric assessment as multimodal strategies to optimize high-risk and frail patients before surgery. Current guidelines reflect a shift toward integrated, patient-centered perioperative assessment that combines cardiovascular risk evaluation with frailty and functional status. For anesthesiologists, incorporating frailty screening, objective functional assessment, and targeted optimization strategies may improve perioperative decision making and postoperative outcomes. However, harmonization of cardiovascular and frailty-based approaches is needed to consistently support implementation in daily clinical practice.
To compare and evaluate the effects of opioid-free anesthesia (OFA) versus opioid-based anesthesia (OA) on intraoperative and postoperative outcomes in video-assisted thoracoscopic surgery (VATS). A meta-analysis of randomized controlled trials. Hospitals. A total of 836 patients from 7 randomized controlled studies were included in the analysis. None. Seven studies involving 836 patients were included. Compared with OA, OFA showed significantly reduced risk of postoperative nausea and vomiting (PONV) (Mantel-Haenszel risk ratio = 0.52; 95% CI, 0.35-0.78). However, no significant difference was seen between the 2 groups for resting postoperative pain (Hedges' g = -0.08; 95% CI, -0.25 to 0.10), dynamic postoperative pain (Hedges' g = -0.52; 95% CI, -1.26 to 0.22), postoperative opioid requirements (Hedges' g = -0.12; 95% CI, -0.43 to 0.20), length of postanesthesia care unit (mean difference [MD] = 4.02; 95% CI, -3.26 to 11.31), or hospital stay (MD = 0.35; 95% CI, -0.06 to 0.77). This meta-analysis compared OA with OFA in VATS and ensured that regional anesthesia techniques were similar in both groups. Compared to OA, OFA reduces the incidence of PONV but showed no significant difference in other clinical outcomes. OFA may become an important part of VATS, especially in patients at high risk of PONV.
This study aimed to compare the predictive performance of the inferior vena cava collapsibility index (IVC-CI) and the caval-aortic (IVC:Ao) index for postinduction hypotension. Prospective observational study. Tertiary care university hospital. One hundred adult patients scheduled for elective surgery under general anesthesia. Before anesthetic induction, ultrasonographic measurements of the inferior vena cava and abdominal aorta were obtained in the supine position. The IVC-CI and IVC:Ao index were calculated using standard definitions. Mean arterial pressures were recorded every 2 minutes for 10 minutes following induction of anesthesia. Postinduction hypotension occurred in 68 patients (68%). The IVC:Ao index demonstrated excellent discriminative performance (area under the curve [AUC], 0.971; 95% confidence interval [CI], 0.916-0.994) and significantly outperformed the IVC-CI (AUC, 0.846; 95% CI, 0.760-0.910; p = 0.025). An IVC:Ao index cutoff value ≤1.1 yielded a sensitivity of 94.1% and a specificity of 93.8%, with a narrow gray zone (values yielding both sensitivity and specificity <90%) including 10% of patients, compared with 53% for the IVC-CI. In multivariable analyses, each 0.1-unit decrease in the IVC:Ao index was associated with increased odds of hypotension (odds ratio, 4.95; 95% CI, 2.43-10.09; p < 0.001). Similarly, each 10-point increase in the IVC-CI was independently associated with hypotension (odds ratio, 6.17; 95% CI, 2.66-14.31; p < 0.001). Preoperative ultrasonographic assessment of the IVC:Ao index provides superior predictive performance and a substantially narrower gray zone compared with the IVC-CI for identifying patients at risk of postinduction hypotension.
To compare preoperative transthoracic echocardiography (TTE) and intraoperative transesophageal echocardiography (TEE) assessment of (1) tricuspid annular diameter (TAd) and (2) tricuspid regurgitation (TR) grade in adults undergoing mitral valve surgery, with or without concomitant tricuspid surgery. Retrospective cohort study. Single tertiary academic medical center. Seventy-seven consecutive adults presenting for mitral valve surgery with an available preoperative TTE performed ≤1 week before surgery. None. Multiple TAd measurements were made with the maximum diastolic TAd recorded per modality (TTE: apical 4-chamber; TEE: mid-esophageal 4-chamber). TR severity was graded per society guidelines. Paired comparisons, correlation, and Bland-Altman analyses were performed. Mean preoperative TTE TAd was 38.0 ± 4.9 mm (TTE) versus mean intraoperative TEE TAd of 37.2 ± 5.4 mm (TEE), with a mean paired difference of +0.83 ± 5.04 mm (95% CI, -0.31 to 1.98; p = 0.152). TEE TAd measurement was decreased compared with TTE in 44 of 77 (57.1%) patients, increased in 27 of 77 (35.1%), and was unchanged in 6 of 77 (7.8%) (p = 0.009 for decreased > increased). TR grade distributions also differed between modalities (p = 0.008), with TEE TR severity increased compared with TTE in 22 of 77 (28.6%), decreased in 15 of 77 (19.5%), and unchanged in 40 of 77 (51.9%). TAd correlation was moderate (Pearson r = 0.526; Spearman ρ = 0.521). Bland-Altman analysis demonstrated a small bias (+0.83 mm) but wide limits of agreement (-9.05 to +10.71 mm), indicating substantial case-level variability. Although TTE and TEE yield similar mean TAd, per-patient agreement is only moderate. In addition, TR grade is frequently reclassified under anesthesia. Reliance on intraoperative TEE for either TAd or TR severity assessment may lead to misclassification, particularly in borderline cases. Relying chiefly on TTE assessment, considering hemodynamic context, and incorporating TEE 3-dimensional annular metrics when available may improve decision-making regarding concomitant tricuspid repair during mitral surgery.
Cesarean delivery in women with Fontan circulation poses significant risks of hemodynamic instability. We aimed to characterize perioperative hemodynamic fluctuations and describe short-term maternal and neonatal outcomes in this population. Single-center retrospective cohort study. Tertiary referral center in Japan. Women with Fontan circulation undergoing cesarean delivery (2009-2025). Neuraxial anesthesia and cesarean delivery. Twelve deliveries (11 women) were analyzed. Median gestational age was 35.5 weeks; all patients were New York Heart Association class I at the initial visit. After neuraxial anesthesia, central venous pressure (CVP) fell from 17.0 to 11.0 mmHg (-6.0 mmHg [-8.5 to -4.0], p = 0.006), and systolic blood pressure fell from 129 to 107 mmHg (-24.5 mmHg [-30.5 to -17.5], p = 0.003). With vasopressor support, clinically significant hypotension was avoided in 11 of 12 deliveries. Immediately after delivery, systolic blood pressure decreased in all cases (estimated paired difference, -21.0 mmHg; 95% CI, -25.0 to -17.0; p = 0.003), whereas CVP showed no consistent change (estimated paired difference, 0.0 mmHg; 95% CI, -7.5 to 2.0; p = 0.96). No new-onset heart failure or arrhythmias requiring treatment occurred intraoperatively, though postoperative arrhythmias developed in 25% of deliveries. In this cohort of carefully selected patients with Fontan circulation, cesarean delivery was associated with manageable hemodynamic fluctuations and acceptable short-term outcomes when continuous CVP monitoring and timely pharmacologic interventions were implemented. These data may inform multidisciplinary peripartum management in this high-risk population.
To determine whether individualized heparin dosing guided by a heparin dose-response (HDR) curve is noninferior to conventional weight-based dosing in achieving target activated clotting time (ACT) of ≥480 seconds before cardiopulmonary bypass (CPB) and to compare total heparin and protamine requirements, postoperative blood loss, and transfusion needs in children younger than 14 years undergoing cardiac surgery with cardiopulmonary bypass support. Single-center, prospective, double-blinded, randomized controlled trial. Cardiothoracic operating theaters and intensive care unit of a tertiary care hospital in India. Pediatric (<14 years) patients undergoing elective cardiac surgery with CPB support. The HDR group received an initial test dose of 100 IU/kg of heparin, and an individualized ACT dose-response curve was constructed to determine the dose required to target an ACT of 480 seconds. Controls received standard 400 IU/kg of heparin. Protamine was given post-CPB per protocol in both groups. In this noninferiority trial, HDR-guided anticoagulation was assessed against conventional weight-based dosing for first-pass attainment of ACT ≥480 seconds before CPB. Target ACT was achieved in 72.2% (26/36) of HDR patients versus 83.3% (30/36) of controls (p = 0.396). Although HDR was associated with lower heparin exposure (260 v 420 IU/kg; p < 0.001) and protamine use (4.1 v 4.8 mg/kg; p = 0.002), as well as reduced 24-hour blood loss (5.2 v 6.5 mL/kg; p = 0.03) and packed red blood cell transfusion (6.8 v 8.2 mL/kg; p = 0.04), it did not demonstrate superior first-attempt ACT attainment. HDR-guided heparinization reduced heparin and protamine exposure and was associated with less bleeding and transfusion, but it did not improve first-pass ACT attainment. Because ACT is an imperfect surrogate for anticoagulant adequacy in children on CPB, these findings should be interpreted as ACT-guided dosing data rather than proof of equivalent anticoagulation. Larger multicenter studies with mechanistic and clinical endpoints are needed to confirm these results.
Pain is common in intensive care unit (ICU) patients with up to one-third experiencing pain at rest and even more during mobilization and clinical procedures. This survey aimed to explore physicians' attitudes and preferences regarding pain management in adult ICU patients in the Nordic countries. We conducted an electronic survey targeting physicians working regularly in an ICU in the Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. The survey focused on pain assessment, pharmacological treatments, and post-discharge follow-up of adult ICU patients. The survey was distributed to 606 physicians, and 360 responses were received (overall response rate 59%). Respondents were primarily from Denmark, with only a few respondents from the remaining Nordic countries. Most respondents were specialists in anesthesiology working in mixed ICUs in public specialist hospitals. Standardized pain assessment tools were widely used in non-sedated patients, while only half of respondents employed standardized pain assessment tools in sedated patients. Respondents reported that pain was assessed multiple times daily in both non-sedated and sedated patients. Daily wake-up calls in sedated patients were considered important by almost all respondents. Morphine was the preferred opioid for oral- and intravenous bolus administration, while remifentanil was preferred for intravenous continuous administration. However, preferences varied across countries with regard to both opioid- and non-opioid analgesics. Nearly half of respondents expressed concerns regarding the development of opioid-induced hyperalgesia. Methadone was the most frequently preferred drug for opioid weaning, although preferences varied between countries. Most respondents acknowledged the importance of ICU-follow up programs, but only about half of respondents reported that their ICU currently offered a follow-up service. This Nordic survey explored ICU physicians' attitudes and preferences regarding pain management in adult ICU patients. Respondents reported assessing pain frequently, employing standardized pain assessment tools primarily in non-sedated patients. Daily wake-up calls in sedated patients were generally perceived as important. Interestingly, preferences regarding opioid- and non-opioid analgesics varied between Nordic countries. ICU-follow up programs were recognized as important but were not consistently implemented. Despite a high overall response rate, the generalizability of our findings is impaired by limited participation in most Nordic countries except Denmark. This survey describes the physician perspective on predominantly pharmacological pain management in selected ICUs within the Nordic countries.
Intraoperative hypotension is associated with adverse postoperative outcomes. This pilot randomized controlled trial evaluated whether hemodynamic-guided management using continuous noninvasive finger-cuff blood pressure monitoring reduces intraoperative hypotension compared with standard intermittent oscillometric monitoring in patients undergoing open thoracic surgery. Pilot randomized controlled trial. Single tertiary university hospital. Forty adult patients undergoing elective open thoracic surgery under general anesthesia. Patients were randomized to either hemodynamic-guided management using continuous finger-cuff blood pressure monitoring with the Hypotension Prediction Index and waveform-derived parameters (protocolized intervention) or standard care using intermittent oscillometric blood pressure monitoring. The primary outcome was the time-weighted average (TWA) of mean arterial pressure (MAP) <65 mmHg. The TWA of hypotension was significantly lower in the finger-cuff group compared with the oscillometric group (median [interquartile range], 0 [0-0] v 0.11 [0-0.40]; p = 0.001). The incidence and duration of hypotensive episodes were also reduced. Fewer patients in the hemodynamic-guided group required vasopressor therapy, primarily ephedrine, than in the oscillometric group (35% v 80%; p = 0.004). No significant differences were observed in postoperative serum creatinine or cognitive outcomes, and no cases of acute kidney injury or postoperative delirium occurred. In this pilot randomized trial, hemodynamic-guided management using continuous noninvasive finger-cuff monitoring was associated with reduced intraoperative hypotension and vasopressor use compared with intermittent oscillometric monitoring. These findings support the feasibility and potential benefit of continuous noninvasive hemodynamic monitoring; however, larger studies are required to confirm clinical outcome benefits.
Opioids remain the mainstay for moderate-to-severe postoperative pain after cardiac surgery but are associated with frequent adverse effects. Gabapentin has been proposed as part of multimodal analgesia to reduce opioid use and related complications. However, existing evidence in cardiac surgery is limited and heterogeneous. This systematic review and meta-analysis aimed to evaluate the latest evidence on the efficacy and safety of perioperative gabapentin for postoperative analgesia in adults undergoing cardiac surgery. PubMed, Embase, and the Cochrane Library were searched through October 1, 2025, for randomized controlled trials (RCTs) comparing perioperative gabapentin with placebo in adults undergoing cardiac surgery via sternotomy. The primary outcome was postoperative pain at 24 hours. Secondary outcomes included pain at other time points, opioid consumption, and adverse events (nausea, vomiting, sedation, atrial fibrillation). Pooled analyses used random-effects models with mean differences for pain outcomes, standardized mean differences for opioid consumption, and risk ratios for dichotomous outcomes, with 95% confidence intervals. The certainty of evidence across outcomes was assessed using the GRADE framework. Six RCTs, including 751 patients, were analyzed. Mean age ranged from 50 to 69.9 years, and 82.9% were male. Gabapentin was not associated with a statistically significant reduction in rest pain (MD -0.69; 95% CI -1.38 to 0.00; p = 0.0507) or cough-elicited pain at 24 hours (MD -0.34; 95% CI -0.71 to 0.04; p = 0.079). However, a modest but statistically significant reduction in cough-elicited pain was observed at 6 hours (MD -1.24; 95% CI -2.45 to -0.03; p = 0.0439). Gabapentin was associated with lower opioid consumption at 24 hours when analyzed using standardized mean difference (SMD ‒1.06; 95% CI ‒2.02 to ‒0.11; p = 0.0295). No significant differences were observed for pain outcomes at other time points or for adverse events, including sedation, nausea, vomiting, or atrial fibrillation. According to the GRADE framework, the certainty of evidence for these outcomes ranged from low to very low. Gabapentin provided a small, isolated reduction in early cough-elicited pain but not a clinically meaningful reduction in opioid consumption or overall analgesic benefit after cardiac surgery via sternotomy. Routine use as part of multimodal analgesia is not supported.
To describe perioperative transfusion rates, hospital variability, temporal trends, and the association between red blood cell (RBC) transfusion and predefined risk factors in Dutch cardiac surgery. Nationwide retrospective cohort study. All 16 cardiac surgery centers in the Netherlands, 2016-2023. Adults undergoing cardiac surgery recorded in the mandatory Netherlands Heart Registration (NHR), between 2016 and 2023 (N = 110,366). None. The primary outcome were transfusion rates of RBCs, plasma, platelets, prothrombin complex concentrate, fibrinogen concentrate, and recombinant factor VIIa. Secondary outcomes included interhospital variability and temporal trends. Transfusion rates among patients with available data were 30.6% for RBCs, 11.0% for plasma, 20.3% for platelets, 7.4% for prothrombin complex concentrate, 13.5% for fibrinogen concentrate, and 0.5% for recombinant factor VIIa. Significant variability existed between centers. Annual transfusion rates increased for almost all products: RBCs (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.02-1.03), plasma (OR 1.08, 95% CI 1.07-1.09), platelets (OR 1.09, 95% CI 1.08-1.10), PCC (OR 1.10, 95% CI 1.09-1.11), fibrinogen (OR 1.15, 95% CI 1.14-1.16). In exploratory analyses, adjustment for patient and procedural characteristics showed a similar temporal trend in RBC transfusion (adjusted OR 1.03, 95% CI 1.02-1.04) per year. Perioperative transfusion rates in Dutch cardiac surgery have increased and have substantial intercenter variability. The observed increase in RBC transfusions was not fully reflected by changes in measured patient and procedural characteristics. These findings highlight the importance of continuous monitoring of transfusion practices to better understand temporal trends and variation in clinical practice.
This study aims to develop a machine learning model for predicting whether patients will experience prolonged mechanical ventilation and to elucidate the roles of various factors in disease prediction. A retrospective study investigating influencing factors of prolonged mechanical ventilation in patients after coronary artery bypass grafting, PARTICIPANTS: The study cohort consisted of patients undergoing coronary artery bypass grafting selected from the MIMIC-IV 2.2 database. The study endpoint was prolonged mechanical ventilation, characterized by mechanical ventilation lasting more than 24 hours. Patients were stratified into normal duration and prolonged duration groups. Feature selection was performed using recursive partitioning and regression trees (RPART), random forest (RF), light gradient boosting machine (LightGBM), kernel k-nearest neighbors (K-KNN), and naive Bayes (NB) machine learning algorithms. Algorithm performance was assessed through multiple metrics including area under the receiver operating characteristic curve, area under the precision-recall curve, accuracy, misclassification rate, sensitivity, and specificity. The predictive importance of features in the top-performing model was quantified using SHapley Additive exPlanations (SHAP) values. The study cohort comprised 2,356 patients who received coronary artery bypass grafting. The machine learning models incorporated 40 baseline features and 5 composite metrics. Assessment revealed that the random forest model achieved superior comprehensive performance, exhibiting an area under the receiver operating characteristic curve of 0.9976 and an area under the precision-recall curve of 0.9976. It maintained high accuracy and low classification error rate. The model preserved remarkably high sensitivity and specificity. SHAP analysis revealed that delirium, percutaneous oxygen saturation, glycemic variability, and Sequential Organ Failure Assessment (SOFA) score made predominant contributions. The random forest model exhibited optimal predictive capability for prolonged mechanical ventilation after coronary artery bypass grafting. Delirium and blood glucose fluctuations served as the key predictive factors in this model.
To evaluate serum lipoproteins and other metabolites and their potential associations with the development of postoperative delirium. Prospective observational cohort study. Single-site academic medical hospital. Patients age 60 years and older scheduled for major cardiac surgery with cardiopulmonary bypass (CPB). Delirium assessments were performed at baseline and twice daily up to postoperative day 3. The primary outcome evaluated serum collected before surgery, at the start and end of CPB, and on postoperative day 1. Sixty-five patients were recruited, with 18% of subjects developing postoperative delirium within 3 days of surgery (10 of 57 subjects with complete cognitive assessments). Metabolomic analysis of serum revealed an association between the abundance of cholesterol in large high-density lipoprotein (L-HDL-C%) at the start of CPB and the development of postoperative delirium (odds ratio per standard deviation increment in biomarker concentration, 0.23; 95% confidence interval [CI], 0.08-0.66). Serum neurofilament light chain was inversely correlated with L-HDL-C% levels at the same time point (Spearman ρ, -0.39; 95% CI, -0.59 to -0.15) and was significantly higher at the end of CPB in subjects who developed delirium compared to subjects who did not develop delirium (median, 20.4 [interquartile range (IQR),16.1-25.4] pg/mL vs 11.9 [IQR, 7.9-16.9] pg/mL). Circulating blood biomarkers during surgery may provide insight into postoperative cognitive outcomes and should be evaluated in larger cohorts.
To compare the analgesic efficacy of serratus posterior superior intercostal plane block (SPSIPB) versus thoracic paravertebral block (TPVB) in patients undergoing video-assisted thoracoscopic surgery (VATS), with a focus on postoperative opioid consumption and pain scores. A prospective, randomized, controlled, single-center clinical trial. A tertiary university hospital. Sixty adult patients aged 18 to 80 years scheduled for elective VATS. Participants were randomized in a 1:1 ratio to receive either SPSIPB (n = 30) or TPVB (n = 30). Baseline characteristics were comparable between groups. Prior to induction of general anesthesia, patients received either ultrasound-guided SPSIPB or TPVB using 30 mL of 0.25% bupivacaine. The primary outcome was cumulative 24-hour postoperative opioid consumption, expressed as oral morphine equivalents. Secondary outcomes included numeric rating scale (NRS, 0-10) for pain scores and the incidence of opioid-related adverse effects at 1, 3, 6, 12, and 24 hours after surgery. Twenty-four-hour opioid use was not significantly different between SPSIPB and TPVB (66.8 ± 29.4 mg v 77.2 ± 40.0 mg; mean difference -10.4 mg; 95% CI, -36.1 to 15.3; p = 0.439). No significant differences were seen in pain scores or opioid-related side effects at any assessed time point (p > 0.05). SPSIPB and TPVB were associated with similar postoperative opioid consumption, pain scores, and the incidence of adverse effects following VATS. Given its potentially simpler application, SPSIPB may serve as an effective alternative regional analgesic technique in thoracic surgery.
To explore the superiority of fibrinogen concentrate (FC) versus cryoprecipitate for bleeding after cardiac surgery. Secondary analysis of the FIBRES randomized trial. Eleven Canadian hospitals, February 2017-November 2018. Adult cardiac surgery patients experiencing significant postbypass bleeding and acquired hypofibrinogenemia (fibrinogen <2.0 g/L or FIBTEM A10 <10 mm). FC (4 g) or cryoprecipitate (10 units) dosed within 24 hours after cardiopulmonary bypass as needed. In total, 735 patients (372 FC, 363 cryoprecipitate) were included in the primary analysis (median age 64 years, 30% women). The primary endpoint was cumulative blood components (red cells, platelets, plasma) administered within 24 hours postbypass. Superiority was assessed using deviance-scaled Poisson regression. FC was superior to cryoprecipitate in the a priori‒defined, well-balanced subgroups of non-critically ill patients (n = 634, 86% of population; mean 13.6 versus 16.2 units, mean ratio 0.84 [95% CI 0.73, 0.96]; p = 0.01) and elective surgery patients (n = 466, 63% of population; 11.7 versus 14.4 units, 0.81 [0.69, 0.96]; p = 0.02). In elective surgery patients, adverse events (relative risk 0.85 [0.75, 0.97]; p = 0.02) and serious adverse events (0.71 [0.52, 0.99]; p = 0.04) were less frequent with FC. FC showed superior hemostatic efficacy to cryoprecipitate in the prespecified subgroups of elective cardiac surgery patients and patients who were not in a critical state before surgery, representing the large majority of patients with bleeding postbypass. FC may also offer safety advantages over cryoprecipitate.
This study describes the development and preliminary validation of an integrated clinical decision support application (Cardiac Critical Care Advisor Pro, CCA Pro v6.0) that combines viscoelastic coagulation analysis, arterial blood gas interpretation, mechanical ventilation management, intraoperative hemodynamic assessment, and extracorporeal membrane oxygenation (ECMO) management with artificial intelligence (AI)-powered image recognition in a single platform. This study used software development and descriptive validation to simulate clinical scenarios in a cardiac surgical intensive care unit at a university teaching hospital. The application was evaluated using 50 simulated clinical scenarios derived from real cardiac surgical cases, with expert review by 3 senior cardiac anesthesiologists. Development of a web-based application incorporated 6 clinical modules with 108 input parameters, over 100 automated calculations, evidence-based treatment algorithms with weight-adjusted dosing, and 7 AI-powered camera zones for automated clinical screen data extraction. The application demonstrated agreement with expert consensus in coagulation management (ROTEM/TEG pathway selection and dosing), acid-base classification, ventilator parameter recommendations, and ECMO troubleshooting. The AI camera system successfully extracted clinical values from photographs of ROTEM displays, blood gas printouts, ventilator screens, patient monitors, and ECMO consoles. All treatment recommendations included weight-adjusted dosing consistent with current guidelines (ARDSNet, Surviving Sepsis Campaign 2021, Extracorporeal Life Support Organization 2021, Berlin criteria for acute respiratory distress syndrome). CCA Pro v6.0 represents a comprehensive, integrated clinical decision support tool for cardiac critical care. By combining multiple clinical domains with AI-powered data capture, the application has the potential to reduce cognitive load, minimize dosing errors, and standardize evidence-based practice in high-acuity settings. Prospective clinical validation is warranted.
To systematically characterize the global research landscape and emerging trends of enhanced recovery after cardiac surgery (ERACS). Bibliometric analysis. Publications were retrieved from the Web of Science Core Collection database, a comprehensive repository of peer-reviewed international literature. A total of 725 publications related to ERACS published between 1979 and 2026 were included. Not applicable. Annual publication output increased markedly after 2015, indicating growing interest in ERACS. The United States and Canada were the leading contributors in both productivity and academic influence. Co-occurrence and clustering analyses identified major research themes, including minimally invasive cardiac surgery, multimodal analgesia, perioperative management, and postoperative complications. Temporal keyword analysis demonstrated a transition from early extubation strategies toward comprehensive perioperative care pathways. Despite this expansion, high-quality randomized evidence remains limited. This bibliometric analysis provides a comprehensive overview of the evolving research landscape of ERACS. The field is rapidly expanding and shifting toward integrated perioperative care models. However, further high-quality studies are required to strengthen the evidence base and support clinical implementation.
To determine the prevalence of iron deficiency and iron deficiency anemia and their association with adverse outcomes in children undergoing cardiac surgery with cardiopulmonary bypass. Retrospective review. Single-center, academic quaternary children's hospital. Eight hundred eighty-six cardiac surgery patients aged 0 to 18 years at the authors' institution between 2019 and 2023. None. Patients were screened for iron deficiency and anemia using ferritin, hemoglobin, and reticulocyte hemoglobin equivalent levels. Perioperative outcomes were measured and analyzed using multiple logistic and linear regression adjusting for both surgical complexity and cardiopulmonary bypass times. Patients with iron deficiency received greater perioperative red blood cell transfusion volumes (31.2 ± 36.8 mL/kg v 21.9 ± 29 mL/kg, p < 0.001) and had an increased incidence of postoperative acute kidney injury (30.2% v 20.8%, p = 0.002) than those without iron deficiency. Patients with iron deficiency anemia received larger red blood cell transfusion volumes (33 ± 33.7 mL/kg v 22 ± 29 mL/kg, p = 0.002) and were more likely to develop acute kidney injury (37% v 21%, p = 0.006) compared with those with normal iron and hemoglobin levels. These findings persisted after adjusting for age, weight, surgical complexity, and cardiopulmonary bypass time. Iron deficiency is common in children undergoing cardiac surgery and is associated with an increased risk of adverse outcomes. Future prospective studies aimed at understanding and managing iron deficiency in patients with congenital heart disease are urgently needed.
To evaluate whether high-frequency, very low tidal volume ventilation with controlled peak inspiratory pressure limitation (HFvLTV-cPP) is associated with reduced respiration-related catheter displacement during atrial fibrillation (AF) ablation, while maintaining short-term physiological tolerance. Prospective, single-center, fixed-sequence within-patient crossover pilot study. Tertiary electrophysiology center. Fifty-two consecutive eligible adult patients undergoing radiofrequency catheter ablation for AF under general anesthesia. Standard ventilation followed by HFvLTV-cPP (50 breaths·min⁻¹, inspiratory-to-expiratory ratio 1:1, tidal volume titrated to minimize catheter displacement, peak inspiratory pressure ≤20 cmH2O), delivered using a standard anesthesia workstation. HFvLTV-cPP was associated with a marked reduction in catheter displacement (6.22 ± 2.18 mm v 1.23 ± 0.69 mm; -4.99 mm, p < 0.001), corresponding to ∼80% reduction. Contact force was similar. Partial pressure of carbon dioxide increased from 38.0 ± 4.9 to 49.9 ± 7.2 mmHg, with values >60 mmHg in 9.6% of patients. Oxygenation remained preserved. Plateau pressures were not increased, and driving pressure was lower. Mean arterial pressure decreased after induction but not after HFvLTV-cPP, with modest vasopressor use. No procedural complications occurred. Early recovery was rapid, without early respiratory or neurologic complications. HFvLTV-cPP was associated with marked motion reduction and short-term physiological tolerance in a selected cohort. These findings represent a mechanistic signal and do not establish clinical benefit or safety. Randomized studies are required.