Journal of cardiothoracic and vascular anesthesia最新文献

{"title":"Association of Increased Septal Echogenicity and Cardiac Function During Surgery on Cardiopulmonary Bypass: A Comparison of Open-Heart Procedures and Coronary Artery Bypass Grafting","authors":"Dr. Thilo Schweizer,&nbsp;Brenken AJ,&nbsp;Charlotte Rose,&nbsp;Maria Ramirez,&nbsp;Kady Fischer,&nbsp;Guensch DP","doi":"10.1053/j.jvca.2026.08.042","DOIUrl":"10.1053/j.jvca.2026.08.042","url":null,"abstract":"<div><h3>Introduction</h3><div>During cardiac surgery on cardiopulmonary bypass (CPB), air bubbles may enter the coronary circulation, particularly upon opening of the cardiac chambers. The right coronary artery and its septal perforators are considered most vulnerable, potentially leading to increased septal echogenicity detectable on transoesophageal echocardiography (TOE). If air embolism by cardiotomy were the primary mechanism, patients undergoing open-heart procedures (valve or aortic surgery) would be expected to show a greater rise in septal echogenicity than patients undergoing coronary artery bypass grafting (CABG), in whom the heart is not opened. We aimed to compare intraoperative septal echogenicity changes between open-heart and CABG procedures and to assess their association with ventricular function.</div></div><div><h3>Method</h3><div>In this retrospective interim analysis, TOE images from patients undergoing cardiac surgery on CPB were analysed at three intraoperative timepoints: before CPB initiation (T1), after aortic declamping (T2), and after decannulation (T3). End-systolic septal and lateral wall echogenicity were measured. The Echogenicity Index (EI) was defined as the septal-to-lateral-wall ratio of the signal intensity. Left and right ventricular peak strain were analysed at all time-points using clinically validated software.</div><div>We included 259 patients (23.5% female, mean age 64.1±10.7 years): CABG 43.5% (n=113), valve 29.2% (n=76), CABG plus valve 8.8% (n=23), aortic 6.5% (n=17), and other surgeries 12.3% (n=31). Both open-heart and CABG patients showed a significant increase in septal echogenicity from T1 to T2: open-heart end-systolic Δ +19.5 [95%-CI 3.8 to 33.1] (p=0.035), CABG Δ +12.3 [95%-CI 5.7 to 19.4] (p&lt;0.001). There was no significant difference between groups (p=0.84). In both groups, lateral wall echogenicity remained unchanged (Δ +0.05, p=0.725), confirming the septum-specific nature of the effect.</div><div>After decannulation (T3), higher EI was associated with worse function in open-heart patients only: higher EI was associated with less negative RV free wall strain (indicating worse RV function Spearman’s ρ=0.401 [95%-CI 0.094 to 0.639], p=0.013) and decreased basal inferoseptal strain (ρ=0.241 [95%-CI 0.004 to 0.452], p=0.046) whereas no such associations were present in patients with only CABG procedures.</div></div><div><h3>Conclusion</h3><div>Septal echogenicity increases after aortic declamping in both CABG and open-heart surgery. This argues against air embolism upon cardiotomy as the primary mechanism. However, the association of septal echogenicity with septal and RV free wall strain was limited to open-heart patients, suggesting that the increased septal echogenicity might be a possible surrogate marker for reduced contractility in the right coronary territory in these patients.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 34-35"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006804","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":"Management of Acute Right Heart Failure Induced by Massive Pulmonary Embolism: Lessons from a Case Report","authors":"Dr Esmerilda Bulku,&nbsp;Dr. Jonela Burimi,&nbsp;Dr Ervin Bejko,&nbsp;Dr Fjorba Mana,&nbsp;Dr Andi Kacani","doi":"10.1053/j.jvca.2026.08.029","DOIUrl":"10.1053/j.jvca.2026.08.029","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Pulmonary embolism (PE) is a critical condition that significantly affects right-sided heart function, primarily due to obstruction of the pulmonary artery, usually from thrombi originating from deep vein thrombosis (DVT). This obstruction leads to a sudden increase in pulmonary arterial pressure, resulting in right ventricular dysfunction (RVD), compromising cardiac output and leading in hypotension and systemic failure. Symptoms include sudden dyspnea, chest pain, tachycardia and in severe cases, syncope. When systemic thrombolysis fails, is contraindicated, or cardiac arrest occurs, surgical pulmonary embolectomy under cardiopulmonary bypass (CPB) provides an essential therapeutic alternative and can ultimately lead to improved survival and recovery for patients facing this critical condition.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Method&lt;/h3&gt;&lt;div&gt;We describe a case of a 15-year-old male patient who presented with a massive central PE secondary to a DVT in the femoral vein. The patient was hospitalized in Cardio-vascular unit and under LMWH treatment for more than 4 days when experienced a sudden cardiac arrest. He was transfered immediately in ICU and intubated under cardiopulmonary resuscitation (CPR). Even though CPR was performed for nearly one hour and the patient was in full drug support, it was not recovering. TEE was showing a large “saddle” pulmonary embolus at the bifurcation of the main pulmonary artery and signs of RV failure. The patient was sent immediately in OR and emergency femoral cannulation was performed to establish CPB. Surgical intervention resulted in the successful removal of a large thrombus from both main pulmonary truncus and pulmonary arteries, restoring hemodynamic stability. Initially, the patient showed signs of improvement and was weaned off CPB and was transferred to the ICU, hemodynamically compensated on high doses of inotropic support and anticoagulation therapy. However, 12 hours postoperatively, despite the medical support, the patient developed recurrent RV failure, progressing to refractory cardiogenic shock and death. ECMO and RVADs are not available in our country.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Result&lt;/h3&gt;&lt;div&gt;This case highlights the aggressive nature of massive pulmonary embolism (PE) and the critical life-saving potential of surgical embolectomy. As PE can lead to rapid hemodynamic deterioration and RV dysfunction, prompt surgical intervention in particular cases is essential for improving patient outcomes. The embolectomy procedure provides immediate mechanical relief from pulmonary obstruction, significantly reducing RV afterload and enhancing cardiac function.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;The case report highlights TEE's vital role in diagnosing Pulmonary Embolism (PE) and right heart failure (RHF) in patients with refractory hemodynamic instability and to improve management in critical situations.&lt;/div&gt;&lt;div&gt;Furthermore, despite the full support of inotrope drugs, the lack of availa","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Page 24"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006910","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":"International Expert Consensus on Perioperative Bleeding Management in Adult Cardiac Surgery: A Modified Delphi Study","authors":"Mr Michel Vezarov,&nbsp;Dr Jeannie Callum,&nbsp;Dr Robert Tanzola,&nbsp;Dr Carolyn Teng,&nbsp;Dr Jerrold Levy,&nbsp;Dr David Mazer,&nbsp;Dr Linda Shore-Lesserson,&nbsp;Dr Pierre Tibi,&nbsp;Dr Daniel Bolliger,&nbsp;Dr Louise Sun,&nbsp;Dr Tarit Saha","doi":"10.1053/j.jvca.2026.08.023","DOIUrl":"10.1053/j.jvca.2026.08.023","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Perioperative bleeding remains a major source of morbidity and resource use in adult cardiac surgery. Although several international guidelines exist (e.g., the 2024 EACTS/EACTAIC and 2021 STS/SCA recommendations), there are still substantial variations in clinical practice across regions.[1,2] This variation reflects differences in institutional resources, regional practice patterns, and gaps in high-quality evidence for many routine decisions. This study aims to address these gaps by bringing together a multidisciplinary international expert panel to develop practical best-practice statements for routine clinical care, informed by existing guidelines, clinical trials, and expert experience.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;To map existing recommendations and identify areas of regional divergence, we first conducted a scoping review (606 records screened across MEDLINE, Embase, and Scopus; PRISMA-ScR), which helped inform a draft set of 27 statements organized by perioperative phase (preoperative; pre-bypass/intraoperative; rewarming/post-protamine; postoperative). Statements were pre-reviewed by a multidisciplinary panel of eight experts for clarity and completeness, with revisions tracked in a change log. A larger international panel of approximately 30–40 experts in cardiac anesthesiology, cardiac surgery, transfusion medicine/hematology, and perfusion was purposively sampled to ensure disciplinary, gender, and regional balance. Panelists will rate each statement on a 7-point Likert scale with optional free-text comments. Consensus to include is defined as an interquartile range ≤1.5 with ≥70% of ratings in the 5–7 range; consensus to exclude as ≥70% in the 1–3 range. The Delphi consists of two rounds, with a third conducted only if prespecified consensus criteria are unmet. Only clarifying edits are permitted between rounds. Surveys are delivered via Qualtrics. No patient data are collected.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;This study is ongoing. The scoping review identified meaningful variation between regional guidelines, supporting the need for consensus. The steering group developed 27 draft statements, refined through multidisciplinary pre-review, and the study is now entering Round 1 of the Delphi. Primary outcomes are the consensus status of each statement (include, exclude, or no consensus) and the proportion of statements achieving consensus by the final round. Exploratory analyses will assess variation in agreement by specialty and region.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;This international modified Delphi study is designed to produce practical, phase-based statements that complement existing guidelines and support everyday clinical decision-making in perioperative bleeding management. By integrating multidisciplinary international input, and grounding the statement set in a structured scoping review of regional differences, the consensus aims to improve consistency of care, support a ","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 19-20"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006912","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 peri-operative management of acute Type A aortic dissection: a single centre audit in Singapore","authors":"Dr Aileen Tan,&nbsp;Dr Hwang Kai Yin","doi":"10.1053/j.jvca.2026.08.013","DOIUrl":"10.1053/j.jvca.2026.08.013","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Acute Type A aortic dissection (ATAAD) is a surgical emergency. Mortality in medically treated patients increases by 1-2% for every hour after onset of symptoms. The time-sensitive nature of this condition makes optimisation of care pathways a critical patient safety imperative.&lt;/div&gt;&lt;div&gt;This audit looks at the patient’s journey from when they first present at our hospital to when they undergo surgery.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;This was a retrospective analysis of patients who underwent emergency surgery for ATAAD from January 2024 to June 2025.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;We identified 30 patients, of whom 26 were diagnosed with ATAAD and 4 with acute aortic syndromes (penetrating aortic ulcer or intramural hematoma) that required emergency aortic surgery. The patients were predominantly males (n= 21) and the median age was 58 years old. 8 patients presented directly to our hospital’s emergency department and 22 patients were transferred from other hospitals that do not offer cardiac surgery.&lt;/div&gt;&lt;div&gt;The median transfer times of these patients are shown in Table 1. 28 out of 30 of the patients were first transferred to our hospital’s intensive care unit to prepare for surgery, the remaining 2 patients were transferred directly from the hospital’s emergency department to the operating theatre. The median time from patient presentation at the emergency department to when they arrive at our hospital’s intensive care unit was 235 minutes. Patients then went on to receive their surgery within 215 minutes.&lt;/div&gt;&lt;div&gt;We identified 14 patients who faced delays in receiving surgery. 3 patients had logistical-related delays. Another 8 were wrongly misdiagnosed. 3 patients had complicated malperfusion syndromes that required consult with other surgical specialties before surgery. All patients going for surgery received a CT aortogram. The most common additional investigation requested for was a trans-thoracic echocardiogram.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;There are no international standards for the peri-operative management of patients with ATAAD. This is likely a reflection of the heterogeneity in patient presentation and differences in healthcare systems across countries.&lt;/div&gt;&lt;div&gt;A recent prospective audit done by the Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) found that the median time from patient presentation until their arrival at a cardiac centre in the United Kingdom was 373 minutes. Patients then went on to receive their surgery within 143 minutes. The shorter time from patient presentation to arrival at our hospital’s intensive care unit probably reflects the close proximity of hospitals within Singapore. However, patients then took a longer time of 215 minutes to receive their surgery.&lt;/div&gt;&lt;div&gt;This audit highlights the significant delay that patients in our hospital experience in receiving appropriate treatment for ATAAD, with potential for workflow sta","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 11-12"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007020","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":"Impact of preoperative hepatic dysfunction on mortality after heart transplantation","authors":"Rita Szentgróti,&nbsp;Dr Alexandra Vereb,&nbsp;Dr Mandula Ifju,&nbsp;Dr Kinga Bianka Koritsánszky,&nbsp;Dr Nóra Fanna Kovács,&nbsp;Dr Katalin Orlovácz,&nbsp;Dr Etelka Krajcsó,&nbsp;Dr Olívia Bottlik,&nbsp;Dr Béla Merkely,&nbsp;Dr Andrea Székely","doi":"10.1053/j.jvca.2026.08.063","DOIUrl":"10.1053/j.jvca.2026.08.063","url":null,"abstract":"<div><h3>Introduction</h3><div>Heart transplantation (HT) is the gold standard therapy for end-stage heart failure. HT candidates often have several comorbidities, including hepatic dysfunction. Our aim was to investigate the association between preoperative hepatic function assessed using the „Model for End-stage Liver Disease” (MELD), MELD 3.0, and „Fibrosis-4” (FIB-4) scores, and postoperative outcomes.</div></div><div><h3>Method</h3><div>We conducted a single-centre retrospective study and analyzed data from 581 patients who underwent HT between 1 January 2012 and 31 December 2024. The MELD score was calculated using preoperative INR, total bilirubin, and creatinine levels. For MELD 3.0, albumin and sodium levels, as well as recipient sex, were additionally included. The FIB-4 score was calculated using recipient age, preoperative aspartate aminotransferase and alanine aminotransferase levels, and platelet count. Descriptive statistics, Mann–Whitney U tests, Kaplan–Meier survival analysis, and Cox proportional hazards regression were used for statistical analyses. In the multivariable Cox regression model, the IMPACT score (Index for Mortality Prediction After Cardiac Transplantation) was included as an adjustment variable. The primary outcome was all-cause mortality.</div></div><div><h3>Result</h3><div>Among the 581 recipients, 426 (73.3%) were male. The mean age was 50.8 ± 10.9 years, and the median follow-up time was 2133 days. The median MELD score was 11.67 (IQR 8.90-14.48), the median MELD3.0 score was 16.12 (IQR 12.12-20.05), and the median FIB-4 score was 1.32 (IQR 0.90-1.85). In IMPACT-adjusted Cox regression analysis, MELD was associated with long-term mortality only [1-year mortality - HR:1.044 (95%CI: 1.005-1.084); p=0.026], 2-year mortality - HR: 1.038 (95%CI: 1.002-1.075); p=0.037], but not with 30-day mortality [HR:1.037 (95%CI: 0.986-1.091); p=0.161]. MELD 3.0 remained independently associated with 30-day [HR: 1.051 (95%CI: 1.008-1.096); p=0.02], 1-year [HR: 1.046 (95%CI: 1.014-1.080); p=0.004] and 2-year mortality [HR: 1.040 (95%CI: 1.010-1.070); p=0.009]. Patients in the highest MELD 3.0 quartile had significantly reduced survival compared with the lower quartiles on Kaplan–Meier analysis (log-rank p = 0.020). FIB-4 was not significantly associated with post-transplant mortality in our analysis.</div></div><div><h3>Conclusion</h3><div>Pre-transplant MELD3.0 was independently associated with both short- and long-term mortality, whereas MELD was associated only with long-term mortality. MELD 3.0 may be a more useful prognostic tool for preoperative risk stratification in HT candidates.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 51-52"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007053","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":"Use of Superficial Parasternal Intercostal Plane Block as Part of Enhanced Recovery In Cardiac Surgery","authors":"Dr Nikhil George,&nbsp;Dr Ayyappa Das,&nbsp;Dr Kavita Mattam,&nbsp;Dr Rakhi K Rethnamma,&nbsp;Dr Aju Joy,&nbsp;Dr Deepak Ajithakumaran,&nbsp;Dr Hanumath Reddy","doi":"10.1053/j.jvca.2026.08.049","DOIUrl":"10.1053/j.jvca.2026.08.049","url":null,"abstract":"<div><h3>Introduction</h3><div>Enhanced Recovery After Cardiac Surgery requires a multimodal approach . Perioperative and post operative pain relief forms a major component in Enhanced Recovery After Cardiac Surgery.</div></div><div><h3>Methods</h3><div>Sixty patients for CABG at a Rural Cardiac Centre in India between November 2025 and March 2026 were enrolled as part of study after informed consent and institution ethic committee approval.</div><div>Two groups A and B were formed.</div><div>In Group A after Induction of General Anesthesia Bilateral Superficial Parasternal Intercostal Plane Block (S-PIP) with Levo bupivacaine 0.25% 40 mls. was administered under ultrasound guidance.</div><div>Group B were not administered any Fascial plane block and was administered normal doses of opioids during induction.</div><div>PRST Score and Entropy Score was used to assess response to pain from incision for both groups along with regular monitoring used for cardiac surgery.</div><div>If PRST score was found to be more than 3 and entropy score was found to be more than 60,additional doses of opioid for analgesia was administered .</div></div><div><h3>Results</h3><div>Group A patients consistently had a lower PRST Score during skin incision showing minimal response to surgical stimulation. as compared to patients in group B. All Group A patients required lesser doses of opioid analgesia and leading to faster extubation and reduced postoperative ventilation duration as compared to Group B patients</div></div><div><h3>Discussion</h3><div>Adding Superficial Intercostal Plane Block as part of multimodal analgesia using Levo bupivacaine helped in significantly lower the doses of opioid requirement during cardiac surgery.</div><div>Superficial plane block was used as concerns was raised about inadvertent injury to Left Internal Mammary artery during Deep Intercostal Plane block.</div><div>Levo Bupivacaine was used for its cardiac safety profile and longer duration of action.</div><div>All patients who received Superficial Parasternal Intercostal Plane Block had reduced pain response during surgery and experienced significant pain relief in the post operative period leading to reduced opioid requirement. This helped in early extubation and early mobilization of post cardiac surgery patients.</div><div>Superficial Parasternal Intercostal Plane Block can be used during cardiac surgery safely as it reduces opioid requirement and postoperative ventilation .It aids in Early recovery after cardiac surgery.</div><div>It can be added to Cardiac Enhanced Recovery Bundle of Care.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Page 40"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007156","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":"Plasma-Induced Endothelial and Tubular Dysfunction in Patients Developing Cardiac Surgery-Associated Acute Kidney Injury","authors":"Dr Teresa Esposito,&nbsp;Prof Elena Grossini,&nbsp;Dr Sakthipriyan Venkatesan,&nbsp;Dr Mohammad Mostafa Ola Pour,&nbsp;Mr Giacomo Giardino,&nbsp;Prof Vincenzo Cantaluppi,&nbsp;Prof Stefania Bruno,&nbsp;Prof Daniela Ferrante,&nbsp;Dr Veronica Daffara,&nbsp;Dr Giulia Rizzotti,&nbsp;Dr Daniele Pierelli,&nbsp;Dr Jonathan Cattani,&nbsp;Dr Carmelo Dominici,&nbsp;Dr Antonio Nenna,&nbsp;Dr Giovanni Casali,&nbsp;Prof Gianmaria Cammarota,&nbsp;Prof Rosanna Vaschetto","doi":"10.1053/j.jvca.2026.08.077","DOIUrl":"10.1053/j.jvca.2026.08.077","url":null,"abstract":"<div><h3>Introduction</h3><div>Cardiac surgery-associated acute kidney injury (CSA-AKI) remains a frequent and severe complication after cardiac surgery with cardiopulmonary bypass. Current diagnostic markers identify kidney injury only after substantial damage has occurred, while the early biological mechanisms predisposing patients to CSA-AKI remain poorly characterized. We investigated whether plasma from patients developing CSA-AKI induces endothelial and tubular dysfunction already before surgery.</div></div><div><h3>Method</h3><div>In this prospective observational study, plasma samples were collected from 20 patients undergoing elective cardiac surgery at anesthesia induction (T0) and 48 h postoperatively (T1). Ten patients developed CSA-AKI according to KDIGO criteria, while ten did not. Plasma redox balance was assessed through thiobarbituric acid-reactive substances (TBARS), glutathione (GSH), and nitric oxide (NO) level evaluation. Human umbilical vein endothelial cells (HUVECs) and renal tubular epithelial cells were exposed to patient plasma to evaluate cell viability, mitochondrial membrane potential, oxidative stress, and endothelial/tubular dysfunction. Five age-matched non-cardiac surgical patients served as healthy controls.</div></div><div><h3>Result</h3><div>Compared with healthy controls, patient plasma already demonstrated an altered redox profile before surgery, characterized by increased TBARS and reduced GSH and NO levels. Plasma exposure induced endothelial and tubular dysfunction already at T0, with reduced cell viability, impaired mitochondrial membrane potential, increased oxidative stress, reduced endothelial NO release, and alterations in endothelial and cytoprotective pathways, including endothelial-to-mesenchymal transition and reduced expression of anti-aging mediators. These alterations were more pronounced in patients who subsequently developed CSA-AKI. At T1, plasma from CSA-AKI patients induced further worsening of endothelial and tubular dysfunction, whereas plasma from non-AKI patients showed partial recovery of cellular and redox alterations.</div></div><div><h3>Conclusion</h3><div>Patients developing CSA-AKI exhibit a preoperative biologically vulnerable phenotype characterized by oxidative imbalance and plasma-induced endothelial and tubular dysfunction. Cardiac surgery may therefore act as a second hit amplifying pre-existing cellular susceptibility. These findings support the existence of circulating pathogenic factors potentially involved in CSA-AKI pathogenesis and suggest that plasma-induced cellular dysfunction may represent an early mechanistic signature of postoperative kidney injury.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 63-64"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007203","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":"Early ICU Admission Parameters and Mortality After Cardiac Surgery. The BAR (Before-and-After Risk) score","authors":"Alessandro Barbaria MD,&nbsp;Tommaso Aloisio MD,&nbsp;Umberto Di Dedda MD,&nbsp;Martina Anguissola BD,&nbsp;Ekaterina Baryshnikova PhD,&nbsp;Marco Ranucci MD, FESC","doi":"10.1053/j.jvca.2026.08.005","DOIUrl":"10.1053/j.jvca.2026.08.005","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Several preoperative and postoperative risk models have been developed to predict mortality after cardiac surgery. While established preoperative scores such as EuroSCORE II provide acceptable discrimination, they do not account for the physiological consequences of surgery itself. Conversely, dedicated postoperative models, including POCAS and CASUS, have demonstrated excellent predictive performance but may rely on variables that are not universally available or easily applicable at the bedside. We hypothesized that routinely collected ICU admission parameters could capture the combined effects of patient baseline risk and intraoperative performance. The aim of this study was to develop and validate a powerful yet pragmatic and parsimonious prediction model based exclusively on universally available ICU admission variables integrated with EuroSCORE II.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;We conducted a retrospective prognostic modeling study using a prospectively maintained database of adult patients undergoing cardiac surgery between January 2015 and February 2026. Candidate predictors included EuroSCORE II and routinely collected ICU admission variables: arterial lactate, hematocrit, PaO₂/FiO₂ ratio, mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), pH, and PaCO₂. The primary endpoint was 30-day all-cause mortality. After data quality control and complete-case selection, 8,045 patients were included and divided into a development cohort (n=6,500) and a temporal validation cohort (n=1,545). Multivariable logistic regression was used to derive the final model, termed the Before-and-After Risk (BAR) score. Model performance was assessed through discrimination, calibration, temporal validation, and reclassification analyses.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;Among 8,045 patients, overall mortality was approximately 3%. Lactate demonstrated the strongest association with mortality, with mean admission values of 4.87 mmol/L in non-survivors versus 1.72 mmol/L in survivors (r = 0.33, 95% CI 0.308–0.351; p&lt;0.001), and showed the highest standalone discriminatory performance (AUC 0.816). In the multivariable analysis, EuroSCORE II, lactate, hematocrit, PaO₂/FiO₂ ratio, MAP, HR, and CVP remained independently associated with mortality, whereas pH and PaCO₂ were excluded from the final model. In the development cohort, the BAR score achieved an AUC of 0.848 compared with 0.707 for EuroSCORE II alone (ΔAUC 0.141, 95% CI 0.102–0.180; p&lt;0.001). Calibration was satisfactory (Hosmer–Lemeshow p=0.366; Brier score 0.029). In the temporal validation cohort, discrimination remained robust (AUC 0.838, 95% CI 0.765–0.912), with acceptable calibration (Hosmer–Lemeshow p=0.113; calibration intercept 0.092; slope 1.20). Reclassification analyses demonstrated significant improvement over EuroSCORE II alone (categorical NRI 0.482; continuous NRI 1.052; IDI 0.130; all p&lt;0.001).&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;C","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 4-5"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007276","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":"Feasibility and Early Outcomes of an Airway-Tubeless Anesthesia Pathway for Heart Transplantation","authors":"Dr. Feng Zhong,&nbsp;Dr. Jiexian Liang,&nbsp;Dr. Zhao Chen,&nbsp;Dr. Min Wu,&nbsp;Dr. Zhaoxin Zhou","doi":"10.1053/j.jvca.2026.08.025","DOIUrl":"10.1053/j.jvca.2026.08.025","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Airway-tubeless anesthesia has emerged as a promising strategy to facilitate enhanced recovery after cardiac surgery. However, evidence regarding its application in heart transplantation remains scarce. We evaluated the feasibility and early outcomes of a structured airway-tubeless anesthesia pathway in consecutive heart transplant recipients.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;We retrospectively reviewed 58 consecutive patients who underwent heart transplantation using a structured airway-tubeless anesthesia pathway at a single center. General anesthesia was maintained with a laryngeal mask airway combined with multimodal regional analgesia. Patients meeting predefined criteria underwent laryngeal mask removal in the operating room. The primary outcome was successful completion of the airway-tubeless pathway. Secondary outcomes included reintubation, postoperative organ support, postoperative complications, intensive care unit (ICU) and hospital length of stay, and 30-day mortality.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;Among the 58 recipients, the median age was 43.5 (29.8–53.0) years, 74.1% were male, and 15.5% were pediatric recipients. Nearly all patients were NYHA class III–IV (98.3%), with a mean LVEF of 28.5 ± 11.3%. Pulmonary hypertension was present in 25 of 49 evaluable patients (51.0%), and 17.2% had an eGFR &lt;60 mL/min/1.73 m². Two patients (3.5%) required preoperative intra-aortic balloon pump support.&lt;/div&gt;&lt;div&gt;Mean cardiopulmonary bypass, aortic cross-clamp, and cold ischemic times were 157.3 ± 35.1, 76.3 ± 16.2, and 169.5 ± 54.6 minutes, respectively. Intercostal nerve block alone was used in 60.3% of patients, whereas 29.3% received an erector spinae plane-based multimodal block.&lt;/div&gt;&lt;div&gt;Successful completion of the airway-tubeless pathway was achieved in 54 patients (93.1%). Four patients (6.9%) required conversion to endotracheal intubation because of intraoperative hemodynamic instability. The laryngeal mask airway was removed 12.4 ± 12.5 minutes after surgery. Postoperative reintubation occurred in 4 patients (7.4%), all due to hemodynamic instability rather than primary respiratory failure. Median ICU and postoperative hospital lengths of stay were 6 (4–8) and 15 (13–24) days, respectively. Pulmonary complications occurred in 15.5% of patients, neurological complications in 8.6% (including one stroke), postoperative ECMO support in 8.6%, new postoperative CRRT in 13.8%, and 30-day mortality was 1.7%.&lt;/div&gt;&lt;div&gt;This consecutive series demonstrates that an airway-tubeless anesthesia pathway can be successfully implemented in the majority of heart transplant recipients despite their high perioperative risk. Notably, all reintubations were attributable to hemodynamic instability rather than primary respiratory failure, suggesting that failure of the pathway was driven predominantly by cardiovascular compromise rather than airway-related factors.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;A struc","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 20-21"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007281","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":"Challenges in identifying and stratifying aortic regurgitation severity arising from valve fenestrations.","authors":"Dr Hwang Kai Yin","doi":"10.1053/j.jvca.2026.08.026","DOIUrl":"10.1053/j.jvca.2026.08.026","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Mr C, a 65-year-old gentleman, was diagnosed with TVD incidentally during work-up for cataract surgery. At that time, the AV was normal with no AR/AS. One year later when he decided to undergo CABG, a repeat TTE showed ?moderately severe AR with ?prolapse of noncoronary cusp, LVEF 60% and no RWMA, no flow reversal in descending TA. Subsequent TEE reported moderate AR with restricted RCC motion resulting in a linear coaptation gap between RCC and NCC. Valve leaflets were otherwise thin and pliant with no vegetations. The AR PHT was 383ms, PISA EROA 0.15cm2, regurgitant volume 31ml, and borderline diastolic flow reversal in descending TA. The patient had good effort tolerance without functional limitation.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Method&lt;/h3&gt;&lt;div&gt;5 months later during the CABG, intraoperative TEE under GA showed an eccentric regurgitant jet directed from the interleaflet trigone between the AV NCC and RCC, towards the anterior mitral leaflet and terminating beyond its tip, causing blunting of the mitral E wave but without significant pressure gradient. The AR severity was variable using different indices; in the standard AV LAX the jet was 12% of the LVOT (mild) with PISA radius 0.3cm, and EROA 0.12cm2 (moderate), regurgitant volume 19.4ml (mild). The broadest AR jet in a nonstandard view was 46% of the LVOT (moderate) and had vena contracta 0.24cm (mild). The doppler beam was aligned as closely as possible to the jet in the transgastric long axis view but only measured PHT &gt;500ms (mild). The descending thoracic aorta showed only early diastolic flow reversal (mild), peak velocity 27cm/s. The AV was otherwise trileaflet, without calcification or leaflet prolapse. The LV size was normal, with an indexed end diastolic volume 55.9ml.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Result&lt;/h3&gt;&lt;div&gt;On cardiopulmonary bypass, despite the mild-moderate findings, the lesion was severe enough to prevent effective cardiac arrest from antegrade cardioplegia via the aortic root. Hence aortotomy was performed, direct ostial cardioplegia was given, and the AV inspected. The RCC leaflet was found to have a 10x5mm fenestration near its coaptation edge, and the LCC and NCC were normal. The aortic root was not dilated. Repair of the fenestration was performed with pericardial cardiocel patch, aortotomy was closed, and root cardioplegia was resumed. AR was significantly reduced and cardioplegia was delivered with adequate root distension without LV distension or high LV vent flow. Post bypass echo showed a residual mild central regurgitant jet, and retrospective review of 3D imaging showed the possible fenestration site,&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;This patient did not have any known episode of infective endocarditis, although he did have repeated episodes of grade 3 hypertension, and multiple coronary angioplasties after the initial normal TTE. These procedures have been known to cause AVF rupture in rare cases. Although as many indices as possible were","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 21-22"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007282","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}