Journal of cardiothoracic and vascular anesthesia最新文献

{"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}

{"title":"What AI Could Not Hear - Reflections on AI-Assisted End-of-Life Communication as an International ICU Fellow","authors":"Dr Nikita Thomas","doi":"10.1053/j.jvca.2026.08.069","DOIUrl":"10.1053/j.jvca.2026.08.069","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;End-of-life communication in intensive care is one of the most emotionally demanding aspects of clinical practice. These conversations ask clinicians to remain clear and compassionate while working under stress, uncertainty, and emotional fatigue.¹ ² AI language tools are becoming increasingly accessible to clinicians, including during communication-heavy and emotionally demanding situations.³&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Method&lt;/h3&gt;&lt;div&gt;I had recently transitioned from medical practice in India to working as an intensive care fellow within the NHS. Conducting end-of-life discussions in a new healthcare system introduced unfamiliar expectations around communication, reassurance, and family interaction. During a night shift, I found myself speaking by telephone with a patient’s relative following transition to end-of-life care and the patient’s subsequent death overnight in the intensive care unit. Unlike structured communication scenarios encountered during formal assessments, this conversation carried a degree of emotional and cognitive burden I had not anticipated. Prior to the discussion, an open access AI language model was used to help structure the conversation, refine wording, and explain withdrawal of life-sustaining treatment, symptom management, and reassurance that the patient was comfortable and not alone during their final moments.&lt;/div&gt;&lt;div&gt;Several human-factor challenges emerged during the interaction. AI assistance reduced cognitive overload by providing rapid conversational structure during an emotionally demanding task. This became particularly relevant while adapting to unfamiliar communication norms within the NHS. Having previously communicated medical information across multilingual healthcare settings in India, discussing end-of-life care within the NHS required recalibration in how clarity, reassurance, and professionalism were expressed. The challenge was not simply finding the right words, but understanding what the words needed to carry.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Result&lt;/h3&gt;&lt;div&gt;The conversation also exposed the limitations of AI-supported communication. During the interaction, the most important moments were often the pauses between sentences. Meaningful communication depended on interpreting silence, hesitation, grief, pacing, and the need for reassurance. Respectful pauses and culturally shaped expectations surrounding death and family communication extended beyond what the AI-generated structure could interpret.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;For an internationally trained clinician adapting to a new healthcare system, AI emerged as a potentially useful supportive tool during difficult conversations. By reducing cognitive overload and providing conversational structure, it created greater space to focus on listening, pacing, and the emotional flow of the interaction. Rather than replacing the human elements of communication, the experience suggested that AI may help create more cognitive spa","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 56-57"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007335","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":"Simulation-Based training in Anaesthesia and Critical Care: Evaluation of a structured simulation day for first-year residents and Future Perspectives.","authors":"Ismahane Kara Slimane,&nbsp;Dr Jean-Pierre Hacquebard,&nbsp;Dr José Cravo,&nbsp;Dr Alexandra Colesnicenco,&nbsp;Dr Wissal Kaidi,&nbsp;Pr Céline Boudart,&nbsp;Dr Laurent Perrin","doi":"10.1053/j.jvca.2026.08.070","DOIUrl":"10.1053/j.jvca.2026.08.070","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;Simulation-based medical education (SBME) provides a psychologically safe environment, free from judgment (“blame or shame”) that fosters clinical skill acquisition and reflective practice.&lt;/div&gt;&lt;div&gt;It is particularly relevant in anesthesia, where clinicians must be prepared for rare, high-stakes events requiring advanced technical expertise and non-technical skills, including Crisis Resource Management (CRM).&lt;/div&gt;&lt;div&gt;SBME has demonstrated effectiveness in improving theoretical knowledge, technical and CRM skills, and in reducing cognitive biases.&lt;/div&gt;&lt;div&gt;The simulation day developed in 2016 has not yet been evaluated. This study analyzes the simulation day conducted in November 2025 to assess its alignment with current recommendations and its educational effectiveness using the Kirkpatrick model.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;This descriptive study included all first-year residents enrolled in the specialized Master’s (24 students). The training program was analysed through instructors materials and direct observation. Evaluation used multiple anonymized online questionnaires: participant satisfaction, debriefing quality, self-confidence, clinical transfer at six months, an open-ended post-course questionnaire, and a pre- and post-simulation Advanced Life Support (ALS) multiple choice test.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;This simulation day showed an overall structure consistent with current (2020-2025) recommendations on Human Factor and Simulation Education from major international and national society (ESAIC, RCoA, SoFraSims, SFAR).&lt;/div&gt;&lt;div&gt;It included Pre-course materials provided in advance, clearly defined learning objectives, level-adapted scenarios, structured briefings, Immersive simulation (= high-fidelity and technology simulation), focused observation of technical and non-technical skills, and structured debriefing (Pearls model).&lt;/div&gt;&lt;div&gt;Kirkpatrick analysis showed an overall positive reception, with high satisfaction levels, well-rated debriefing quality, a positive perception of skill acquisition, and favorable perceived clinical transfer.&lt;/div&gt;&lt;div&gt;However, some items related to emotional comfort and the perceived impact of discussion on learning received lower scores.&lt;/div&gt;&lt;div&gt;Despite prior exposure to simulation, pre-course questionnaire revealed limited knowledge of CRM principles across social, cognitive, and personal domains (teamwork, leadership, communication, situation awareness, decision-making, cognitive readiness, task management, stress and fatigue management)&lt;/div&gt;&lt;div&gt;The ALS pre-test showed heterogeneous baseline knowledge, with no significant improvement at 6 month post-test.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Discussion&lt;/h3&gt;&lt;div&gt;Lower comfort scores and limited perceived impact of debriefing highlight the emotional weight of error in simulation, where the vulnerability associated with exposure clinical limitations can compromise psychological safety. Nevertheless, the debrie","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 57-58"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007336","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":"Assessment of split-dose enoxaparin for therapeutic anticoagulation in high bleeding risk post-cardiac surgery patients: a prospective observational auditAssessment of split-dose enoxaparin for therapeutic anticoagulation in high bleeding risk post-cardiac surgery patients: a prospective observational audit","authors":"Dr Khadiga Abdelkerim,&nbsp;Dr Noha Khalil,&nbsp;Dr Smitangshu Mukherjee","doi":"10.1053/j.jvca.2026.08.074","DOIUrl":"10.1053/j.jvca.2026.08.074","url":null,"abstract":"<div><h3>Introduction</h3><div>Therapeutic anticoagulation following cardiac surgery carries a significant bleeding risk. A split-dose enoxaparin strategy — dividing the 1.5 mg/kg once-daily dose into 0.75 mg/kg twice daily to reduce peak anticoagulant exposure — is used pragmatically in high bleeding-risk patients despite limited evidence. This audit evaluated its anticoagulation effectiveness and associated clinical outcomes.</div><div>A prospective observational audit was conducted in a tertiary cardiothoracic ICU. Post-cardiac surgery patients at high bleeding risk requiring therapeutic anticoagulation and managed with split-dose enoxaparin (0.75 mg/kg twice daily) were included. Peak anti-factor Xa levels were measured 3–4 hours post-dose. As no validated therapeutic target exists for this regimen, a range of 0.4–1.0 IU/mL was applied following specialist haematology input, consistent with standard therapeutic twice-daily LMWH monitoring (1 mg/kg twice daily). Outcomes included attainment of therapeutic anti-factor Xa levels, time to therapeutic anticoagulation, and associated thrombotic and bleeding complications. Data were analysed descriptively.</div></div><div><h3>Method</h3><div>Eighteen post-cardiac surgery patients were included, with 69 anti-Xa measurements analysed. Split-dose enoxaparin was used due to increased postoperative bleeding risk, particularly in patients with surgical drains in situ. Indications for therapeutic anticoagulation included atrial fibrillation, mechanical valve anticoagulation, and other thrombotic indications.</div></div><div><h3>Results</h3><div>Overall, 47 anti-Xa measurements (68.1%) were therapeutic, 16 (23.2%) subtherapeutic, and 6 (8.7%) supratherapeutic. Seventeen patients (94.4%) achieved therapeutic anticoagulation at least once: 11 (61.1%) after the first dose, 5 (27.8%) after the second, and 1 (5.6%) after the third. One patient remained persistently subtherapeutic. However, only 7 patients (38.9%) remained consistently within therapeutic range throughout treatment. No bleeding complications were documented. Two thrombotic events occurred: an MCA stroke on postoperative day two, before full anticoagulation would routinely be expected, and an IJV thrombus in a patient with substantial baseline thrombotic risk.</div></div><div><h3>Conclusion</h3><div>Split-dose enoxaparin appears to be a pragmatic anticoagulation strategy in high bleeding-risk post-cardiac surgery patients, achieving therapeutic anticoagulation in most cases. However, variability in sustained anticoagulation control highlights the need for anti-Xa monitoring, individualised dose optimisation, and further prospective evaluation to better define its role in this high-risk population.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 60-61"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149007340","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":"A Hematoma in a Giant Hiatal Hernia Causing Left Atrial Compression: An Instructive Transthoracic Echocardiography Image.","authors":"Maria Sanabra Loewe,&nbsp;Abraham Mera Olivares,&nbsp;Tobias Koller,&nbsp;Carolina Garcia Bartolo,&nbsp;Manuel Martin Navarro,&nbsp;Alejandro Guiterrez Marques,&nbsp;Frank Pastrana,&nbsp;Paula Bardina","doi":"10.1053/j.jvca.2026.08.041","DOIUrl":"10.1053/j.jvca.2026.08.041","url":null,"abstract":"<div><h3>Introduction</h3><div>Extrinsic compression of the left atrium is an uncommon but clinically important cause of hemodynamic compromise. Although hiatal hernia has been described as a potential mechanism, a postoperative hematoma contained within a hiatal hernia is exceptionally rare. We present a case in which transthoracic echocardiography (TTE) provided a particularly instructive image by directly demonstrating left atrial compression and clarifying the mechanism of immediate postoperative instability.</div></div><div><h3>Method</h3><div>We describe the perioperative course and multimodality imaging findings of a 78-year-old man who underwent elective laparoscopy colonic resection for transversus cancer within a giant hiatal hernia. Relevant comorbidities included hypertension, dyslipidemia, prior ischemic heart disease treated with percutaneous coronary intervention, preserved left ventricular ejection fraction, and previously treated prostate cancer. In the immediate postoperative period, hypotension and progressive anemia prompted urgent bedside evaluation with TTE, followed by confirmatory computed tomography.</div><div>The patient developed immediate postoperative hypotension accompanied by progressive anemia. TTE, performed as part of the urgent hemodynamic assessment, revealed a mass causing marked extrinsic compression of the left atrium, suggesting impaired cardiac filling as a contributor to the clinical deterioration. Computed tomography subsequently demonstrated a mesenteric hematoma adjacent to the colo-colonic anastomosis, with low-flow active bleeding and moderate hemoperitoneum, along with an additional hematoma component extending into a large sliding hiatal hernia. Correlation of the TTE and CT findings established that the lesion compressing the left atrium was a hematoma contained within the hiatal hernia . Following multidisciplinary discussion, the patient was managed conservatively. Unsuccessful attempt to place a nasogastric tube. Three blood cell products were administered. Goal-directed fluid therapy and positional management were established with a favorable clinical outcome.</div></div><div><h3>Conclusion</h3><div>This case highlights a rare cause of postoperative hemodynamic instability: extrinsic left atrial compression by a hematoma contained within a giant hiatal hernia. The main educational value of the poster lies in the TTE image, which provides a clear and compelling demonstration of the relationship between an intrathoracic extracardiac mass and impaired cardiac filling. In patients with postoperative bleeding and a large hiatal hernia, intrathoracic extension of a hematoma should be considered when the clinical picture is not fully explained by abdominal findings alone. TTE may be especially valuable when rapid functional assessment is required and can yield highly instructive images for perioperative, cardiac, and critical care practice.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 33-34"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006803","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":"Complex Management of Mitral and Aortic Valve Replacement with CABG for Infective Endocarditis: A Case of Challenging CPB Wean and Post-operative Recovery","authors":"Dr Stephen McAleer","doi":"10.1053/j.jvca.2026.08.075","DOIUrl":"10.1053/j.jvca.2026.08.075","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Introduction&lt;/h3&gt;&lt;div&gt;A 67-year-old male with a history of aortic arch surgery (debranching of the aortic arch and TEVAR for proximal descending aortic aneurysm in 2016) presented with severe decompensated heart failure, secondary to native valve infective endocarditis caused by Enterococcus faecalis. The patient had severe mitral regurgitation, moderate aortic regurgitation, and dilated ventricles with impaired systolic function. Despite six weeks of antibiotic therapy, he required high-risk surgery due to significant valve damage. Pre-operative echocardiography revealed elevated pulmonary pressures.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Method&lt;/h3&gt;&lt;div&gt;The patient underwent Mitral Valve Replacement with a 29mm Hancock modified orifice II biological valve, Aortic Valve Replacement with a 21mm Avalus biological valve, and Coronary Artery Bypass Grafting x2. The surgery involved extended cardiopulmonary bypass lasting 11.5 hours, with deep hypothermic circulatory arrest at 20°C and antegrade cerebral perfusion, necessitated by dense adhesions from prior aortic arch surgery. The mitral valve was excised via a transseptal approach, and both valves were replaced using biological prostheses. A vein graft was harvested from the left leg for the RCA bypass, with the graft connected to the innominate artery due to the lack of space on the aorta. Intraoperative complications included difficult weaning from CPB, requiring extensive inotropic and mechanical support.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Intra-operative Challenges&lt;/h3&gt;&lt;div&gt;During CPB weaning, the patient exhibited heart block and junctional rhythm, with both right and left ventricles showing hypokinetic behaviour. The right femoral vessels were cannulated for arterial return, and the chest was left open post-operatively due to haemodynamic instability. Intra-operative support included IABP and vasopressors and inotropes to support cardiac output. The patient required transfusion of 19 units of RBC, 6 units of platelets, and 6 units of FFP, along with cryoprecipitate and fibrinogen to manage bleeding.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Post-operative Course&lt;/h3&gt;&lt;div&gt;The patient had a challenging post-operative period, including acute renal failure requiring continuous venovenous hemofiltration, severe RV systolic dysfunction, and ongoing inotropic support. His post-operative management included IABP for haemodynamic support, as well as aggressive vasopressor and inotropic therapy: adrenaline, noradrenaline, milrinone, dopamine, argipressin, levosimendan, and inhaled nitric oxide. After 48 hours, IABP was weaned. The patient's chest was closed on the third post-operative day, and efforts to wean ventilatory and inotropic support continued.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Result&lt;/h3&gt;&lt;div&gt;His clinical status stabilised with improved renal function, normalised electrolytes, and resolution of sepsis. Post-operative day 9, a tracheostomy was performed due to critical illness myopathy and ventilator dependency.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;T","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"40 10","pages":"Pages 61-62"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149006918","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}