Survival with acute cardiopulmonary failure remains a formidable challenge despite advances in mechanical circulatory support (MCS). Although venoarterial extracorporeal membrane oxygenation (ECMO) provides combined cardiopulmonary support, patients with improving cardiac function and persistent respiratory failure may no longer require arterial ECMO. We describe our early experience using a combine venovenous (VV) ECMO and Impella 5.5 (VVECPella) as a de-escalation strategy in this setting. We report a series of five patients supported with the VVECPella configuration at our institution from January 2025 to January 2026. Impella 5.5 was implanted via axillary, innominate, or direct ascending grafts. Operative details, hospital course, and patient outcomes were retrospectively reviewed. In total, five patients underwent VVECPella support. The most common indication was persistent severe respiratory failure despite improving hemodynamics following cardiogenic shock. Median VV ECMO duration was 4 days (range 1-8), Impella support 6 days (3-15), and combined support 4 days (2-8). Four patients (80%) were successfully weaned from both devices with recovery of cardiac and respiratory function, while one patient died from multiorgan failure. Major hemolysis occurred in 3 patients (60%), whereas vascular complications were attributable to prior VA ECMO cannulation rather than the VVECPella configuration. In conclusion, VVECPella appears to be a feasible de-escalation strategy for carefully selected patients with improving circulatory failure but persistent respiratory insufficiency, allowing independent titration of cardiac and respiratory support while avoiding prolonged arterial ECMO. Larger multicenter studies are warranted.
Early postoperative risk stratification after surgical aortic valve replacement remains challenging in patients with severe aortic stenosis and reduced left ventricular ejection fraction. Although postoperative troponin elevation is expected after open-heart surgery, the discriminatory value of ICU admission high-sensitivity cardiac troponin T (hs-cTnT) in this specific myocardial phenotype remains uncertain. We evaluated whether ICU admission hs-cTnT provides useful early discrimination for 30-day all-cause mortality after surgical aortic valve replacement in patients with severe aortic stenosis and reduced left ventricular ejection fraction and compared its performance with other postoperative ICU biomarkers. We conducted a single-center retrospective cohort study of 184 adults with severe aortic stenosis and left ventricular ejection fraction ≤40% who underwent surgical aortic valve replacement between 2020 and 2024 and had complete 30-day follow-up. ICU admission hs-cTnT was available in 183 patients. Biomarkers included ICU admission hs-cTnT, ICU admission lactate, peak ICU C-reactive protein, and ICU admission B-type natriuretic peptide. Discrimination was assessed using receiver operating characteristic analysis, DeLong comparisons, repeated stratified 5-fold cross-validation, and bootstrap optimism correction. Multivariable models were interpreted as exploratory because of the limited number of mortality events. Thirty-day mortality occurred in 29 of 184 patients (15.8%). ICU admission hs-cTnT showed poor discrimination for 30-day mortality in the hs-cTnT analytic cohort and remained non-discriminatory after repeated cross-validation. In the common four-biomarker cohort, lactate outperformed hs-cTnT by DeLong testing, whereas the four-biomarker model did not significantly improve discrimination beyond lactate alone. Bootstrap optimism correction attenuated the apparent performance of multimarker models, supporting cautious interpretation. Exploratory analyses also suggested that mortality did not increase monotonically across hs-cTnT quartiles. In patients with severe aortic stenosis and reduced left ventricular ejection fraction undergoing surgical aortic valve replacement, ICU admission hs-cTnT did not provide reliable early mortality discrimination. Lactate remained the strongest early individual biomarker, whereas multimarker models showed exploratory discrimination but require external validation. These findings support a phenotype-specific interpretation of postoperative hs-cTnT rather than reliance on universal postoperative troponin assumptions.
Implantable cardioverter-defibrillators (ICDs) are critical for the prevention of sudden cardiac death due to ventricular arrhythmias and are commonly encountered in the perioperative space. Traditional devices contain transvenous leads that are susceptible to mechanical failure or infection. To reduce these complications, two entirely extravascular ICDs are currently approved for implantation: the subcutaneous Emblem MRI S-ICD and the extravascular Aurora EV-ICD. This article provides an evidence-based review of the indications for use, implantation technique, and anesthetic considerations for these novel systems.
Penetrating chest injuries are associated with high mortality because visceral and vascular structures are situated close together, and injury to these can be devastating due to the limited time for resuscitation. Such injuries often cause massive hemorrhage, tension pneumothorax, hemothorax, cardiac tamponade, or direct penetration of the heart and great vessels. Survival in penetrating chest injuries involving the heart, especially with delayed hospital presentation, is very uncommon. The mechanism of penetration significantly influences the diagnostic approach and necessary interventions. Bedside POCUS protocols, such as eFAST, RUSH, and BLUE, enable immediate resuscitation before further investigations. High-velocity injuries like gunshots and crossbow bolts are linked to high mortality due to rapid tissue destruction caused by kinetic energy transfer. Certain pathological conditions, such as cardiac tamponade or effusion, may sometimes be beneficial in these injuries. We present a case of an accidental penetrating arrow injury to the chest, piercing the heart, yet the patient survived after more than three days of delayed transfer to higher care with hemopneumothorax and mediastinal involvement. Survival after a penetrating chest injury through the heart is very rare. Prompt, rapid resuscitation with a multidisciplinary approach can improve outcomes. However, the prognosis depends on factors such as the type and location of the injury, the speed of medical response, the presence of cardiac tamponade, and the patient's pre-existing clinical condition.
Alpha-gal syndrome (AGS) is an IgE-mediated hypersensitivity to galactose-α-1,3-galactose, an oligosaccharide found in mammalian tissues, including bovine or porcine-derived bioprosthetic valves and heparin. Concerns exist regarding perioperative hypersensitivity reactions in patients with AGS undergoing cardiac surgery involving xenogeneic materials. We present three patients with documented AGS who underwent transcatheter aortic valve replacement (TAVR) using bovine or porcine-derived bioprostheses. All patients underwent a preoperative evaluation by allergists, and two received no pharmacological pre-treatment. Intraoperative heparin administration was without adverse reactions in all cases. Postoperative courses were uncomplicated, with no evidence of immediate or delayed allergic responses. Follow-up periods ranged from 4 to 6 years without structural valve deterioration attributable to AGS. These cases demonstrate that patients with AGS can safely undergo TAVR with bovine or porcine-derived valves and heparin, provided they are appropriately evaluated and monitored. Despite theoretical concerns, perioperative hypersensitivity appears to be rare in this population, supporting the feasibility of xenogeneic valve use in AGS patients.
ObjectivesVasopressor choice potentially contributes to postoperative delirium due to differences in end-organ perfusion. This study seeks to determine the rates of postoperative delirium after perioperative phenylephrine, ephedrine, or norepinephrine administration.DesignRetrospective, propensity-score matched multicenter database study.ParticipantsPatients aged 60 and older undergoing surgery of the integumentary, musculoskeletal, respiratory, hematologic/lymphatic, gastrointestinal, genitourinary/reproductive, endocrine, or sensory organ systems.InterventionsPerioperative vasopressor administration (phenylephrine, ephedrine, norepinephrine).Measurements and Main ResultsThe primary outcome was the incidence of postoperative delirium based on ICD-10 diagnostic codes within seven days of surgery. After propensity score matching, there was no difference in the rate of postoperative delirium between phenylephrine and norepinephrine (OR 0.97; 95% CI 0.61-1.54; P = .9065) or between ephedrine and norepinephrine (OR 0.74; 95% CI 0.41-1.32; P = .3062). Phenylephrine was associated with a higher rate of postoperative delirium when compared to ephedrine (OR 1.30; 95% CI 1.05-1.60; P = .0162), although absolute risk difference was small (0.05%).ConclusionsThis study highlights the potential influence of vasopressor selection on postoperative neurocognitive outcomes in older adults. Understanding the physiologic and pharmacologic mechanisms underlying these associations may help guide individualized intraoperative management and reduce delirium risk in clinical practice.
High-dose opioid use in cardiac anesthesia has been challenged due to its association with increased postoperative complications. We retrospectively compared postoperative opioid consumption in a cohort of adult cardiac surgery patients who received low, moderate, or high doses of intraoperative opioids. We also examined variability in intraoperative opioid use among cardiac anesthesiologists. Within our cohort, we categorized patients into "lower opioid recipients" (LOR), "mid opioid recipients" (MOR), or "higher opioid recipients" (HOR) based on the distribution of intraoperative opioids administered in morphine milligram equivalents (MME) within our cohort. After summarizing their demographics and clinical characteristics, we assessed the association between their intraoperative opioid dose group and our outcomes of interest including postoperative opioid consumption. A total of 6390 patients who underwent cardiac surgery between 2014 and 2022 met our inclusion criteria. Our multivariable models indicated that the HOR group was significantly associated with less postoperative opioid consumption relative to the LOR (MME: Mean Ratio (MR) = 0.51 (0.47, 0.56), P < 0.001; MME/kg: MR = 0.51 (0.48, 0.55), P < 0.001) and the MOR (MME: MR = 0.53 (0.50, 0.57), P < 0.001; MME/kg: MR = 0.55 (0.55 (0.51, 0.58), P < 0.001). Among patients undergoing elective adult cardiac surgery, higher doses of intraoperative opioids were associated with lower postoperative opioid consumption. Marked variability in opioid administration was observed among cardiac anesthesiologists, where higher intraoperative opioid use remains a common practice. This highlights the need for precise distinction between high and low dose opioid techniques.
The t-test is a mainstay statistical test that allows researchers to use the observed averages (arithmetic means) of data samples to draw evidence-supported conclusions about the corresponding averages in the populations they represent. This article serves as an introduction to this common and useful technique for clinicians with a limited statistical background, who seek to deepen their understanding of the t-test, its reasoning, and its implications in clinical research. We describe the three basic forms of the t-test, its applications and alternatives, and some related concepts while avoiding technical concepts and jargon as much as possible.
The objective of this study is to discuss the implementation, safety, and potential benefits of on-table extubation (OTE) in surgeries involving hypothermic circulatory arrest (HCA). A retrospective analysis of all consecutive cases involving HCA from 2021 to 2024 was completed. The setting of this study is a single, tertiary academic medical center. All cardiac surgery patients undergoing HCA during the study period were evaluated for inclusion in this study. The intervention in this study was the implementation of OTE in patients undergoing HCA. Twelve out of 85 (14%) patients underwent OTE following HCA. In this cohort, there were no post-operative reintubations, major complications, or mortalities. The median intensive care unit (ICU) length of stay was 21.5 hours, and the median duration of hospitalization was 6.6 days. Patients undergoing fast track extubation (FTE) (extubation within 6 hours post-operatively), or extubation >6 hours had a median ICU length of stay of 42.1 hours (P = 0.12) and 91.8 hours (P < 0.01) and a hospital length of stay of 5.0 days (P = 0.03) and 11.5 days (P = 0.02), respectively. There were no reintubations or mortalities in the FTE group, and five reintubations and ten mortalities in the >6 hour group. OTE in patients undergoing HCA is feasible and demonstrated minimal post-operative complications in our cohort. Consideration of these cases for OTE may improve outcomes and appears to be safe in select patients. Centers experienced with OTE should consider internal evaluation of their readiness to broaden OTE to traditionally more "high-risk" populations on a case-by-case basis.
Lung transplantation presents numerous intraoperative challenges, particularly related to pulmonary artery and vein anastomotic integrity and hemodynamic stability. We present 3 cases where intraoperative transesophageal echocardiography (TEE) provided real-time diagnostic insights that directly altered surgical decision-making. Case 1 highlights pulmonary vein flow acceleration initially concerning for ostial stenosis, ultimately diagnosed as external compression from a retractor. Case 2 demonstrates true right pulmonary vein stenosis requiring immediate revision. Case 3 illustrates severe right pulmonary artery narrowing, detected by TEE and corrected intraoperatively to prevent early graft dysfunction. These cases underscore the critical role of intraoperative TEE in detecting subtle anastomotic abnormalities, distinguishing functional from structural stenosis, and guiding timely surgical correction. Incorporating comprehensive 2D and 3D TEE evaluation into routine lung transplant protocols enhances diagnostic accuracy, reduces postoperative complications, and contributes to improved long-term allograft function. Intraoperative 3D TEE should be considered an essential imaging modality in cardiothoracic transplantation and an invaluable educational tool for perioperative teams.
This article reviews noteworthy literature published in 2025 pertinent to the care of critically ill cardiothoracic surgical patients. We reviewed over 9000 articles to identify 12 publications that provided new or supportive evidence on a diverse range of topics including the management of cardiogenic shock, pulmonary and renal failure, precision immunotherapy in sepsis care, and resuscitation. Additional topics included outcomes following mechanical thrombectomy and methods of hemodynamic monitoring.
This review highlights the published literature in 2025 that pertains to the anesthetic management of patients with congenital heart disease. Four major themes are discussed: (i) anesthesia for adults with congenital heart disease (ii) perioperative blood management and cardiopulmonary bypass-associated decision-making (iii) enhanced recovery after cardiac surgery and (iv) noncardiac procedural safety and workforce sustainability.
Noteworthy in Cardiothoracic Surgery 2025 highlights several of the most influential trials and emerging trends shaping cardiothoracic surgical practice. In structural heart disease, new randomized data have expanded consideration of transcatheter aortic valve replacement to asymptomatic patients while reinforcing the importance of longer-term durability and lifetime valve management in lower-risk populations. In heart transplantation, advances in minimally invasive and robotic techniques, alongside growing international experience with donation after circulatory death, underscore both the promise of innovation and the need for disciplined management of ischemic and preservation times. Endovascular management of complex thoracic aortic disease continues to evolve with broader use of branched devices. In thoracic oncology, practice changing trials support a shift towards perioperative chemotherapy and immunotherapy for resectable esophageal, gastroesophageal junction, and lung cancers, redefining surgical timing, coordination, and multidisciplinary care. Finally, continued adoption of minimally invasive and robotic approaches reflects a broader trend toward reducing surgical morbidity while maintaining oncologic and transplant outcomes.
Preoperative cardiorespiratory fitness, muscle strength, and frailty influence outcomes after cardiac surgery, but these modifiable physical factors are often not routinely incorporated into standardized risk assessments. This study examined the association between preoperative physical fitness and adverse postoperative outcomes across different elective cardiac surgery procedures. Logistic regression analyses were used to assess the association between preoperative cardiorespiratory fitness, muscle strength, functional mobility, frailty, and quality of life and delayed postoperative recovery of physical functioning (Modified Iowa Level of Assistance Scale), in-hospital complications, and postoperative atrial fibrillation in patients undergoing cardiac surgery via sternotomy, mini-thoracotomy, and transfemoral incision (transcatheter aortic valve implantation). Results showed that higher patient-reported preoperative cardiorespiratory fitness, functional mobility, frailty, and physical health-related quality of life were significantly associated with faster recovery of physical functioning and fewer postoperative complications in patients undergoing sternotomy. In patients undergoing mini-thoracotomy, preoperative cardiorespiratory fitness and functional mobility were significantly associated with in-hospital complications. No significant associations were found in patients undergoing transfemoral incision (transcatheter aortic valve implantation). Conclusively, preoperative physical fitness is associated with postoperative outcomes in patients undergoing sternotomy. These findings highlight the importance of incorporating physical fitness assessments into standard preoperative care to facilitate preoperative shared decision-making and optimize modifiable preoperative risk factors.
The left internal mammary artery (LIMA) is commonly selected as the graft of choice for coronary artery bypass procedures. Various pharmacological agents have been used to enhance LIMA blood flow. Left stellate ganglion block (LSGB) has been utilized to achieve sympathetic blockade, promote vasodilation in the upper extremities, and manage refractory angina. This randomized controlled clinical trial aimed to evaluate the effect of preoperative LSGB on LIMA blood flow in patients undergoing elective coronary artery bypass grafting (CABG). Seventy patients (aged 18-80 years, of both genders) scheduled for elective CABG were equally divided into two groups: the LSGB group and the control group. Patients in the intervention group received an ultrasound-guided LSGB using 8 mL of 0.25% bupivacaine. Both groups received topical nitroglycerin during LIMA harvesting. LIMA diameter was measured at baseline and again after an equal time interval before the induction of anaesthesia. Additionally, LIMA free flow after harvesting and mean graft flow were measured using a transit time flow metre (TTFM). LIMA free blood flow was significantly increased in the LSGB group (50.57 ± 5.79 mL/min) compared to the control group (46.86 ± 8.32 mL/min), with a P-value = 0.034. Similarly, the LIMA diameter was significantly greater in the LSGB group (2.38 ± 0.17 mm) than in the control group (2.31 ± 0.14 mm), with a P-value = 0.04, suggesting that preoperative LSGB significantly enhances LIMA blood flow and diameter in patients undergoing CABG.
. This single-center prospective observational study aimed to assess the correlation of net atrioventricular compliance (Cn) with pulmonary artery pressure in 26 adult patients with severe mitral stenosis (MS) undergoing surgical mitral valve replacement (MVR). Cn was estimated by doppler echocardiography, and pulmonary artery pressures measured by pulmonary artery catheter. Early outcomes including duration of intensive care unit (ICU) stay, mechanical ventilation duration, and vasoactive inotropic scores (VIS) were recorded. Cn showed moderate to strong negative correlation with systolic, diastolic, and mean pulmonary artery pressures at all time points. Receiver operating characteristic (ROC) curve analysis determined a cut-off of 2.31 to predict postoperative pulmonary artery systolic pressure. Cn with a cut-off value of 2.3 ml/mmHg serves as an indicator of persistent pulmonary hypertension following MVR surgery.
We present the case of a 73-year-old female with chemotherapy-induced cardiomyopathy, severe mitral regurgitation status post bioprosthetic mitral valve (MV) replacement one year prior, and atrial fibrillation, admitted for evaluation for left ventricular assist device (LVAD) implantation. While her preoperative transthoracic echocardiogram (TTE) did not reveal a discrete mass, it showed a mean mitral gradient of 7 mmHg; intraoperative transesophageal echocardiography (TEE) identified a 2 cm × 1.2 cm thrombus on the bioprosthetic MV. Given these findings, the surgical team decided to replace the mitral valve concurrently with LVAD implantation. Although this approach is not routine, the goal was to improve her quality of life and reduce postoperative complications. Post-procedure TEE showed an improved MV mean gradient of 3 mmHg with no evidence of paravalvular leak. The patient was subsequently discharged home in stable condition without any thromboembolic events. This case highlights the challenges of managing complex valvular pathology in patients undergoing LVAD placement.
PurposeThis study quantified trends and regional disparities in cardiothoracic anesthesia procedures across China from 2016 to 2023, assessing workforce adequacy to inform policy development.MethodsData were extracted from the White Book of Chinese Cardiovascular Surgery and standardized monthly reports of the Chinese Society of Cardiothoracic and Vascular Anesthesiology (CSCTVA). Cardiac anesthesia volumes reflected national aggregates, while thoracic anesthesia data derived from 100 CSCTVA member hospitals. Regional economic stratification (GDP tiers) and workforce surveys from top-tier centers complemented procedural analyses.ResultsCardiac anesthesia procedures increased by 25% (2016: 158,268 and 2023: 197,937), with cardiopulmonary bypass utilization growing at 13.3% CAGR. Thoracic anesthesia volumes tripled from 114 460 in 2016 to 301 412 in 2023, coinciding with a rise in minimally invasive techniques from 67% to 91.4% of all procedures. Significant regional disparities emerged: High-GDP regions exhibited fivefold greater thoracic surgery density (52.26 vs 10.56 per 100 000; P < .01). Top 10 centers performed 32%-42% of thoracic procedures, yet a 60.5% workforce expansion lagged demand, yielding sub-optimal doctor-patient ratios (e.g., 1:4.7).ConclusionsRapid growth in cardiothoracic anesthesia is juxtaposed with persistent geographic inequities and critical workforce shortages. Strategic interventions are urgently needed to ensure equitable access; these findings establish a comprehensive baseline framework for hypothesis-driven research on health system optimization.
