Clinical perfusionists manage and optimize extracorporeal circulation as well as physiological and metabolic stability, to support positive patient outcomes under artificial physiological conditions, such as cardiopulmonary bypass, extracorporeal membrane oxygenation, and other extracorporeal circulation systems. Despite the central role of the profession in patient safety and surgical outcomes, clinical perfusion remains inconsistently defined, regulated, and recognized across Europe. In response to these challenges, the European Board of Cardiovascular Perfusion, together with the European Association for Cardio-Thoracic Surgery and the European Association of Cardiothoracic Anaesthesiology and Intensive Care, convened a multidisciplinary task force to develop a unified expert consensus on the minimum academic education, supervised clinical training, and continuing professional development for safe and independent practice. It defines essential technical competencies, such as the operation of heart-lung machines and mechanical circulatory support devices, alongside critical non-technical skills in decision-making, communication, and interdisciplinary collaboration. The document also introduces a tiered framework to classify perfusionists by experience level and proposes mechanisms for certification and recertification through the European Certificate in Cardiovascular Perfusion. Furthermore, the statement highlights the importance of structured quality assurance programs, simulation-based education, and incident reporting systems in advancing perfusion safety and clinical effectiveness. A harmonized European approach is urgently needed to ensure consistent training standards, enhance workforce mobility, and support formal recognition of clinical perfusion as a regulated healthcare profession. This consensus aims to serve as a benchmark for national regulatory efforts and future professional development across Europe.

OBJECTIVES:To evaluate whether preoperative anxiety was associated with higher opioid consumption and higher pain scores after cardiac surgery. DESIGN:A prospective cohort study. SETTING:University hospital, single-center study. PARTICIPANTS:A total of 220 adult patients undergoing their first elective cardiac surgery by sternotomy. INTERVENTIONS:Preoperative anxiety (A) was assessed the day before surgery using the Hospital Anxiety and Depression Scale (HADS). In-hospital opioid consumption and daily assessments of postoperative pain using a visual analog scale (VAS) were performed until 5 days after surgery. A HADS-A score of >7 of 21 was considered abnormal. MEASUREMENTS AND MAIN RESULTS:Patients with or without anxiety were compared using the Mann-Whitney U test and the chi-square test. Linear regression analyses assessed the relationship between preoperative anxiety and postoperative opioid consumption, as well as VAS scores, at day (D) 1, D2, and D5. Of the patients, 186 of 220 (84.5%) completed the HADS-A, and 90 of 186 (48.4%) had preoperative signs of anxiety. There was no significant difference in terms of age between patients with and without anxiety. Twenty of 31 female patients (64.5%) had anxiety versus 70 of 155 men (45.2%) (p = 0.049). There was no difference in in-hospital opioid consumption (p = 0.311). However, anxious patients described significantly higher VAS scores at several moments from D1 to D5 after surgery. CONCLUSIONS:A significant proportion of our cardiac surgery patients, especially women, experienced preoperative anxiety. Although the latter did not influence in-hospital opioid consumption, anxiety had a significant impact on postoperative VAS pain scores. Screening and management of anxiety before elective cardiac surgery could improve postoperative recovery by reducing pain severity.

Neonatal cardiac surgery requires cardiopulmonary bypass (CPB) strategies that minimize hemodilution while maintaining adequate oxygen delivery and hemostatic balance. Despite increasing emphasis on patient blood management (PBM), contemporary CPB priming and perioperative hemostasis practices across European neonatal cardiac surgery programs remain poorly characterized. This prospective, 26-item, web-based cross-sectional survey was designed to evaluate current practices in CPB priming, availability of blood products, and perioperative coagulation management strategies in neonatal cardiac surgery across Europe. The participants included anesthesiologists, congenital cardiac surgeons, and perfusionists from active neonatal cardiac surgery programs. A 26-item survey was distributed to 122 identified European neonatal cardiac surgery centers; 71 centers from 32 countries responded (58% response rate). Three main CPB machine platforms and four oxygenator types were reported. Priming volumes varied substantially across centers, ranging from 75 mL to 450 mL. Packed red blood cells were incorporated into the CPB prime in 58 centers (82%), while plasma products were used in 37 centers (52%). Coagulation factor concentrates were available in nearly half of the responding centers, and 64% reported that their use did not require hematology approval. Point-of-care coagulation testing was used to guide intraoperative hemostasis management in 86% of centers, although device availability and turnaround times varied widely. These results provide a contemporary snapshot and highlight substantial heterogeneity across European neonatal cardiac surgery programs in CPB priming strategies, blood product availability, and perioperative hemostasis management. While many centers have adopted point-of-care-guided PBM approaches and targeted factor replacement strategies, considerable variability persists in circuit configuration, priming volume, and transfusion resources. These findings highlight opportunities for collaborative research and for developing consensus-driven PBM frameworks to optimize neonatal CPB and perioperative hemostasis management.

Lagios, Marie-Hélène MD; Bidoul, Thomas MD; Momeni, Mona MD, PhD; Khalifa, Céline MD, PhD Author Information

BACKGROUND:Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery. OBJECTIVE:To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery. DESIGN:Randomized controlled trial. (ClinicalTrials.gov: NCT03505723). SETTING:54 centers, 19 countries. PARTICIPANTS:2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years). INTERVENTION:In the hypotension-avoidance strategy, the intraoperative mean arterial pressure (MAP) target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld, and other chronic antihypertensive medications were administered for systolic blood pressures of 130 mm Hg or greater following an algorithm. In the hypertension-avoidance strategy, the intraoperative MAP target was 60 mm Hg or greater; all chronic antihypertensive medications were continued perioperatively. MEASUREMENTS:Delirium on postoperative day 1 to 3 (primary outcome); decline of 2 points or more at the Montreal Cognitive Assessment (MoCA) 1 year after surgery compared with baseline (secondary outcome). RESULTS:95 of 1310 patients (7.3%) in the hypotension-avoidance and 90 of 1293 patients (7.0%) in the hypertension-avoidance group had delirium (relative risk [RR], 1.04 [95% CI, 0.79 to 1.38]). Among 701 patients who completed 1-year MoCA (full or telephone version), 129 of 347 (37.2%) in the hypotension-avoidance and 117 of 354 (33.1%) in the hypertension-avoidance group had a decline of 2 or more points (RR, 1.13 [CI, 0.92 to 1.38]). Nineteen percent in the hypotension-avoidance and 27% in the hypertension-avoidance strategy had hypotension requiring an intervention (RR, 0.63 [CI, 0.52 to 0.76]), mostly intraoperatively; only 5%, in both groups, had hypotension postoperatively. LIMITATION:The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected. CONCLUSION:There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies. PRIMARY FUNDING SOURCE:Canadian Institutes of Health Research, Canada; National Health and Medical Research Council, Australia; Research Grant Council, Hong Kong SAR, China.

Although postoperative delirium is a frequent complication, its pathophysiological mechanisms have not been completely elucidated yet. Recent studies suggested indirect influences of apolipoprotein Eε4 (APOEε4) allele, a genetic risk factor of Alzheimer’s disease, on the association between postoperative delirium and some known risk factors. This preplanned secondary analysis (ClinicalTrials.gov NCT03706989) aimed to determine whether APOEε4 carrier status played an indirect role on postoperative delirium incidence related to (1) preoperative cognitive impairment and to (2) postoperative inflammation in cardiac surgery. 220 adult patients undergoing elective cardiac surgery were included in the study. Preoperative cognitive assessment was performed the day before surgery using both a battery of five neuropsychological tests and the Mini-Mental State Examination. Postoperative inflammation was evaluated by C-reactive protein (CRP) concentrations in blood. Patients were screened for postoperative delirium from the Intensive Care Unit until discharge from the hospital using CAM-ICU (3 times a day in the ICU), CAM (2 times a day at the ward) and a chart review. Comparisons between groups were performed using a χ2 test for dichotomous variables and a Student t-test for continuous variables. Association between the studied exposure (preoperative cognition or postoperative systemic inflammation) and the incidence of postoperative delirium, as well as their respective interactions with APOEε4 carrier status, were assessed using multivariable logistic regression models. Among 220 cardiac surgery patients, 65 (29.5%) developed delirium. Fifty-three patients (24%) carried at least one allele ε4. Multivariable logistic regression models showed that (1) interactions between APOEε4 carrier status and preoperative cognitive status or between APOEε4 carrier status and postoperative CRP concentrations were negligible, and (2) extensive preoperative cognitive testing remained a key predictor of postoperative delirium. APOEε4 carrier status did not modify the effect of preoperative cognitive impairment or the effect of higher postoperative systemic inflammation on postoperative delirium occurrence in our clinical series.

OBJECTIVE:To define low-performing colleagues in cardiothoracic and vascular anesthesia (LPC-CTVA), evaluate institutional preparedness to identify and manage such individuals, and identify predictors of recognition, reporting, and response behaviors. DESIGN:International cross-sectional survey. SETTING:Web-based data collection from June to September 2024. PARTICIPANTS:Of 878 responses, 537 (61.2%) were complete and analyzed, representing 57 countries. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:A 43-item questionnaire was developed by a multidisciplinary team and distributed via professional societies, social media, and email. It assessed definitions of LPC-CTVA, institutional protocols, and preparedness to address underperformance. Consensus was defined as ≥70% agreement. Thirteen of the 18 statements met consensus. Common indicators included non-compliance with infection control (80.0%), outdated knowledge (80.3%), repeated procedural failures (80.0%), and persistent negligence (79.1%). Institutional support was limited: among 464 respondents, 22.2% reported active supervision for underperformance, 15.3% reported the presence of identification mechanisms, and 11.7% indicated the existence of formal management processes. Although 39.9% of 434 had encountered a low-performing colleague, only 23.1% of 447 had reported one. Preparedness to manage impaired colleagues was reported by 46.2% of 418 respondents, and preparedness to manage underperforming colleagues by 44.1% of 416 respondents. Key barriers included the belief that others would act (33.7% of 265), perceived ineffectiveness (28.3%), and fear of retaliation (21.9%). Preparedness was more prevalent among older, more experienced clinicians, those in leadership roles, and those with prior experience in reporting. CONCLUSIONS:A consensus-based definition of LPC-CTVA has been established. However, institutional readiness and clinician confidence remain limited. Experience and structured systems enhance response capability.

Purpose:Olfactory dysfunction has emerged as a marker of neurodegeneration and frailty in older adults, yet its value for perioperative risk stratification remains underexplored. This prospective study aimed to assess the interplay between three olfactory modalities (Threshold, Discrimination, Identification: TDI), baseline frailty, and postoperative outcomes in older patients undergoing surgery. Patients and Methods:We enrolled adults aged 65 years or older scheduled for elective aortic/lower limb vascular or orthopedic procedures under general anesthesia. The day before surgery, patients underwent olfactory testing using the Sniffin' Sticks extended test (yielding a composite TDI score), and frailty evaluation with the Edmonton Frail Scale (EFS) and Clinical Frailty Scale. Postoperative moderate/severe complications or death occurring within one year were recorded. Statistical analyses included univariable and multivariable regression adjusted for age, sex, comorbidities, and surgical parameters. Results:From 362 screened patients, a final cohort of 209 patients (160 orthopedic, 49 vascular) was included after accounting for ineligibility, 42 refusals, and 6 data access exclusions. Lower olfactory performance (TDI score ≤ the 25th percentile) was identified in 74 (35.4%) patients. Frailty (EFS ≥6/17) was present in 51 cases (24.4%). Frail patients had significantly lower TDI scores (median 25.25 vs 28.75, p<0.001), with all three modalities independently correlated with frailty after adjustment. Within one year, 54 (25.8%) experienced postoperative complications and 3 (1.4%) patients died. Reduced olfaction was associated with a higher risk of postoperative morbidity/mortality (39.2% vs 20.7%, p=0.004), and this association remained significant after accounting for age and gender, comorbidities, surgery type, and frailty. Lower olfactory performance, but not frailty, predicted poor outcomes in vascular patients (odds ratio 6.34, p=0.004), while only frailty was predictive in orthopedic patients. Conclusion:Global poorer olfaction is closely associated with frailty and may serve as a robust indicator of adverse postoperative outcomes in older adults, beyond conventional frailty scales.

Objective of the study Anxiety can affect pregnancy rate following an in-vitro-fertilisation procedure. Hypnosis reduces emotional distress associated with medical procedures. Virtual reality (VR) is an immersive 3D experience, created using a visual headset and headphones. The goal of this study was to evaluate the effect of VR session with and without hypnosis before sedation for oocyte retrieval (OR) on anxiety levels and on pregnancy rate. Methods After written informed consent, 342 women scheduled for OR under sedation were randomised in this double-blinded study (NCT03064061). A Visual Analogue Scale for anxiety (VAS) and a Spielberger State-Trait Anxiety Inventory (STAI) questionnaire before (baseline) and after VR session, and at hospital discharge were administered. VRD Group (n=178) received a VR session (goal of distraction) and VRH group (n=164) received the same VR session with hypnosis focused on slowing respiratory rhythm and suggestions of reusing the technique later as needed (AQUA Oncomfort/HypnoVR TM). The primary endpoint was ongoing pregnancy at 12 weeks. Mann Whitney, Wilcoxon signed rank test and Chi-square tests were used; p value <0.05 considered significant. Results Although anxiety scores decreased from baseline in both VRD and VRH groups (p <0.001 baseline vs post VR session and baseline vs hospital discharge), there was no difference between them. Nor was there a difference in pregnancy rate (18,6% VRD group vs 22,5% VRH group). Conclusion Although both VRD and VRH sessions before sedation for OR significantly reduced women's anxiety, the type of suggestions used during the hypnosis VR session did not influence the pregnancy rate.

The En-bloc Rotation of the Outflow Tracts, as suggested by Anderson in 2016(1) is a surgical approach for complex congenital heart defects, particularly in patients with transposition of the great arteries (TGA) and associated ventricular septal defect (VSD) and left ventricular outflow tract (LVOT) obstruction (LVOTO). Despite its effectiveness, concerns have arisen following a study by Stoica et al.(2022), which reported that 16% of patients developed at least moderate aortic regurgitation (AR) post-surgery. The mechanisms behind this complication remain unclear. This case report presents a 4-year-old patient who developed significant AR (grade 3+/4), with left ventricular dilation (LVEDD : 43 mm), three years after an En-bloc Rotation, necessitating aortic valve repair. Initial echocardiography showed trivial AR, with progression of AR within 18 months and associated annular dilation (24 mm). The repair procedure involved plication of the left ventricular outflow tract (LVOT), annuloplasty, and leaflet adjustments. At discharge, residual AR was mild to moderate (1+/4). Seven months later, echocardiography revealed stable left ventricular dimensions and moderate AR (grade : 2+/4). This case emphasizes the need for early detection and intervention for AR in patients after En-bloc Rotation surgery. Further research is needed to identify predisposing factors and refine surgical strategies.

Purpose Pre-operative assessment of cardiovascular risk currently relies on scores, such as the American Society of Anesthesiologists (ASA) score, biased towards high-risk, but neglecting middle/lower risk patients. Endothelial dysfunction is a precursor to cardiovascular events (CVEs), due to impaired nitric oxide (NO) bioavailability. We previously showed that the erythrocytic NO-ferroheme including the 5-coordinated NO-heme-alpha-hemoglobin (HbNO), a complex between NO and deoxyhemoglobin correlates with endothelial function assessed by digital tonometry. The aim of this study was to evaluate if HbNO is associated with the different cardiovascular risk factors and to explore its association with CVE in patients undergoing elective non-cardiac surgery. Methods We conducted a prospective, monocentric study in adult patients scheduled for elective non-cardiac surgery. At preoperative visit, blood samples were collected, and erythrocytes isolated to measure baseline HbNO levels, along with other biomarkers routinely used to evaluate pre-operative risk factors. NO-ferroheme signals were quantified using electron paramagnetic resonance spectroscopy. Follow-up visits and data analysis using electronic health records were conducted at 1-, 3-, 6- and 12- months postoperatively. The primary endpoint was the occurrence of a composite of CVE, including arrhythmias, chest pain/unstable angina, myocardial infarction/ischemia, pulmonary edema, pulmonary embolism, stroke, deep venous thrombosis, cardiac failure and death of any cause. Results Between November 2019 and June 2022, 2,500 patients were screened and 1,066 patients underwent an elective non-cardiac surgery. Among the 1,066 patients kept for the final analysis, 23 subjects developed a peri-operative CVE up to 30 days after surgery (p-30d CVE). Linear regression analysis revealed several independent factors significantly correlated with HbNO levels, including hemoglobin, anticoagulant usage, and smoking status. Patients who developed p-30d CVE exhibited lower mean HbNO levels (124.2 +/- 96.6 nM) compared to those who did not (154.8 +/- 104.1 nM; p = 0.028). Using a threshold of 124 nM for HbNO, levels below this cutoff (HbNO < 124 nM) were associated with an increased risk of p-30d CVE (OR [95% CI] = 4.21 [1.55-11.41]), as did classification in ASA III or higher (OR [95% CI] = 3.23 [1.38-7.59]). However, after excluding patients at high risk of CVE a priori, HbNO < 124 nM remained associated to p-30d CVE (OR [95% CI] = 5.52 [1.57-19.33]) while the association to ASA-score was no longer significant (OR [95% CI] = 0.89 [0.20-3.97]). Conclusion In patients scheduled for non-cardiac surgery, known cardiovascular risk factors, such as active smoking independently and negatively correlates with erythrocytic NO-ferroheme including HbNO. In patients without severe comorbidities, despite the limited number of CVEs observed, HbNO levels under 124 nM were independently and positively associated with p-30d CVE up to 30 days after surgery, while the ASA score was no longer correlated to p-30d CVE. HbNO measurements could help to improve the preoperative evaluation of low/intermediate risk patients. Trial registration Registered at ClinicalTrials.gov on June 19, 2019 (NCT03994900).

Perioperative electroencephalography (EEG) has been widely studied in the last decade, not only as a useful brain state monitor but also as a potential tool to identify vulnerable patients at risk of perioperative neurocognitive disorders. Current literature has mostly focused on the oscillatory components of the EEG signal. Recently, interest in the functional role of the aperiodic activity of the EEG signal has increased both in neuroscience and in anesthesiology. This narrative review aims to provide clinicians and researchers with practical and methodologic insights into characterizing aperiodic EEG activity, focusing on its neurophysiological significance in neuroscience and anesthesia. It furthermore provides the reader with observed variations of aperiodic activity and periodic activity during general anesthesia and highlights whether those parameters could be useful to infer cognitive frailty and perioperative neurocognitive disorders and monitor depth of anesthesia during surgery.

Hemodynamic monitoring is an integral part of the perioperative care of the patient. Over the years, several different tools and techniques have been developed. The current contribution reviews the various currently available hemodynamic monitoting techniques.

Background:Vascular rings represent 1% of congenital cardiovascular abnormalities. Phenotypic expression varies from asymptomatic to severe forms related to either oesophageal or tracheal compression. While refinement in prenatal screening led to an increase in fetal diagnosis, optimal management in asymptomatic neonates and infants is currently a matter of debate. We report our center experience of vascular ring management over three decades.Methods:In this single-center retrospective study, data were extracted from patient medical records. To obtain information on symptoms/medication at follow-up, clinical records from pediatric clinics were reviewed. For patients followed in other institutions, a web-based questionnaire was sent to referring pediatricians.Results:Out of 82 patients, 69 were symptomatic (84%). Common symptoms included recurrent respiratory tract infections (43%), stridor (32%), gastro-esophageal reflux (33%), and dysphagia (26%). Diagnosis relied on cardiac ultrasound, barium swallow studies, and chest computerized tomography scan. Surgical repair (thoracotomy 91%) was performed in 79 patients (96%). Median age at repair was 13 [interquartile range (IQR), 4.4-48] months. There was no mortality. Minor complications occurred in 14 patients (18%). Median hospital length of stay was 7 (IQR, 6-9) days. In total, 24% of patients remained symptomatic (median follow-up 54 months). Half of those were asthma-related, with nearly 90% freedom from ring-related symptoms.Conclusions:Most patients were symptomatic at the time of diagnosis. Vascular rings such as pulmonary slings or tracheal compression syndromes require prompt management. Despite surgery, 24% of patients were not symptom-free at follow-up. Finally, surgery in asymptomatic patients resulted in low morbidity supporting the current recommendation of early surgical repair.Level of Evidence:III.

Background: The use of healthcare kiosk is increasing in the medical community. However, there are scares data on its use in a pre-operative clinic. Objective: The aim of this study is to validate an electronic questionnaire to assess the ASA physical status. Design: monocenter retrospective pilot study Setting: Tertiary hospital. Patients: 323 adults having a pre-operative visit prior to elective non-cardiac surgery. Main outcome measures: A questionnaire including 20 items (yes/no) was designed and inserted in the Kiosk. The ASA score was then retrospectively estimated by an anaesthesiologist not involved in preoperative visit, considering the total number of positive answers of the questionnaire inserted in the Kiosk. The answers to the questionnaire from the Kiosk were blinded to the anaesthesiologist performing the pre-operative face-to-face assessment. Agreement between both ASA scores provided from both anaesthesiologists was analysed using Cohen’s Kappa test (κ). Results: Agreement between ASA score estimated by kiosk answers and ASA score from face-to-face examination was substantially good with K=0.628 (P<0.001). Conclusion: Our electronic questionnaire is accurate in estimating patient’s physical status. A kiosk can be used to detect low risk patients in order to facilitate the preoperative assessment. However, it cannot replace a complete evaluation by a physician.

We read with interest the recent work of Gong et al.1 The authors compared the ultrasound-guided supraclavicular and infraclavicular approaches for subclavian vein cannulation in children with congenital heart disease. Compared with the infraclavicular approach, supraclavicular cannulation of the subclavian vein had a higher success rate (90.6% vs. 71.4%), shorter time to access (median difference -4.2 seconds), and less frequent catheter malposition. The study's findings may be at least partially explained by the operators' lack of familiarity with the supraclavicular approach.