Journal of cardiothoracic and vascular anesthesia最新文献

{"title":"Anaphylactic shock from Praxbind in a cardiac surgical patient: from literature to experience","authors":"Doctor Martina Tocco,&nbsp;Maria Bisi,&nbsp;Tommaso Antonio Giacon,&nbsp;Ilaria Valeri,&nbsp;Martina Tocco,&nbsp;Demetrio Pittarello","doi":"10.1053/j.jvca.2026.08.024","DOIUrl":"10.1053/j.jvca.2026.08.024","url":null,"abstract":"<div><h3>Introduction</h3><div>Only one case of mild anaphylaxis to Idarucizumab has been described in literature until this moment, in a stroke related 77-year-old woman case¹. To our knowledge, this is the first case during cardiac surgery. To prevent bleeding complications, several reversal agents have been developed to counteract direct oral anticoagulants. Among them, Idarucizumab is a monoclonal antibody, approved for the first time in the USA in 2015², suitable for use in adult patients treated with Dabigatran when rapid reversal is required, for emergency surgery/urgent procedure in life-threatening or uncontrolled bleeding³.</div></div><div><h3>Methods</h3><div>In November 2025, a 66-year-old man was listed in our center for heart transplant due to dilatative cardiomyopathy. During surgery, he showed a severe anaphylactic reaction after Idarucizumab administration, with need for emergent ECMO VA support, that was removed at the end of the procedure. After ICU admission, a new episode of refractory shock occurred, needing new ECMO VA support. Acute kidney damage was a complication, requiring Cytosorb hemoadsorption as immunomodulant treatment alongside plasmapheresis. Unfortunately, severe cerebral damage occurred, leading to patient cerebral death.</div></div><div><h3>Result</h3><div>Severe anaphylaxis has never been detected after Idarucizumab administration. Prolonged hypotension, refractory to ECMO and vasoactive drugs infusion, globally impaired clinical condition of a heart-transplant patient. A multi-organ failure setting led to a poor prognosis and to cerebral death.</div></div><div><h3>Conclusion</h3><div>Further studies, in order to detect potential severe adverse effects to reverse agents of DOAC are necessary. Cardiac surgery is still a poorly-investigated field.</div><div>Careful monitoring for internationally approved drugs has a key role in daily practice with the request of a multidisciplinary and methodological-based approach.</div><div>The patient is deceased: informed consent for publication of anonymized clinical data was obtained from the patient's next of kin. This case report follows the Declaration of Helsinki’s principles.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Page 20"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006801","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"To Assess the Usefulness of Pre Op Strei Index Derived From Tee in Predicting the Short- Term Outcomes of Mitral Valve Surgeries","authors":"Dr Kanagarajan Natarajan,&nbsp;Dr Arun Ramar","doi":"10.1053/j.jvca.2026.08.043","DOIUrl":"10.1053/j.jvca.2026.08.043","url":null,"abstract":"<div><h3>Introduction</h3><div>Right heart dysfunction plays a major role in clinical management of patients undergoing mitral valve surgeries especially in predominant stenotic lesions. We hypothesised that the STREI index which combines both RV free wall strain and RA reservoir strain (STREI index = 2.RV FWS+ RASr) which was developed to prognosticate the patients with free TR, can be a better predictor of short term outcomes in patients undergoing mitral valve surgeries for mitral stenotic lesions.AIMS AND OBJECTIVES:The aim of the study is to assess the usefulness of pre op STREI index derived from TEE in predicting the short term outcomes of mitral valve surgeries. The objective of the study is to study the utility of various pre CPB TEE parameters in predicting the requirement of ionotropes (VIS score) on DOS, POD-1 and POD-2, the length of ICU stay, hospital stay, MACCE including mortality.</div></div><div><h3>Method</h3><div>This prospective observational study was conducted over a period of 6 months in Madras Medical Mission Hospital, Chennai, India. After IEC approval and informed consent, consecutive 40 patients with predominantly severe mitral stenosis patients undergoing mitral valve replacement surgeries were enrolled in the study. Baseline patients characteristics were collected. Detailed TEE examination was carried out after induction of anaesthesia, before skin incision. The parameters collected viz LV, RV, LA, RA dimension, LV EF, LV GLS, mitral and tricuspid annulus, mitral EOA, grade of tricuspid regurgitation, RVSP, RV dimension, RV FAC, TAPSE, RV lateral S velocity, RV FWS, RA Rs were measured by experienced personnels in TEE. Strain was measured offline with TOMTEC software, Philips CVX, X8-3T TEE probe.RESULTS:Of the 40 patients, 18 patients were male and 22 patients were females. Univariate linear regression showed that STREI significantly predicted VIS-DOS (F – static – 56.69, R2-0.599,p&lt;0.000), VIS - POD1 (F -static-57.046, R2- 0.600,p – 0.000) and VIS - POD2 (F-static – 25.971,R2- 0.412,p -0.00). Increasing STREI Index values were associated with a reduced likelihood of MACCE (Odds Ratio 0.851, p = 0.002 and reduced likelihood of (OR=0.837), of the 4 in-hospital deaths. STREI Index, LV EF, LV GLS and RVSP were included in the Final model for performing Multivariable Linear Regression based on the Univariate and Correlation Analysis as they had acceptable multicollinearity. Although RV FAC and RV FWS were significant predictors in univariate analysis, STREI Index consistently demonstrated superior explanatory ability and yielded the highest model performance when incorporated into multivariable analysis (table).CONCLUSION:STREI index is a better predictor of short term outcomes in patients with mitral valve surgeries for stenosis than the conventional parameters and hence help in better prognostication. Pre op evaluation of STREI index can help in early intervention and better survival.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 35-36"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006805","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Geriatric assessment in preoperative screening for cardiac surgery: treatment allocation and survival outcomes in a large cohort","authors":"Lucas Bruins,&nbsp;Drs. Michael Ritt,&nbsp;Drs. Anouk Andriessen,&nbsp;Prof. dr. Isabella Kardys,&nbsp;Dr. Jeannette Goudzwaard,&nbsp;Dr. Maarten ter Horst","doi":"10.1053/j.jvca.2026.08.018","DOIUrl":"10.1053/j.jvca.2026.08.018","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;The number of geriatric patients undergoing cardiac surgery is rising. Preoperative geriatric assessment is increasingly integrated into preoperative screening (POS) for cardiac surgery, yet its role in treatment allocation and the predictive value of geriatric scores beyond standard risk assessment remains unclear. This study describes treatment allocation following POS including a comprehensive geriatric assessment (CGA) in a large cohort referred for cardiac surgery and evaluates whether geriatric scores add predictive value for all-cause mortality beyond EuroSCOREII.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;A single-centre retrospective cohort study of 692 geriatric patients referred for cardiac surgery (AVR, CABG, AVR+CABG or MVP/R) at a tertiary centre in the Netherlands. All patients underwent standard POS and additional CGA. Based on multidisciplinary decision-making and patient preferences, patients either underwent cardiac surgery, were referred for interventional cardiology, or received conservative treatment. Primary outcome was all-cause mortality at 1-year and full follow-up after POS. Kaplan-Meier curves with log-rank tests were used to evaluate outcomes across groups defined by combinations of the geriatric decision and the actual treatment received. Additionally, Cox proportional hazards regression was performed separately per cohort, with univariable models for individual geriatric scores and multivariable models adjusting for EuroSCOREII if events per variable permitted.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;Of 692 patients (median age 75.0 years, IQR 72.6-77.3), 578 underwent cardiac surgery (83.5%), 88 were referred for interventional cardiology (12.7%) and 26 had conservative treatment (3.8%). The patients in the interventional cardiology and conservative treatment group had higher EuroSCOREII compared to the cardiac surgery group (6.1 and 5.8 vs. 1.9). During follow-up (median 32.0 months, IQR 19.6-44.6), 62 patients died (two interventional cardiology patients were excluded owing to missing mortality status), 32 (5.5%) in the cardiac surgery group, 15 (17.4%) in the interventional cardiology group and 15 (57.7%) in the conservative treatment group. Kaplan-Meier curves demonstrated significantly different survival across treatment groups (log-rank p&lt;0.0001). One-year mortality in these groups was 2.2%, 8.1% and 38.5%, respectively. In the operated cohort, IADL was independently associated with mortality after adjustment for EuroSCOREII (HR 1.13, 95% CI 1.03-1.23, p = 0.009) at full follow-up. No geriatric scores significantly predicted mortality at 1-year follow-up or in the non-operated cohort, which may be attributed to limited statistical power (13 and 30 events, respectively).&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;POS including a CGA of patients referred for cardiac surgery showed 16.5% receiving alternative treatment and significant differences in survival between the surgical and non-sur","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 15-16"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007024","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Investigating the use of FEIBA in Cardiac Surgery","authors":"Dr Manan Bajaj,&nbsp;Miss Jenna West,&nbsp;Miss Anisha Surman,&nbsp;Dr Mario Ferrante,&nbsp;Dr Phillip Howells","doi":"10.1053/j.jvca.2026.08.060","DOIUrl":"10.1053/j.jvca.2026.08.060","url":null,"abstract":"<div><h3>Introduction</h3><div>Factor Eight Inhibitor Bypassing Activity (FEIBA) is an anti-inhibitor coagulant complex licensed for use in patients with haemophilia and factor VIII/IX inhibitors [1]. It has been used to treat refractory bleeding in cardiac surgery, but there are limited studies relating to this use in clinical practice. Current case series indicate FEIBA contributing to achieving haemostasis, mainly in the neonatal and paediatric population, but there may be significant complications including thromboembolic events [2]. Following the use of FEIBA in our adult cardiac surgical population for refractory haemostatic failure, this audit was undertaken to assess its clinical benefits and potential side effects.</div></div><div><h3>Methods</h3><div>Two years’ patient data, retrospectively collected from patients who were administered FEIBA during cardiac surgery at the Queen Elizabeth Hospital Birmingham. FEIBA was used as an adjunct, where the surgeon and anaesthetist agreed there was ongoing haemostatic failure refractory to conventional management with blood products, including conventional factor concentrates, following cardiopulmonary bypass. Doses of 10-20 units/kg were administered. Based on expected complications and prior studies [2], ten variables were measured for each patient, which including pre- and post-operative thromboelastograms (TEGs), other clotting products administered, 30 and 90-day mortality, and post-operative thromboembolic events. Data were obtained from anaesthetic charts, the electronic patient record and outpatient correspondence.</div></div><div><h3>Results</h3><div>FEIBA improved refractory bleeding enough to allow surgical closure of the chest in all patients. Comparing pre- and post-FEIBA TEGs, there was a reduction in the R time following administration in all patients (figure 1), which correlated with the effects seen clinically. There was 25% 30-day mortality, and 37.5% 90-day mortality. Additionally, two of patients experienced post-operative thromboembolic events, but these both occurred days to weeks after the surgery rather than perioperatively.</div></div><div><h3>Discussion/Conclusions</h3><div>Initially there was an observed clinical benefit and bleeding was reduced in all patients, there was a high rate of mortality and thromboembolic events. The high mortality likely reflects both the high-risk surgery these patients underwent, and the intraoperative challenges with coagulation, rather than necessarily an effect of FEIBA itself [2]. The high post-operative thromboembolic rate is in keeping with this high-risk cohort, and events may have been more stringently sought knowing FEIBA was used, thus this may reflect the Hawthorn effect. These data suggest the R-time may be a useful biomarker of FEIBA’s effectiveness, which matches with its known mechanisms of action [1]. Dosing studies and randomised trials are required to better understand FEIBA’s clinical effectiveness [3].</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 49-50"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Predictive Value of ROTEM Parameters for Postoperative Bleeding in High-Risk Cardiovascular Surgery: A Retrospective Cohort Study","authors":"Imre Kukel MD,&nbsp;DSAIC Stanislaw Vander Zwaar MD,&nbsp;Jens Faßl Professor, MD, PhD","doi":"10.1053/j.jvca.2026.08.054","DOIUrl":"10.1053/j.jvca.2026.08.054","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Postoperative bleeding remains challenging in cardiovascular surgery. Viscoelastic point-of-care testing guides individualized haemostatic therapy, but its value for bleeding risk stratification remains uncertain. We evaluated associations between ROTEM® parameters and clinically relevant postoperative bleeding, defined by selected criteria analogous to moderate-or-greater bleeding in the Universal Definition of Perioperative Bleeding (UDPB), and explored clinically relevant cut-offs.[1]&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;We conducted a retrospective secondary analysis of a previous observational study at a tertiary academic cardiac centre.[2] Adults undergoing cardiac or aortic surgery from May 31, 2022, to August 31, 2024, were eligible when ROTEM was assessed after aortic declamping and after coagulation factor supplementation for persistent microvascular bleeding. Exclusion criteria were ongoing or residual dual antiplatelet or direct oral anticoagulant therapy, &gt;1,000 mL crystalloid between ROTEM measurements, or haemostatic therapy after the reference ROTEM before ICU admission.&lt;/div&gt;&lt;div&gt;FIBTEM, EXTEM, and INTEM CT, A5, and A10 were analysed for association with clinically relevant postoperative bleeding, defined by selected UDPB-analogous criteria after ICU or ward admission: 12-hour chest tube output &gt;800 mL, transfusion of ≥2 units packed red blood cells or fresh frozen plasma, platelet concentrate transfusion, prothrombin complex concentrate administration, reexploration, or tamponade. Associations were assessed using logistic regression and ROC analysis; Youden cut-offs, bootstrap 95% CIs for AUCs (1,000 resamples), ORs, and adjusted ORs were estimated.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;Of 2,368 adults screened, 198 patients were identified with two ROTEM measurements, of whom 45 were excluded according to predefined criteria. The eligible cohort comprised 153 patients; 123 had complete data for CT and A5 in FIBTEM, EXTEM, and INTEM, and 83 had complete data for CT, A5, and A10. ROC curves and AUCs of the former are shown in Figure 1.&lt;/div&gt;&lt;div&gt;INTEM CT was the only ROTEM parameter with a 95% CI for the AUC that excluded 0.5 (AUC, 0.668; 95% CI, 0.556–0.763), with sensitivity of 0.57, specificity of 0.77, and a Youden-index threshold of 269 seconds.&lt;/div&gt;&lt;div&gt;INTEM CT was associated with clinically relevant postoperative bleeding in univariable logistic regression (per 10 seconds: OR, 1.11; 95% CI, 1.04–1.21; p = 0.002). After adjustment for EuroSCORE II and preoperative haemoglobin, the adjusted OR was 1.06 (95% CI, 0.98–1.16; p = 0.13).&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Discussion/Conclusions&lt;/h3&gt;&lt;div&gt;INTEM CT was the ROTEM parameter most consistently associated with clinically relevant postoperative bleeding, but discriminatory performance was modest and the adjusted association was attenuated. Larger independent cohorts are needed to validate these findings and evaluate whether ROTEM alone or combined w","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 44-45"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of mechanical power on mechanically ventilated post cardiac surgery patients: A retrospective cohort study","authors":"Miss Willemijn Mooij,&nbsp;Marcus Schultz,&nbsp;Greta Emilia Kiavialaitis,&nbsp;Peter Wohlrab,&nbsp;Johannes Hofer,&nbsp;Johannes Geilen,&nbsp;Philipp Datler,&nbsp;David Lorant,&nbsp;Daniel Essl,&nbsp;Arno Schiferer,&nbsp;Julian Lemmel,&nbsp;Julia Dumfarth,&nbsp;Daniel Zimpfer,&nbsp;Edda Tschernko,&nbsp;Pedro D. Wendel-Garcia","doi":"10.1053/j.jvca.2026.08.082","DOIUrl":"10.1053/j.jvca.2026.08.082","url":null,"abstract":"<div><h3>Introduction</h3><div>Lung-protective mechanical ventilation is a cornerstone of critical care, particularly in acute respiratory distress syndrome (ARDS). Mechanical power (MP), the energy transferred from the ventilator to the respiratory system per unit time, has recently emerged as a prognostic marker of ventilator-induced lung injury and has been associated with mortality in ARDS [1, 2]. Critically ill patients requiring mechanical ventilation after cardiac surgery present a distinct pathophysiology of respiratory failure, driven largely by left heart failure rather than the diffuse alveolar damage characteristic of ARDS. Whether MP carries comparable prognostic weight in this population is unknown, and both the distribution of delivered MP and its association with outcome remain poorly characterized.</div></div><div><h3>Method</h3><div>We performed a retrospective observational cohort study of all patients mechanically ventilated on admission to a cardiothoracic anesthesiology ICU between July 2016 and April 2026, in whom MP data were available. MP was calculated hourly using a previously published equation [3]. The primary objective was to determine whether MP during the first 48 hours after admission was associated with ICU mortality, using multivariable logistic regression adjusted for age, SOFA score, and oxygenation. Secondary analyses examined the dose–response relationship between delivered MP and ICU mortality, and a cumulative-dose-over-threshold relationship in which both the duration of exposure and the magnitude of MP exceeding a mortality-associated threshold were modeled.</div></div><div><h3>Result</h3><div>A total of 7,024 patients were included. Median age at ICU admission was 65 [55 – 72] years, initial SOFA score 7 [5 – 9], P/F ratio 232 [162 – 310] mmHg and MP 11.33 [8.84 – 14.99] J/min. In multivariable analysis, MP was independently associated with ICU mortality (OR per +5 J/min 1.12, 95% CI 1.04–1.21; p=0.004). The optimal threshold for mortality was 12.69 J/min. Both longer exposure above this threshold (OR per hour 1.06, 95% CI 1.05 – 1.07; p&lt;0.0001) and greater cumulative MP excess above it (OR per J/min 1.01, 95% CI 1.01 – 1.01; p&lt;0.0001) were associated with higher odds of death. MP was also associated with longer ICU stay (+1.85 days per +5 J/min, 95% CI 1.56 – 2.13; p&lt;0.001).</div></div><div><h3>Conclusion</h3><div>In critically ill patients after cardiac surgery, MP was independently associated with ICU mortality. The association was reinforced by the findings that longer exposure to high MP and greater cumulative excess above a putative safe threshold were each associated with mortality. These findings identify MP as a possible candidate modifiable target for optimizing mechanical ventilation in this population and warrant prospective evaluation.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Page 68"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007208","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"From Resuscitation to Transplantation: Successful Cardiac Replacement Therapy Using Sequential Mechanical Circulatory Support as Bridge to Transplant in a 6-Year-Old Girl with Refractory Cardiogenic Shock Following Scarlet Fever-Associated Myocarditis","authors":"Johannes Meuser BSc,&nbsp;Niklas Sturm BSc,&nbsp;Ronja Beran BSc,&nbsp;Prof. Dr. Hakan Akintuerk,&nbsp;Prof. Dr. Matthias Mueller,&nbsp;Thomas S. Zajonz M.D.","doi":"10.1053/j.jvca.2026.08.087","DOIUrl":"10.1053/j.jvca.2026.08.087","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Refractory cardiogenic shock in pediatric patients represents one of the most critical challenges in intensive care medicine. Post-infectious myocarditis following Streptococcus pyogenes infection — though rare — can precipitate fulminant cardiac failure with devastating hemodynamic compromise. The combination of prolonged resuscitation, multi-organ failure, and absent myocardial recovery demands rapid, structured escalation of mechanical circulatory support (MCS) as a bridging strategy to heart transplantation (HTX). We report the case of a previously healthy 6-year-old girl who developed fulminant myocarditis following scarlet fever and was successfully bridged to orthotopic heart transplantation using sequential MCS — venoarterial ECMO followed by a biventricular assist device (BVAD).&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;A previously healthy 6-year-old girl presented with fulminant cardiogenic shock in the context of scarlet fever-associated myocarditis. She was transferred as a secondary admission under ongoing resuscitation (ROSC after &gt;110 minutes). On admission, severe cardiogenic shock was present (pH 6.8; lactate 23 mmol/L) under high-dose catecholamine therapy (norepinephrine 2.5 µg/kg/min, epinephrine 6 µg/kg/min) alongside developing multi-organ failure. Echocardiography revealed marked left ventricular dilatation with severely reduced global pump function. Following comprehensive neurological evaluation (EEG, cranial CT, transcranial Doppler) — excluding hypoxic-ischemic encephalopathy — venoarterial ECMO was implanted (VA-ECLS, right femoral artery and vein) with systemic heparin anticoagulation. In the absence of cardiac recovery and with progressive multi-organ failure, the patient was transitioned after 14 days to a biventricular assist device (Berlin Heart EXCOR BVAD) as bridge to transplant.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;Under VA-ECMO, lactate levels stabilized, hepatic function improved, and pulmonary congestion was reduced. Complications included recurrent cannula-site bleeding, pulmonary hemorrhage, progressive pulmonary edema requiring interventional ASD creation, and the need for continuous hemodialysis. Following BVAD implantation, despite repeated surgical hemostasis, pump revision, and an ischemic stroke with hemorrhagic transformation, significant neurological and functional recovery was observed: the patient regained consciousness, communication ability, and independent mobility. After 4 months on BVAD support, a suitable donor organ became available and orthotopic heart transplantation was performed successfully. The patient was extubated within 24 hours postoperatively; renal function recovered fully. She was discharged home in good general condition approximately 5 months after initial admission.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;This case impressively demonstrates the potential of a consistent, sequential MCS strategy even under extreme initial conditions. Scarlet fev","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Page 72"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007334","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing human underestimation using a Machine-Assisted Decision Algorithm to individualize Fibrinogen prescription in bleeding situation. A pilot study of a computed formula based on Quantra® Qplus® FCS in cardiac surgery.","authors":"Dr Rudy Berthezene,&nbsp;Pr Bruce Spiess","doi":"10.1053/j.jvca.2026.08.055","DOIUrl":"10.1053/j.jvca.2026.08.055","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Fibrinogen, binding to platelets via glycoprotein IIb/IIIa and interaction with Factor XIII, is hemodiluted and degraded by cardiopulmonary bypass (CPB). Postoperative bleeding may be reduced by raising targeting Fibrinogen to &gt;2.5-3 g/L.¹ but at considerable cost.&lt;/div&gt;&lt;div&gt;Under stress, data overload and workflow disruptions raise cognitive biases which can lead to delayed diagnosis and suboptimal patient care. Calculation and dosing of fibrinogen can be complex, but precision cardiovascular medicine could reduce latent failures occurrence at high-risk decision moments.²&lt;/div&gt;&lt;div&gt;Real-time point-of-care (POC) viscoelastic testing (VET) based on sonorheometry (Hemosonics Quantra® Qplus®, Durham, NC) quickly assess the fibrinogen contribution to clot strength (FCS). By utilizing a formula based on estimated total body Fibrinogen level, one can solve for a targeted dose of Fibrinogen concentrate.&lt;/div&gt;&lt;div&gt;We conducted a pilot study of a calculation app® helping practitioners to guide Fibrinogen administration in post-CPB bleeding patients.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;Twenty-three patients were informed and signed an institutional approved consent fibrinogen concentrate (Fibryga®, Octapharma, Parsippany, NJ). In prior work Qplus® FCS (hPa) has a 91.7% sensitivity for low Claus Fibrinogen.³ Anesthetic, surgical and perfusion techniques were standard. Fifteen minutes after protamine administration, a Qplus® FCS test was run. Each patient had a target FCS (tFCS) determined by the anesthesia team regarding clinical bleeding. The calculated Fibrinogen dose was administered. One hour after, a second Qplus® was run to evaluate how close it was to the chosen target. Data was analyzed for mean, median and SD. FCS and tFCS were compared by one-way ANOVA. Correlation to tFCS level was broken into categories of 0-10%, 0-25% and &gt;25% variance.It was arbitrarily accepted that ± 25% variance from the tFCS was successful for this pilot. Bleeding (up to 24 h) was assessed and compared between those groups.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;Surgically related bleeding occurred in 3 patients. In 78% of patients the formula allowed acceptable dose targeting (± 25%) and 52% of patients showed a 0-10% variance. In patients outside of the 25% acceptable range, 80% of them received transfusions., with more 24h cumulated post-operative bleeding (1190mL (IQR 1155) vs 785mL (IQR 575), p=0,47).&lt;/div&gt;&lt;div&gt;Fibrinogen dose-targeting using FCS is reasonable. Most patients had a variance trending to underdosing, especially when active bleeding (&gt;200mL/h), potentially receiving blood products or fluid, and consuming Fibrinogen. However, a corrective trend factor can prevent the predictive tool from being less accurate. Using an estimated circulating volume with pre-CPB weight could also cause underdosing.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Discussion/Conclusions&lt;/h3&gt;&lt;div&gt;Goal-directed Fibrinogen dosing using POC-VET Qplus® FCS as an estimate o","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 45-46"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007339","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hormonal stress response in cardiac surgery patients received an opioid-free anesthesia or opioid-based anesthesia","authors":"Larissa Vozjaeva MD,&nbsp;Yuliya Pinevich MD,&nbsp;Serhej Soloviev MD","doi":"10.1053/j.jvca.2026.08.012","DOIUrl":"10.1053/j.jvca.2026.08.012","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Opioid-based anesthesia (OBA) remains the standard in cardiac anesthesiology but it might be associated with some negative effects. Opioid-free anesthesia (OFA) is a multimodal alternative; however, data on its efficiency and safety compared to OBA in cardiac surgery patients are not sufficiently clear. The aim of this pilot study was to determine which of these anaesthesia techniques is more effective in restoring hormonal stress markers after coronary artery bypass grafting (CABG) under cardiopulmonary bypass (CPB).&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Method&lt;/h3&gt;&lt;div&gt;A non-randomized, comparative pilot study with parallel design using OBA (control group) and OFA (study group). Twenty-four patients (N=12 per group) planned for CABG were enrolled. Exclusion criteria were met. Patients undergoing CABG ± aortic valve replacement received either OFA with multimodal analgesia (ketamine, lidocaine, dexmedetomidine, magnesium sulfate, dexamethasone) or traditional OBA with fentanyl. The effectiveness of anesthesia was assessed based on the severity of the perioperative stress response. The hormonal stress markers included serum cortisol, salivary cortisol, serum DHEA-S levels, and the serum cortisol to DHEA-S ratio (CDR) and were measured at five perioperative points: preoperatively, after heparin introduction (pre-CPB), 1 hour after extubation, 24 and 48 hours after surgery. The pain intensity postoperatively assessed using a 10-point visual analogue scale (VAS).&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Result&lt;/h3&gt;&lt;div&gt;Patient data, surgical and ASA risk, CPB and ventilation duration did not differ (p&gt;0.05). The baseline cortisol level was comparable to (OFA: 406.4 [369.3; 499.1] vs. OBA: 433.4 [310.7; 467.9] nmol/L; p=0.63). Although the cortisol rise 1 hour after extubation was similar in both groups (p=0.114), the dynamics were differ. After 24 hours, cortisol levels in patients in the OFA group decreased below baseline (median change -51.6%; p=0.043), whereas in the OBA group they returned to basal levels (median change -13.7%; p=0.756). It was noticed the tendency of the decrease in the OFA group (p=0.068). Salivary cortisol levels after 24 hours were lower in the OFA group: 10.3 [7.3; 36.2] versus 39.3 [19.0; 77.9] nmol/L in the OBA group (p=0.033). DHEA-S levels and the CDRs stayed in the adaptive stress range (0.05–0.2) in both groups; no intergroup differences were detected. The postoperative VAS score (average 2–4 points) was also consistent.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;In this study both techniques provide adequate pain relief. OFA showed no disadvantages compared to traditional OBA. Moreover, OFA was associated with a more rapid cortisol return to baseline in the first 24 hours after surgery, which may indicate less evident hormonal stress after regaining consciousness and quicker restoration of baseline hormone levels. According to the study data, OFA appears to be a safe and effective alternative to OBA in CABG. Given the small ","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 10-11"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006689","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intravenous anaesthesia during deep hypothermic circulatory arrest: pharmacokinetics, cortical suppression, and autonomic stress activation","authors":"Dr. Tereza Bartošová,&nbsp;Jan Kunstýř,&nbsp;doc. PharmDr. Martin Šíma,&nbsp;Dr. Tomáš Brožek,&nbsp;prof. Pavel Jansa,&nbsp;Dr. Petr Kopecký,&nbsp;Petr Kozlík,&nbsp;Tomáš Křížek,&nbsp;Dr. Michal Lipš,&nbsp;prof. Pavel Michálek,&nbsp;Dr. Tomáš Prskavec,&nbsp;prof. Ondřej Slanař","doi":"10.1053/j.jvca.2026.08.015","DOIUrl":"10.1053/j.jvca.2026.08.015","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Target-controlled infusion (TCI) systems and processed electroencephalographic (pEEG) monitoring are standard components of modern intravenous anaesthesia. However, their validity during procedures requiring deep hypothermic circulatory arrest (DHCA) remains uncertain. Cardiopulmonary bypass and deep hypothermia alter drug pharmacokinetics and suppress cerebral electrical activity, potentially compromising pharmacokinetic predictions and interpretability of pEEG-derived indices. As conventional physiological signs of anaesthetic adequacy are also affected under these conditions, clinicians have limited means to assess hypnosis and stress suppression during DHCA. We aimed to characterise the relationship between intravenous anaesthetic pharmacokinetics, cortical suppression, and autonomic stress activation during pulmonary endarterectomy requiring DHCA.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Method&lt;/h3&gt;&lt;div&gt;This prospective, single-centre, low-intervention study included 30 adults undergoing elective pulmonary endarterectomy with cardiopulmonary bypass and DHCA. Anaesthesia was maintained using target-controlled infusions of propofol and sufentanil using the Eleveld and Gepts models. Serial blood samples were collected at predefined perioperative time points (T0–T13) to determine serum concentrations of propofol, sufentanil, and endogenous norepinephrine. Continuous pEEG monitoring was performed using SedLine technology, including Patient State Index (PSI) and Suppression Ratio (SR). Predicted and measured drug concentrations were compared during cooling, circulatory arrest, and rewarming. Associations between anaesthetic concentrations, pEEG-derived indices, and norepinephrine release were evaluated.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Result&lt;/h3&gt;&lt;div&gt;Profound cortical suppression was observed throughout the peri-arrest period. Mean SR was 98.4% and mean PSI was 0.4, with patients spending 92.6% and 88.6% of monitored time at SR ≥90% and ≥95%, respectively. Despite near-complete cortical electrical silence, endogenous norepinephrine concentrations increased during reperfusion and after circulatory arrest, indicating persistent autonomic stress activation. No patient reported intraoperative awareness. The predictive performance of the Eleveld model progressively deteriorated during cooling and improved during rewarming. Population pharmacokinetic analysis identified hypothermia as a major determinant of propofol clearance, explaining increasing divergence between predicted and measured concentrations during cooling. In contrast, the Gepts model exhibited a pronounced loss of predictive accuracy immediately after initiation of cardiopulmonary bypass (median prediction error −65.5%), while subsequent hypothermia had little additional effect.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;Hypothermia substantially altered propofol pharmacokinetics, while cardiopulmonary bypass primarily impaired sufentanil model performance. Cortical activity remained near-isoe","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 12-13"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006802","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}