Objective:Optimal anticoagulation during bilateral lung transplantation (BOLTx) supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) remains uncertain. We compared outcomes among zero-heparin (ZH), low-intensity heparin (LIH), and high-intensity heparin (HIH) strategies during intraoperative VA-ECMO-supported BOLTx. Methods:A retrospective pilot study of 59 consecutive patients undergoing BOLTx with intraoperative VA-ECMO at Vanderbilt University Medical Center between November 1, 2024, and May 1, 2025, was performed. Patients were stratified according to intraoperative anticoagulation strategy: ZH (no intraoperative anticoagulation; n = 22), LIH (single bolus ≤2000 units without continuous infusion; n = 16), and HIH (single bolus >2000 units followed by heparin infusion 200-500 units/hour; n = 21). The primary outcome was thromboembolic events within 90 days after transplantation, including stroke, myocardial infarction (MI), pulmonary embolism, deep venous thrombosis (DVT), and intraoperative vascular anastomotic thrombosis. Secondary outcomes included estimated blood loss, transfusion requirements, extracorporeal membrane oxygenation circuit thrombosis, primary graft dysfunction at 72 hours, hospital length of stay, and in-hospital mortality. Results:Of the 59 patients, 31 (52.5%) experienced thromboembolic complications within 90 days (HIH: 14/31, 45.2%; LIH: 9/31, 29% and ZH: 8/31, 25.8%). This included 26 DVTs (HIH:11, LIH: 8, ZH:7) detected on routine surveillance imaging at POD 7. Therapeutic anticoagulation for DVT was initiated for 8 of 11 in the HIH, 5 of 8 in the LIH and 4 of 7 in the ZH groups Two patients had strokes (HIH: 1 on POD 11, LIH: 1 on POD 83), 2 patients with pre-existing coronary artery disease experienced an MI (HIH:1 on POD 1, ZH:1 on POD 3) that required PCI, and 1 patient had evidence of an intraoperative vascular anastomotic clot (HIH: 1) that was easily flushed out after lung reperfusion. No extracorporeal membrane oxygenation circuit or oxygenator thrombosis were noted in any of the groups. Operative duration and transfusion requirements for red blood cells and fresh frozen plasma were greater in the HIH group (P = .010 and P = .044, respectively), whereas lung ischemic time, primary graft dysfunction, estimated blood loss, and other transfusion requirements were similar across groups (all P > .05). Conclusions:In this single-center cohort, intraoperative VA-ECMO without heparin was feasible and was not associated with an observed increase in early thromboembolic events compared with other anticoagulation strategies. Larger prospective studies are warranted.

BACKGROUND:Donation-after-circulatory-death (DCD) heart transplantation remains constrained by warm ischemic injury, particularly the asystole-to-reperfusion interval (AWIT). We evaluated whether intraoperative oxygen debt-summarized by oxygen extraction ratio (O₂ER), a physiologic substrate for goal-directed perfusion (GDP)-is associated with early outcomes and modifies risk among prolonged-AWIT grafts. METHODS:Adult DCD heart transplant recipients recovered using thoracoabdominal normothermic regional perfusion (TA-NRP) from October 2021 to February 2025 were retrospectively analyzed. O₂ER (VO₂i/DO₂i) was computed from minute-by-minute cardiopulmonary bypass (CPB) records; burden was quantified as cumulative minutes with O₂ER >20% and dichotomized at the cohort mean (≤70 vs >70 min). Patients were stratified by AWIT (<10 vs ≥10 min). Outcomes included severe primary graft dysfunction (PGD), 90-day mortality, and a composite morbidity-mortality endpoint. Associations were estimated using inverse-probability weighting and weighted Firth-penalized logistic regression with dose-response modeling. RESULTS:Among 112 recipients, 40 (36%) had prolonged AWIT. The prolonged-AWIT/high-O₂ER group (n = 18) had the highest incidence of severe PGD (22%), 30-day mortality (17%), and 90-day mortality (22%). Within prolonged-AWIT recipients, lower O₂ER burden (≤70 min) was associated with reduced odds of severe PGD (OR 0.09, 95% CI 0.07-0.87) and the composite endpoint (OR 0.13, 95% CI 0.07-0.54). Continuous modeling demonstrated consistent directional associations between increasing O₂ER burden and adverse outcomes. CONCLUSIONS:Intraoperative O₂ER burden was jointly associated with early graft dysfunction and mortality, particularly in the setting of prolonged AWIT. These hypothesis-generating findings support the potential role for GDP strategies that minimize intraoperative oxygen debt to mitigate warm ischemic vulnerability in DCD heart transplantation.

OBJECTIVES:Goal-directed perfusion strategies during cardiopulmonary bypass typically target indexed oxygen delivery thresholds to reduce acute kidney injury and other complications. This delivery-only paradigm may not fully reflect patient-specific metabolic demand. The oxygen extraction ratio integrates delivery and consumption and may better reflect perfusion adequacy. We tested the hypothesis that intraoperative oxygen extraction ratio is associated with postoperative outcomes. METHODS:We retrospectively analyzed 885 adults who underwent isolated coronary artery bypass grafting (October 2021 to July 2025). Unsupervised clustering identified distinct extraction ratio trajectory phenotypes. Baseline, intraoperative, and postoperative variables were compared across phenotypes, and weighted logistic models assessed associations with Society of Thoracic Surgeons major morbidity or mortality and acute kidney injury. An exploratory subgroup analysis evaluated whether maintaining higher indexed oxygen delivery mitigated risk in patients with elevated extraction ratio. RESULTS:Three oxygen extraction ratio trajectories were identified: low (mean 21%), moderate (mean 23%), and high (mean (24.4%). Patients with high extraction ratio had more anemia, diabetes, and heart failure and lower average oxygen delivery. After adjustment for baseline risk, high extraction ratio was associated with greater morbidity and mortality (odds ratio, 2.04 [1.5-2.8], P < .001) and acute kidney injury (odds ratio, 1.6 [1.2-2.1], P < .001). In the high extraction ratio group, maintaining an indexed oxygen 300 mL/min/m2 or greater for 92% or more of cardiopulmonary bypass time would have relatively reduced the incidence of acute kidney injury (relative risk reduction, 66.8%; 13.9-97.9) and morbidity and mortality (63.8%; 15.2-96.8). CONCLUSIONS:Elevated oxygen extraction ratio was independently associated with postoperative morbidity and acute kidney injury. Incorporating extraction ratio into goal-directed perfusion frameworks may enable a more individualized, physiology-guided perfusion strategy.

OBJECTIVE:To determine the relationship between the intraoperative lowest measured temperature (LMT) during cardiac surgery using cardiopulmonary bypass (CPB) and the risk for postoperative stroke. Secondarily, to determine the association between LMT and the risk for 30-day mortality and other adverse outcomes. BACKGROUND:The effectiveness of deliberate hypothermia during CPB for the prevention of cardiac surgery-associated stroke and adverse outcomes remains uncertain. METHODS:This cohort study from the Society of Thoracic Surgeons Adult Cardiac Surgery Database included 1,847,808 patients who underwent coronary artery bypass graft surgery, valve surgery, and combined coronary artery bypass graft-valve procedures between July 1, 2011 and March 1, 2022. Using propensity score-weighted regression analysis, we analyzed the effect of LMT on the incidence of postoperative stroke and other adverse outcomes. Since the relationship between LMT and the examined outcomes was nonlinear, LMT was treated as a continuous variable. RESULTS:In risk-adjusted analyses, no association was observed between the LMT and the primary outcome of postoperative stroke ( P =0.316). For the secondary outcomes, encephalopathy or coma ( P =0.649) or 30-day mortality ( P =0.691) were also not associated with lower LMT. Acute kidney injury ( P <0.001) was less common with lower and more common with higher LMTs. Pneumonia ( P =0.002) was less common, yet reoperation for bleeding ( P <0.001) was more common with higher LMTs. CONCLUSIONS:Hypothermia during CPB did not alter the risk of postoperative stroke. Secondary outcomes varied in their directionality of association with temperature, indicating that certain cardiac surgery patients may benefit, but others could be harmed by routine therapeutic hypothermia during CPB.

Solid organ transplant is associated with high rates of anaemia and transfusion, but there is little comparative data on interventions such as erythropoietin-stimulating agents (ESAs) and intravenous (IV) iron. We conducted a systematic review examining the association of ESAs and IV iron with outcomes in adults undergoing solid organ transplant. This review was registered with PROSPERO (CRD42023474722). EMBASE and MEDLINE were searched from inception to April 11, 2025. Identified studies included adults (≥18 years of age) undergoing heart, liver, lung, or kidney transplant who received any ESA and/or IV iron before, during, or up to 1 month following solid organ transplant surgery compared to patients who did not. Article screening, full text review and data extraction were performed by two independent reviewers. The primary outcome of interest was transfusion volume, with secondary outcomes including haematological parameters, graft-related outcomes and rates of major morbidity and mortality. Results were analysed descriptively and compiled into tables, and the risk of bias was assessed using the CLARITY framework. From 1693 studies identified, 22 were included (kidney transplant, n = 16; heart transplant or Left Ventricular Assist Device as a bridge to transplant, n = 4; liver transplant, n = 2). Due to heterogeneity in design, interventions and outcomes, meta-analysis was not attempted. The quality of evidence was graded as Very Low. On the whole, a comprehensive strategy implementing ESAs and IV iron may improve haematological parameters and facilitate transfusion avoidance. High-quality prospective studies assessing the impact of protocols for haemoglobin optimisation and transfusion avoidance in solid organ transplant are needed.

To determine the relationship between intraoperative lowest measured temperature (LMT) during cardiac surgery using cardiopulmonary bypass (CPB) and the risk for postoperative stroke. Secondarily, to determine the association between LMT and risk for 30-day mortality and other adverse outcomes. The effectiveness of deliberate hypothermia during CPB for the prevention of cardiac surgery-associated stroke and adverse outcomes remains uncertain. This cohort study from the Society of Thoracic Surgeons Adult Cardiac Surgery DatabaseTM included 1,847,808 patients who underwent coronary artery bypass graft surgery (CABG), valve surgery, and combined CABG-valve procedures between July 1, 2011, to March 1, 2022. Using propensity score-weighted regression analysis, we analyzed the effect of LMT on the incidence of postoperative stroke and other adverse outcomes. Since the relationship between LMT and the examined outcomes was non-linear, LMT was treated as a continuous variable. In risk adjusted analyses, no association was observed between the LMT and the primary outcome of postoperative stroke (P=0.316). For the secondary outcomes, encephalopathy or coma (P=0.649), or 30-day mortality (P=0.691) were also not associated with lower LMT. Acute kidney injury (P<0.001) was less common with lower and more common with higher LMTs. Pneumonia (P=0.002) was less common, yet reoperation for bleeding (P<0.001) was more common with higher LMTs. Hypothermia during CPB did not alter the risk of postoperative stroke. Secondary outcomes varied in their directionality of association with temperature, indicating that certain cardiac surgery patients may benefit, but others could be harmed by routine therapeutic hypothermia during CPB.

Venoarterial extracorporeal membrane oxygenation is increasingly used for mechanical circulatory support during lung transplant. Optimal intensity of intraoperative anticoagulation would be expected to mitigate thromboembolism without increasing bleeding and blood product transfusions. Yet, the optimal intensity of intraoperative anticoagulation is unknown. We performed a retrospective cohort study of 163 patients who received a bilateral lung transplant at a single center. We categorized the intensity of anticoagulation into 4 groups (very low to high) based on the bolus dose of unfractionated heparin given during lung transplant and compared the rates of intraoperative blood transfusions and the occurrence of thromboembolism between groups. When compared to the very low-intensity group, each higher intensity group was associated with higher red blood cell, fresh frozen plasma, and platelet transfusions. The occurrence of thromboembolism was similar across groups. These preliminary data suggest that lower intensity anticoagulation may reduce the rate of intraoperative blood transfusions, although further study is needed.

Cardiac surgery is associated with numerous peri- and post-operative haemostatic complications and blood transfusion requirements. Complex procedures such as redo-sternotomy heart transplantation or type A aortic dissection repairs are at high-risk for severe coagulopathy and significant transfusion requirements. However, current practice guidelines do not specifically address high-risk surgeries, resulting in variable practice. To optimise outcomes, a multidisciplinary approach to blood transfusion and haemostasis is critical. How individual institutions construct these multidisciplinary teams, delegate responsibilities, and build procedures may differ depending on the institution and availability of resources. In this article, we compare how the transfusion medicine services support their cardiac surgery and transplant programs at three large medical centres-Vanderbilt University Medical Center (the largest heart transplant centre in the world by volume in 2021), Toronto General Hospital-University Health Network (a quaternary-care centre in Canada's most populous city, performing more >20 heart transplants annually), and Vancouver General Hospital (a quaternary-care centre that performs numerous high-risk cardiac surgeries). This article discusses management from multiple perspectives, including the blood bank and perioperative environments, and highlights how institutions have evolved their programs in accordance with nation-specific policies and provisions.

We appreciate the letter and comments from Condello and Condello 1 Condello I. Condello S. “The research of the angels’ sex!” Postoperative delirium and cardiopulmonary bypass correlation. Ann Thorac Surg. 2023; 115: 796-797 Abstract Full Text Full Text PDF Scopus (2) Google Scholar in response to our publication on the association between intraoperative processed electroencephalogram (pEEG) use and adverse neurologic outcomes after cardiac surgery. 2 Lombard F.W. Roy S. Shah A.S. Feng X. Shotwell M.S. Kertai M.D. Processed electroencephalographic use during anesthesia and outcomes: analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2022; 114: 1688-1694 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Using data from The Society of Thoracic Surgeons National Database, collected between 2017 and 2019, we found no association between pEEG use and adverse neurologic outcomes. As we pointed out in our paper, and echoed by Drs Condello, 1 Condello I. Condello S. “The research of the angels’ sex!” Postoperative delirium and cardiopulmonary bypass correlation. Ann Thorac Surg. 2023; 115: 796-797 Abstract Full Text Full Text PDF Scopus (2) Google Scholar the causes of neurologic complications are multifactorial. They therefore suggest that multiple monitoring modalities may be required. We agree, and are in fact planning a further more extensive study to similarly examine the association between cerebral near-infrared spectroscopy (NIRS) use and adverse neurologic outcomes after cardiac surgery. “The Research of the Angels’ Sex!” Postoperative Delirium and Cardiopulmonary Bypass CorrelationThe Annals of Thoracic SurgeryVol. 115Issue 3PreviewPostoperative delirium (POD) after cardiac surgery with cardiopulmonary bypass is a major problem. Potential pathways of delirium include neurotransmitter interference, global cognitive disorder, and neuroinflammation. The development of delirium after cardiac surgery is associated with worse outcomes in the perioperative period. Multiple interventions are being explored for the prevention and treatment of delirium. In cardiac surgery, the exposure to cardiopulmonary bypass and the stress endured by the patient produce significant inflammation, and the processes of neuroinflammation provides a logical pathway. Full-Text PDF

This case report describes the implementation of a heparin desensitisation strategy for a patient with confirmed galactose-alpha-1,3-galactose (alpha-gal) allergy, prior to cardiac surgery. We describe the pre-, intra- and postoperative management. We believe this report can enhance the limited data currently in existence on alternative strategies for heparin utilisation in cardiopulmonary bypass in a previously intolerant patient population.

A bedridden patient with empyema presented for thoracoscopic decortication. During the procedure, despite a post-tetanic count (PTC) of 0 via calibrated quantitative neuromuscular monitoring, persistent diaphragmatic movement impaired operating conditions, so rocuronium was re-dosed. After surgery, the patient had 0 PTC. Sugammadex was titrated to achieve baseline neuromuscular strength, monitoring the effect of each 200-mg dose. Ultimately, 1200 mg was required to achieve baseline strength. We describe monitor troubleshooting, considerations with unexpectedly deep neuromuscular blockade, the importance of routine quantitative neuromuscular monitoring, and one strategy for sugammadex reversal in patients with profound paralysis outside of the standard dosing guidelines.

BACKGROUND:This study assessed associations between processed electroencephalographic (pEEG) use during anesthesia, surgery- and anesthesia-related risk factors, and neurologic outcomes and mortality after cardiac surgery. METHODS:Drawing from The Society of Thoracic Surgeons Adult Cardiac Surgery Database and its Adult Cardiac Anesthesiology Section, we identified 42 932 records for elective, urgent, and emergency cardiac surgical procedures between July 1, 2017 and December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the associations between pEEG use during anesthesia on the primary outcome, postoperative delirium (POD), and secondary outcomes of stroke, encephalopathy, coma, and operative mortality. RESULTS:The rate of pEEG use during anesthesia use was 32.8% (n = 14 086), and its use was not associated with decreased odds for POD (odds ratio [OR], 0.88; 95% CI, 0.78-1.02) or encephalopathy (OR, 0.85; 95% CI, 0.70-1.03). Intraoperative pEEG monitoring use was also not associated with increased odds for stroke (OR, 1.17; 95% CI, 0.97-1.42) or coma (OR, 1.44; 95% CI, 0.82-2.52). In contrast, pEEG use during anesthesia was associated with higher odds for operative mortality (OR, 1.23; 95% CI, 1.05-1.44). This association remained significant after adjusting for POD (OR, 1.21; 95% CI, 1.03-1.41), stroke (OR, 1.21; 95% CI, 1.04-1.42), and encephalopathy (OR, 1.28; 95% CI, 1.07-1.52). CONCLUSIONS:This large retrospective database study found no association between pEEG use during cardiac surgery and postoperative neurologic outcomes such as POD, stroke, encephalopathy, or coma. However, patients who underwent pEEG monitoring during anesthesia experienced higher mortality, even after adjustment for neurologic outcomes.

BACKGROUND:We examined how intercostal nerve block (ICNB) with standard bupivacaine and ICNB with extended-release liposomal bupivacaine, compared with thoracic epidural analgesia (TEA), were associated with postoperative opioid pain medication consumption and hospital length of stay (LOS) after thoracic surgery.METHODS:We studied 1935 patients who underwent thoracic surgery between January 1, 2010, and November 30, 2017, at a tertiary academic center. Primary and secondary outcomes were postoperative opioid consumption expressed as morphine milligram equivalents (MMEs) at 24, 48, and 72 hours after surgery, the LOS, and total MME consumption from surgery to discharge.RESULTS:Of these patients, 888 (45.9%) received TEA, 730 (37.7%) ICNB with standard bupivacaine, 127 (6.6%) ICNB with liposomal bupivacaine, and 190 (9.8%) no regional analgesia. Compared with epidural analgesia, in 2017, ICNB liposomal bupivacaine provided similar pain control in terms of MME consumption at 24 and 72 hours, but decreased MME consumption at 48 hours (odds ratio [OR] = 0.33; confidence interval [CI] = 0.14-0.81) and at discharge (OR = 0.28; CI = 0.12-0.68) and was associated with a higher likelihood for a shorter LOS (hazard ratio = 3.46; CI = 2.42-4.96). Compared with TEA, ICNB with standard bupivacaine and no regional analgesia use showed varying impact on MME consumption between 24 and 72 hours after surgery, and their use was not associated with a significantly reduced MME consumption at discharge but with a shorter hospital LOS.CONCLUSIONS:Multimodal analgesia involving regional anesthetic alternatives to TEA could help manage postoperative pain in thoracic surgery patients.

Purpose of review In this review, we discuss recent developments and trends in the perioperative management of thrombocytopenia. Recent findings Large contemporary data base studies show that preoperative thrombocytopenia is present in about 8% of asymptomatic patients, and is associated with increased risks for bleeding and 30-day mortality. Traditionally specific threshold platelet counts were recommended for specific procedures. However, the risk of bleeding may not correlate well with platelet counts and varies with platelet function depending on the underlying etiology. Evidence to support prophylactic platelet transfusion is limited and refractoriness to platelet transfusion is common. A number of options exist to optimize platelet counts prior to procedures, which include steroids, intravenous immunoglobulin, thrombopoietin receptor agonists, and monoclonal antibodies. In addition, intraoperative alternatives and adjuncts to transfusion should be considered. It appears reasonable to use prophylactic desmopressin and antifibrinolytic agents, whereas activated recombinant factor VII could be considered in severe bleeding. Other options include enhancing thrombin generation with prothrombin complex concentrate or increasing fibrinogen levels with fibrinogen concentrate or cryoprecipitate. Summary Given the lack of good quality evidence, much research remains to be done. However, with a multidisciplinary multimodal perioperative strategy, the risk of bleeding can be decreased effectively.

BETA-ADRENERGIC BLOCKERS (β-blockers) represent a heterogeneous class of cardiovascular drugs with different characteristics regarding their pharmacologic properties and clinical effects. As a class, β-blockers have been around for more than 50 years, and their use in the chronic treatment of ischemic heart disease and heart failure is well established.1 Currently, β-blockers are indicated as long-term therapy in patients with a history of prior myocardial infarction (associated with a lower reinfarction and mortality rate) and in patients with systolic heart failure (survival benefit).

BACKGROUND: Erythropoiesis-stimulating agents, such as erythropoietin (EPO), can be used to treat preoperative anemia. Some studies suggest an increased risk of mortality and thrombotic events, and use in cardiovascular surgery remains off-label. This study compares outcomes in cardiac surgery patients declining blood transfusion who received EPO with a matched cohort who did not. METHODS: After institutional review board approval, we conducted a retrospective review of all patients who decline blood transfusion who underwent cardiac surgery and received EPO between January 1, 2004, and June 15, 2015, at a single institution. Control patients who did not receive EPO and were not transfused allogeneic red blood cells perioperatively were identified during the same period. Two controls were matched to each EPO patient using an optimal matching algorithm based on age, date of surgery, gender, operative procedure, and surgeon. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) and baseline characteristics remaining unbalanced in the matched cohorts were controlled for in assessing patient outcomes. The primary outcome was a composite of mortality and thrombotic events, and secondary outcomes included change in hemoglobin (Hb) from baseline to discharge, acute kidney injury (AKI), sternal wound infection, atrial fibrillation, time to extubation, intensive care unit, and hospital length of stay (LOS). RESULTS: Fifty-three patients who decline transfusion and received EPO were compared to 106 optimally matched control patients who did not receive EPO or red blood cell transfusion in the perioperative period. The median additive EuroSCORE was similar between the EPO and control group [6 (4, 9) vs 5 (3, 7), respectively; P = .39]. There was no difference in the primary outcome (P = .12) and mortality was zero in both groups. The EPO group had a higher mean preoperative Hb (13.91 g/dL vs 13.31; P = .02) and a smaller change in Hb from baseline (−2.65 vs −3.60; P = .001). The incidence of AKI (47.17% vs 41.51%; P = .49) was similar and there was no significant difference in all other outcomes, including time to extubation, hospital LOS, or intensive care unit LOS. CONCLUSIONS: In this retrospective matched cohort study of patients declining transfusion and receiving EPO matched to control patients, there were no clinically meaningful differences in the outcomes.

Anesthesiologists administer excess supplemental oxygen (hyper-oxygenation) to patients during surgery to avoid hypoxia. Hyper-oxygenation, however, may increase the generation of reactive oxygen species and cause oxidative damage. In cardiac surgery, increased oxidative damage has been associated with postoperative kidney and brain injury. We hypothesize that maintenance of normoxia during cardiac surgery (physiologic oxygenation) decreases kidney injury and oxidative damage compared to hyper-oxygenation.

We present a case in which we electively used venovenous extracorporeal membrane oxygenation (VV-ECMO) to facilitate safe resection of a nearly obstructing airway tumor near the carina in a 37-year-old male. The patient was brought to the operating room and underwent bifemoral cannulation for VV-ECMO under light sedation while maintaining spontaneous ventilation. After VV-ECMO was initiated, general anesthesia was induced, and the tumor was resected via rigid bronchoscopy. After resection, the patient was intubated, weaned from ECMO, decannulated, awoken, extubated, and taken to the postanesthesia care unit for recovery.