Cor triatriatum is a congenital anomaly in which the left atrium (LA) is essentially partitioned into two chambers with a small orifice between them. The cephalad chamber receives the pulmonary veins and the caudal chamber is connected to the mitral valve. The concept of "cor triatriatum" as an acquired condition is new. Recently, however, we studied the heart of a 31-year-old opiate addict who had three chambers at the atrial level rather than two. He had developed Staphylococcus aureus endocarditis of the aortic valve resulting in severe aortic regurgitation (AR), causing severe congestive heart failure and associated with hemorrhagic pericardial tamponade. At operation, each of the three aortic valve cusps was virtually destroyed by the active infection. A ring abscess was found at operation and the mouth into it was just caudal to the junction of the left and posterior cusps. The cusps were excised and the mouth into the ring abscess was debrided. A porcine bioprosthesis (23 mm size) was inserted at the level of the "anulus." The patient died of a narcotic overdose 75 days after an otherwise uneventful clinical postoperative course. A murmur of AR was never present postoperatively and he had received antibiotics for 6 weeks after operation. Echocardiograms recorded 2 days before and 18 days after operation are shown in Figure 1.

Despite the benefits established for multiple surgical specialties, enhanced recovery after surgery has been underused in cardiac surgery. A cardiac enhanced recovery after surgery summit was convened at the 102nd American Association for Thoracic Surgery annual meeting in May 2022 for experts to convey key enhanced recovery after surgery concepts, best practices, and applicable results for cardiac surgery. Topics included implementation of enhanced recovery after surgery, prehabilitation and nutrition, rigid sternal fixation, goal-directed therapy, and multimodal pain management.

Critical care physicians continue to be challenged to recognize an environment that has the potential to result in acute kidney injury, with its associated short- and long-term consequences. The recent development of cell cycle arrest biomarkers that signal the potential development of acute kidney injury is part of an evolution in the molecular diagnosis and understanding of acute kidney injury. A preinjury phase that may lead to acute kidney injury has been described as “acute kidney stress.” This concept has the potential to stimulate research and innovation that will lead to early implementation of measures to prevent or reverse acute kidney injury.

Background. Acute kidney injury (AKI) after major cardiac operations is a potentially avoidable complication associated with increased morbidity, death, and costly long-term treatment. The financial impact of AKI at the population level has not been well defined. We sought to determine the incremental index hospital cost associated with the development of AKI. Methods. All patients undergoing coronary artery bypass grafting (CABG) or valve replacement operations, or both (clinical classification software codes 43 and 44), between 2008 and 2011 were identified from the Nationwide Inpatient Sample. AKI was identified using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes (584.xx); patients with chronic renal failure were excluded. Mean total index hospitalization costs were compared between patients with and without AKI. Results. At the population level, 1,078,036 individuals underwent major cardiac procedures from 2008 to 2011, with AKI developing in 105,648 (9.8%). Specifically, AKI developed in 8.0% of CABG, 11.4% of valve replacement, and 17.0% of CABG plus valve replacement patients (p < 0.001). Death was more common among patients with AKI vs those without (13.9% vs 1.3%, p < 0.001). Mean total index hospitalization cost was $77,178 for patients with AKI vs $ 38,820 for those without (p < 0.001). At the national level, the overall incremental annual index hospitalization cost associated with AKI was $ 1.01 billion. Conclusions. AKI developed in 1 in every 10 patients nationwide after a cardiac operation. Achieving a 10% reduction in AKI in this population would likely result in an annual savings of approximately $ 100,000,000 in index-hospital costs alone. Support for research on mechanisms to detect impending damage and prevent AKI may lead to reduced patient morbidity and death and to substantial health care cost savings. (C) 2018 by The Society of Thoracic Surgeons

Central MessageA consult for “supportive care” is preferable to one for “palliative care,” because it provides the patient, the family, and the providers with a balanced focus on the potential for recovery.See Editorial Commentary page 2032. A consult for “supportive care” is preferable to one for “palliative care,” because it provides the patient, the family, and the providers with a balanced focus on the potential for recovery. See Editorial Commentary page 2032. An increasing number of cardiothoracic (CT) surgical patients require prolonged critical care. Several factors are responsible. Patients currently tend to be older and to have more associated conditions. Complex and reoperative procedures are more common and include open chest protocols for coagulopathies and edema. There is widespread use of mechanical support devices that provide prolonged circulatory and respiratory support. This technology includes ventricular assist devices and extracorporeal membrane oxygenation.1Katz N.M. Meeting the expanded challenges of the cardiothoracic intensive care unit.J Thorac Cardiovasc Surg. 2015; 150: 777-778Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar As part of the response to the challenges of caring for severely ill patients who are close to death or on maximal mechanical support, medical centers have created support teams. These “supportive” care teams address the complex psychologic, ethical, and financial issues that patients and families are experiencing. The teams may include psychologists, social workers, and religious leaders, as well as physicians trained in providing communication support during end-of-life care. The teams have unfortunately been termed “palliative care” teams by some centers.2Nelson J.E. Curtis J.R. Mulkerin C. Campbell M. Lustbader D.R. Mosenthal A.C. et al.Choosing and using screening criteria for palliative care consultation in the ICU: a report from the improving palliative care in the ICU (IPAL-ICU) advisory board.Crit Care Med. 2013; 41: 2318-2327Crossref PubMed Scopus (140) Google Scholar This term conflicts with the basic goal of CT surgery, which is to restore the patient to a meaningful life outside the hospital. The patient has been offered the surgery with the potential for recovery from the clinical condition that led to the patient's hospital admission. The term “palliative” sends a negative message. However, the surgeon's perspective may be too optimistic and unrealistic. Members of the “supportive care” team can provide a balanced perspective to a patient's family and health care providers, and provide support if “end-of-life care” is instituted. This latter role is the same as that of “palliative care” teams in hospitals when patients with cancer and stroke have a dismal prognosis with no chance for recovery. McKenna and Clark3McKenna M. Clark S.C. Palliative care in cardiopulmonary transplantation.BMJ Support Palliat Care. 2015; 4: 427-434Crossref Scopus (9) Google Scholar addressed this discordance in terminology in relation to cardiopulmonary transplant recipients. They emphasized that the term “palliative care” creates the misperception among patients, their families, and transplant clinicians that the consult is for “end-of-life care.” This contrasts with the role of cardiopulmonary transplantation as a life-prolonging therapy. It is appropriate for health care providers in the CT intensive care unit (ICU) to request consultation with a team that can provide support to the patient and the patient's family during this very stressful time. Such “supportive care” teams can supplement care by CT ICU staff and provide additional counseling regarding psychologic issues, social services, religious issues, and financial matters. Recent emphasis on participation of patients together with their families during critical care rounds fits well with the role of a supportive care team in the CT ICU. With the increasing expertise of critical care professionals to manage complex conditions, including multisystem failure, survival to a meaningful life outside the hospital is now possible, when previously it was not thought to be. The time for recovery may extend to weeks and even months; however, achievement of the ultimate goal of the CT surgery to return the patient to a meaningful life is now possible. Remarkable recoveries have been well documented, such as recovery from refractory postsurgical cardiogenic shock to a New York Heart Association Class I and II functional status.4Khorsandi M. Dougherty S. Sinclair A. Buchan K. MacLennan F. Bouamra O. et al.A 20-year multicenter outcome analysis of salvage mechanical circulatory support for refractory cardiogenic shock after cardiac surgery.J Cardiothorac Surg. 2016; 11: 151Crossref PubMed Scopus (21) Google Scholar The overall goal of the CT surgery and the postoperative care then is recovery, and not palliation. However, despite optimal care, the patient's clinical situation may be unresponsive to intensive measures with a downward course and no chance for recovery. Supportive care teams in this case need to provide counseling to families and care providers, and guidance for “end-of-life” care. The term “supportive care” is the appropriate term for both situations and reflects the supportive needs of patients and their families. A benefit of the term “supportive care team” is that it may lead CT surgeons to request such a consult when they might otherwise not do so, concerned that the term “palliative care” sends a negative message to patients and their families. Author has nothing to disclose with regard to commercial support. Who is not comfortable with the term “palliative care”—patient, family, or surgeon?The Journal of Thoracic and Cardiovascular SurgeryVol. 155Issue 5PreviewPalliative care is an approach that improves quality of life for patients and their families facing life-threatening illness through prevention and relief of suffering.1 It helps reduce symptom burden, addresses psychologic and spiritual distress, provides support to both patient and family, and assists in establishing goals of care through difficult communications. It is interdisciplinary care and is offered concurrently with other life-prolonging measures, such as cardiothoracic surgery. Full-Text PDF Open Archive

Acute kidney injury after cardiac surgery is associated with increased morbidity and mortality. Methods for measuring urine output in real time may better ensure renal perfusion perioperatively in contrast to the current standard of care where urine output is visually estimated after empiric epochs of time. In this study, we describe an accurate method for monitoring urine output continuously during cardiopulmonary bypass. This may provide a means for setting patient-specific targets for blood pressure and cardiopulmonary bypass flow as a potential strategy to reduce the risk for acute kidney injury.

Alshaikh, Husain N. MD; Kacker, Seema; Katz, Nevin M. MD, FACS; Canner, Joseph K. MHS; Schneider, Eric B. PhD Author Information

See related article on pages 604-6. See related article on pages 604-6. The report from Du and colleagues1Du Y. Haitao Zhang H. Feng X. Reprint of: Continuous renal replacement therapy and mild hypothermia for acute left heart failure after cardiovascular surgery.J Thorac Cardiovasc Surg. 2015; 149: 604-606Abstract Full Text Full Text PDF Scopus (2) Google Scholar at the Fu Wai Hospital in Beijing, China, describes an innovative approach to manage acute severe left ventricular failure without the use of a left ventricular assist device. Hypothermia is now recognized as a valuable technique to allow cerebral recovery after a period of cardiac arrest. With the approach described in this report, the concept is extended to allow myocardial recovery in the postcardiotomy patient with severe acute cardiac failure. With this strategy, moderate hypothermia permits the reduction of cardiac preload, afterload, and inotrope and vasopressor support, thereby reducing cardiac workload and facilitating myocardial recovery. The management with hypothermia includes renal replacement therapy and full ventilator support to reduce overall metabolic requirements. The goal is to facilitate cardiac recovery without the development of multi–organ system failure. Although the experience reported is limited to 12 patients, and it is not a prospective, randomized trial, the favorable survival results in these patients with severe acute heart failure are encouraging. In this era of limited hospital and financial resources, this innovative approach may well see application in a variety of situations, especially in hospitals without access to advanced cardiac support technology. Reprint of: Continuous renal replacement therapy and mild hypothermia for acute left heart failure after cardiovascular surgeryThe Journal of Thoracic and Cardiovascular SurgeryVol. 149Issue 2PreviewManagement of severe heart failure with high doses of inotropes and vasopressors and increased ventricular volume will result in a high work load for the failing heart, with progressive decompensation. Recovery of heart function as a result of a period of rest for a failing heart has been well documented. However, few hospitals in China currently have the resources to provide extracorporeal membrane oxygenation or left ventricular assist device services. Management has continued to be a major challenge for cardiovascular surgical teams. Full-Text PDF Open Archive

The cardiothoracic (CT) intensive care unit (ICU) increasingly represents an extension of the operating room. Over the years, the CT ICU has functioned to some extent as an operating room, for emergency procedures, including reopening of the chest for control of bleeding, and for small procedures, such as tracheostomy. However, with the increasing use of mechanical support devices, including extracorporeal membrane oxygenation and ventricular assist devices, and employment of "open chest protocols" for cases with coagulopathies and severe edema, CT surgeons and their operating teams are performing more procedures in the ICU. Hospitals have expanded the amount of support technology that is immediately available in these units. Given the complexity level of the CT critical care that is now being performed, ICUs have the additional challenge of increasing monitoring capabilities, to optimize care and prevent organ injuries. Key to avoiding complications is the early detection of inadequate perfusion, to the brain, heart, kidneys, and intestinal tract. Metabolic markers are helpful, such as serum lactate levels; however, more specific monitoring is available, such as monitoring of cerebral perfusion with near-infrared spectroscopy.1Maldonado Y. Singh S. Taylor M.A. Cerebral near-infrared spectroscopy in perioperative management of left ventricular assist device and extracorporeal membrane oxygenation patients.Curr Opin Anaesthesiol. 2014; 27: 81-88Crossref PubMed Scopus (38) Google Scholar The evolution of CT critical care has led to further expansion of CT critical care teams in many hospitals.2Katz N.M. The evolution of cardiothoracic critical care.J Thorac Cardiovasc Surg. 2011; 141: 3-6Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Critical care nurses, surgeons, intensivists, anesthesiologists, perfusionists, and respiratory therapists have always been recognized as fundamental personnel on these teams. Many centers have come to recognize that nurse practitioners, physician assistants, and pharmacists have essential roles in providing timely optimal critical care, and actively participate on rounds and in "huddles" when sudden changes occur in a patient's condition. The multidisciplinary team now includes speech and language pathologists, physical therapists, and nutritionists, who all have important roles in patient evaluation and therapy. The increasing challenges regarding severely ill patients who are in immediate danger of dying, or on maximal mechanical support, with no obvious "end of life," have led centers to create "supportive care" teams. They consist of staff with expertise in psychological, ethical, and financial issues for patients and families, as well as religious leaders. Unfortunately, these teams have been called "palliative care" teams by some centers. This term reflects an approach that is counter to the basic goal of the CT surgeon, which is to ultimately restore the patient to a meaningful life outside the hospital, and potentially "cure" the CT clinical issue that led to the patient's hospital admission. Clearly, "supportive care" is the appropriate term, and reflects the needs of many patients and families. This care is usually very much appreciated. Communication among the multidisciplinary CT critical care team members continues to be a major challenge, as the numbers of both team members and complex situations they face increase. The CT surgeon continues to have a leadership role on the critical care team, even though the surgeon does not supervise the minute-to-minute care of the patient.3Katz N.M. The emerging specialty of cardiothoracic surgical critical care: the leadership role of cardiothoracic surgeons on the multidisciplinary team.J Thorac Cardiovasc Surg. 2007; 134: 1109-1111Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar As a specialty, CT surgery can embrace principles of the aviation industry referred to as "crew resource management."4Grogan E.L. Stiles R.A. France D.J. Speroff T. Morris J.A. Nixon B. et al.The impact of aviation-based teamwork training on the attitudes of health-care professionals.J Am Coll Surg. 2004; 199: 843-848Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar In addition to effective use of checklists, simulations, and debriefing procedures, crew resource management emphasizes the team concept, allowing any member of the team to raise an issue and suggest a change. An application of these principles was evident in the saving of all lives during the sudden ditching of US Airways flight 1549 into the Hudson River in New York, in 2009. Most recently, federal legislation to create a value-based reimbursement system, as well as mandates to change surgical reimbursement from a 30-day to a 0-day global fee, has important implications. The Affordable Care Act has created a value-based system that focuses on optimal outcomes and reduction of complications and readmissions.5Lancaster E. Postel M. Satou N. Shemin R. Benharash P. Introspection into institutional database allows for focused quality improvement plan in cardiac surgery: example for a new global healthcare system.Am Surg. 2013; 79: 1040-1044PubMed Google Scholar To avoid penalties, medical centers need to refine their approach to the multidisciplinary specialty of CT critical care, which focuses on providing optimal care for optimal outcomes. The expanded challenges highlight the importance of certification in critical care for CT surgeons. The American Board of Thoracic Surgery defines critical care as a core component of thoracic surgery and has specifically written6American Board of Thoracic SurgeryBooklet of information. ABTS, Chigaco, ILJanuary 2012Google Scholar: "Thoracic Surgery encompasses the operative, perioperative, and surgical critical care of patients with acquired and congenital pathologic conditions within the chest." Cardiothoracic surgeons have defined fundamental concepts in CT critical care.7Sherif H.M. Developing a curriculum for cardiothoracic surgical critical care: impetus and goals.J Thorac Cardiovasc Surg. 2012; 143: 804-808Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar With the expansion of critical care training in thoracic surgery residencies, as well as the continuing medical education resources available, thoracic surgery as a specialty has established its credibility for certification.8Katz N.M. It is time for certification in cardiothoracic critical care.J Thorac Cardiovasc Surg. 2013; 145: 1446-1447Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar It is the CT surgeon who best understands those aspects of the physiology of cardiopulmonary bypass, as well as the cardiovascular, pulmonary, esophageal, and chest wall complications that are unique to thoracic surgery patients. In addition, thoracic surgeons perform procedures that are unique to CT critical care, such as insertion and removal of intra-aortic balloon pumps and other support devices. Cardiothoracic surgeons will continue to draw on the expertise of medical specialists such as cardiologists, pulmonologists, nephrologists, and infectious disease specialists. However, the CT surgeon with expertise in CT critical care is in the best position to direct the critical care of CT patients.9Whitson B.A. D'Cunha J. The thoracic surgical intensivist: the best critical care doctor for our thoracic surgical patients.Semin Thoracic Surg. 2011; 23: 12-13Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Clearly, if the American Board of Thoracic Surgery can certify surgeons to perform adult and congenital cardiac surgery, pulmonary surgery, esophageal surgery, and chest surgery, it should be able to certify CT surgeons to provide the critical care needed by thoracic surgery patients. Clinical experience, continuing medical education courses, and examinations can form the criteria for certification. Overall, the expanded challenges of CT critical care may require important changes in the organization and technology of ICU care at centers where CT surgery is performed. The CT surgeon has a leadership role on the multidisciplinary team that addresses these challenges.

In June of 2008, the American Board of Thoracic Surgery (ABTS) convened a special committee to consider certification in cardiothoracic critical care. The committee included ABTS chair Richard H. Feins, Thoracic Surgery Directors Association president John H. Calhoun, William A. Baumgartner, David A. Fullerton, William A. Gay, Jr, George L. Hicks, Jr, Valerie W. Rusch, and Curtis G. Tribble, all leaders in thoracic surgery education. As one of the thoracic surgeons who had emphasized that cardiothoracic critical care was a unique specialty and that cardiothoracic surgeons had a leadership role in the specialty,1Katz N.M. The emerging specialty of cardiothoracic surgical critical care: the leadership role of cardiothoracic surgeons on the multidisciplinary team.J Thorac Cardiovasc Surg. 2007; 134: 1109-1111Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar I was invited to participate in the meeting. The consensus of the meeting, after reviewing the situation in specialty board certification, was that the time was not right to move ahead with certification of cardiothoracic critical care by the ABTS. With the emphasis on cardiothoracic critical care since that time within the specialty of thoracic surgery, however, I now believe that the groundwork has been accomplished for the ABTS to proceed with creating its own pathways to certification in cardiothoracic critical care. At the meeting in 2008, the committee recognized that critical care is a core component of Thoracic Surgery. The ABTS specifically has written, "Thoracic Surgery encompasses the operative, perioperative, and surgical critical care of patients with acquired and congenital pathologic conditions within the chest."2The American Board of Thoracic SurgeryBooklet of information. The Board, Chicago2012Google Scholar Although it was recognized that a good case could be made for proceeding with the certification at that time, there was concern that other specialty boards might criticize and potentially block the process because thoracic surgery did not then have extensive credibility in critical care education. Residency programs were recognized to be relatively weak in this area, and there was only a single annual cardiothoracic critical care continuing medical education course, the Foundation for the Advancement of CardioThoracic Surgical Care (FACTS-Care) course "Cardiothoracic Surgical Critical Care" created in 2004. Although that course was created by a thoracic surgeon and thoracic surgeons made up the majority of the faculty, it was believed that overall thoracic surgery did not have sufficient credibility for the ABTS to create a certification in cardiothoracic critical care. Since that time, there have been a remarkable number of educational developments. The ABTS has enlarged its curriculum for training in critical care and the critical care content of examinations has been expanded. Fellowships in cardiothoracic critical care have been created. The annual FACTS-Care course, which changed its title to "Cardiovascular-Thoracic (CVT) Critical Care" to recognize the merging of the fields of cardiovascular surgery and interventional cardiology, continues to update surgeons and their critical care teams. In addition, there are now cardiothoracic critical care postgraduate courses at both the American Association for Thoracic Surgery (AATS) and Society of Thoracic Surgeons (STS) annual meetings. Breakout sessions in mechanical assist, extracorporeal membrane oxygenation, and bedside ultrasonography are regular components of the AATS, STS, and FACTS-Care courses, and case scenario hemodynamic simulations are now part of the AATS and FACTS-Care courses. All this is a reflection of the work by leaders from both the AATS and STS. Articles regarding the importance of thoracic surgeons performing critical care and providing educational resources have been published.3Stamou S.C. Camp S.L. Stiegel R.M. Reames M.K. Skipper E. Watts L.T. et al.Quality improvement program decreases mortality after cardiac surgery. J Thorac Cardiovasc.Surg. 2008; 136: 494-499Scopus (45) Google Scholar, 4Kumar K. Zarychanski R. Bell D.D. Manji R. Zivot J. Menkis A.H. et al.Impact of 24-hour in-house intensivists on a dedicated cardiac surgery intensive care unit.Ann Thorac Surg. 2009; 88: 1153-1161Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 5Katz N.M. The evolution of cardiothoracic critical care.J Thorac Cardiovasc Surg. 2011; 141: 3-6Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 6Whitson B.A. D'Cunha J. The thoracic surgical intensivist: the best critical care doctor for our thoracic surgical patients.Semin Thoracic Surg. 2011; 23: 12-13Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 7Sherif H.M. Developing a curriculum for cardiothoracic surgical critical care: impetus and goals.J Thorac Cardiovasc Surg. 2012; 143: 804-808Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In the last year The Journal of Thoracic and Cardiovascular Surgery, led by its Editor Lawrence Cohn, has created an associate editorship in perioperative management. Overall, thoracic surgery has created the educational platform that was envisioned at the 2008 meeting. Currently, it can be difficult for thoracic surgeons to practice cardiothoracic critical care in their intensive care units, both for their patients and those of other thoracic surgeons. Hospitals in this era are driven to require intensivists to be certified by the American Board of Internal Medicine, the American Board of Anesthesiology, or the American Board of Surgery. Remarkably, although these boards represent expertise in the broad field of critical care, they do not provide the depth of understanding and knowledge that is unique to the specialty of cardiothoracic critical care. Thoracic surgeons recognize the advantages of having non–thoracic surgeon intensivists on the cardiothoracic critical care team, as they have special areas of expertise. Thoracic surgeons also recognize, however, that it is the cardiothoracic surgeon who best understands the unique physiologies of cardiopulmonary bypass and cardiovascular, pulmonary, esophageal, and chest wall surgery, as well as the unique associated complications. Thoracic surgeons also perform procedures unique to cardiothoracic critical care, such as insertion and removal of intra-aortic balloon pumps and other support devices. Accordingly, it is highly appropriate for the thoracic surgeon to have a leadership role on the multidisciplinary cardiothoracic critical care team. Remarkably, cardiothoracic surgeons find that they cannot provide credentialing to hospitals to perform cardiothoracic critical care, despite in many cases thousands of hours of experience in the specialty. The ABTS administration has responded to requests to provide verification to hospitals that cardiothoracic critical care is a core component of thoracic surgery. Recognizing the potential political obstacles faced by the ABTS in creating its own certification in cardiothoracic critical care, leaders of the ABTS have worked diligently with the American College of Surgery to create a pathway for thoracic surgeons to achieve critical care certification. William Baumgartner and Valerie Rusch are to be commended for their efforts in this regard. They have paved the way for cardiothoracic fellowships and for certification. Fellowships have been created on the basis of their work. Ultimately, however, more pathways are needed for surgeons already in practice, and for residents who desire to apply their surgical training immediately after completing their cardiothoracic residency. In setting up criteria for certification, it is important that surgeons currently in practice do not become disenfranchised from performing critical care for their patients and those of their colleagues. It is important that surgeons continue to be updated in the latest concepts and management methods and protocols. It should be possible for any ABTS-certified thoracic surgeon to practice cardiothoracic critical care and to be certified in cardiothoracic critical care through a combination of experience, continuing medical education courses, and examinations. A formal process of ABTS certification in cardiothoracic critical care, with several pathways, can now be defined. Certification can be based on a variety of criteria: formal training, such as in cardiothoracic residencies and fellowships; documented clinical experience; participation in continuing medical educational programs; completion of Self-Education Self Assessment in Thoracic Surgery; and ABTS examinations. Cardiothoracic surgeons recognize that their colleagues in cardiothoracic anesthesiology are in a position to share the surgeon's unique understanding of cardiothoracic operations, the associated physiologic changes, and the potential complications. In many centers, cardiovascular or cardiothoracic anesthesiologists have an important role on the multidisciplinary team in the cardiothoracic intensive care unit. It therefore seems appropriate, as the ABTS develops its approach to certification in cardiothoracic critical care for thoracic surgeons, that consideration be given to inclusion of our colleagues in anesthesiology. Overall then, I believe that the ABTS, working with leaders of the AATS and STS, is now in a position to create certification in cardiothoracic critical care. It will be important to address the need for several pathways for thoracic surgeons at various stages of their careers. Once this certification is in place, thoracic surgeons will be able to point out to hospitals that, just as the ABTS certifies thoracic surgeons to perform cardiac and thoracic operations, the ABTS certifies thoracic surgeons to perform cardiothoracic critical care, which is a core component of the specialty.

OBJECTIVES:To determine whether mean arterial blood pressure excursions below the lower limit of cerebral blood flow autoregulation during cardiopulmonary bypass are associated with acute kidney injury after surgery.SETTING:Tertiary care medical center.PATIENTS:Four hundred ten patients undergoing cardiac surgery with cardiopulmonary bypass.DESIGN:Prospective observational study.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Autoregulation was monitored during cardiopulmonary bypass by calculating a continuous, moving Pearson's correlation coefficient between mean arterial blood pressure and processed near-infrared spectroscopy signals to generate the variable cerebral oximetry index. When mean arterial blood pressure is below the lower limit of autoregulation, cerebral oximetry index approaches 1, because cerebral blood flow is pressure passive. An identifiable lower limit of autoregulation was ascertained in 348 patients. Based on the RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease), acute kidney injury developed within 7 days of surgery in 121 (34.8%) of these patients. Although the average mean arterial blood pressure during cardiopulmonary bypass did not differ, the mean arterial blood pressure at the limit of autoregulation and the duration and degree to which mean arterial blood pressure was below the autoregulation threshold (mm Hg × min/hr of cardiopulmonary bypass) were both higher in patients with acute kidney injury than in those without acute kidney injury. Excursions of mean arterial blood pressure below the lower limit of autoregulation (relative risk 1.02; 95% confidence interval 1.01 to 1.03; p < 0.0001) and diabetes (relative risk 1.78; 95% confidence interval 1.27 to 2.50; p = 0.001) were independently associated with for acute kidney injury.CONCLUSIONS:Excursions of mean arterial blood pressure below the limit of autoregulation and not absolute mean arterial blood pressure are independently associated with for acute kidney injury. Monitoring cerebral oximetry index may provide a novel method for precisely guiding mean arterial blood pressure targets during cardiopulmonary bypass.

The cardiorenal syndrome (CRS) is a disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. The general definition has been expanded into five subtypes reflecting the primacy of organ dysfunction and the time-frame of the syndrome: CRS type 1 = acute worsening of heart function leading to kidney injury and/or dysfunction; CRS type 2 = chronic abnormalities in heart function leading to kidney injury or dysfunction; CRS type 3 = acute worsening of kidney function leading to heart injury and/or dysfunction; CRS type 4 = chronic kidney disease leading to heart injury, disease and/or dysfunction, and CRS type 5 = systemic conditions leading to simultaneous injury and/or dysfunction of heart and kidney. Different pathophysiological mechanisms are involved in the combined dysfunction of heart and kidney in these five types of the syndrome. Copyright (C) 2010 S. Karger AG, Basel

Different definitions for acute kidney injury (AKI) once posed an important impediment to research. The RIFLE consensus classification was the first universally accepted definition for AKI, and has facilitated a much better understanding of the epidemiology of this condition. The RIFLE classification was adapted by a broad platform of world societies, the Acute Kidney Injury Network group, as the preferred AKI diagnostic and staging system. RIFLE defines three increasing severity stages of AKI. One- to two-thirds of intensive care unit (ICU) patients develop AKI according to these criteria which is associated with worse outcomes such as increased length of ICU stay, costs, and mortality. Over the last decade the incidence of AKI has increased, probably as a consequence that baseline characteristics of ICU patients have changed. Another factor that may explain this is that more patients are treated in clinical settings that are associated with high risk for development of AKI. In addition, there may be genetically predetermined risk profiles for development of AKI such homozygotes for the low activity form of the COMT gene. Mortality of AKI patients has decreased over the last few decades, especially when underlying severity of illness is considered. An important consequence of this is the increasing number of surviving AKI patients who develop chronic kidney disease and end-stage kidney disease. In the specific setting of cardiac surgery, AKI occurs in 19-45% of patients. Renal replacement therapy is necessary in approximately 2% of this cohort. AKI that occurs within a 7-day period after cardiac surgery is related to perioperative risk factors, such as preexisting chronic kidney disease, acute ischemia, aorta cross-clamping, or use of cardiopulmonary bypass. AKI that occurs after the first week is mostly a consequence of sepsis or heart failure.

Patrick M. Honore, Ottignies-Louvain-la-Neuve, Belgium Andrew A. House, London, Ont., Canada Todd S. Ing, Hines, Ill., USA Michael Joannidis, Innsbruck, Austria Achim Joerres, Berlin, Germany Andre A. Kaplan, Farmington, Conn., USA Nevin M. Katz, Washington, D.C., USA Hideki Kawanishi, Hiroshima, Japan John A. Kellum, Pittsburgh, Penn., USA Peter Kerr, Clayton, Vic., Australia David Klein, Toronto, Ont., Canada Peter Kotanko, New York, N.Y., USA Martin K. Kuhlmann, Homburg/Saar, Germany Nathan W. Levin, New York, N.Y., USA Robert M. Lindsay, London, Ont., Canada Wai-Key Lo, Hong Kong, SAR, China Francesco Locatelli, Lecco, Italy Gérard M. London, Fleury Mérogis, France F. Lopot, Prague-Strahov, Czech Republic Ikuto Masakane, Yabuki, Japan Piergiorgio Messa, Milan, Italy Massimiliano Migliori, Pisa, Italy M. Mineshima, Tokyo, Japan Bruce A. Mueller, Ann Arbor, Mich., USA Federico Nalesso, Vicenza, Italy Kosaku Nitta, Tokyo, Japan Norma J. Ofsthun, Lexington, Mass., USA P.M. Palevsky, Pittsburgh, Penn., USA Vincenzo Panichi, Pisa, Italy Roberto Pecoits-Filho, Curitiba, Brazil Andreas Pierratos, Toronto, Ont., Canada J.V. Polvsen, Aarhus, Denmark Hamid Rabb, Baltimore, Md., USA Pedro Aljama, Cordoba, Spain Richard Amerling, New York, N.Y., USA Massimo Antonelli, Rome, Italy Sean M. Bagshaw, Edmonton, Alta., Canada Ian C. Baldwin, Heidelberg, Vic., Australia Rinaldo Bellomo, Heidelberg, Vic., Australia Diego Brancaccio, Milan, Italy Fiona Brown, Clayton, Vic., Australia Timothy E. Bunchman, Grand Rapids, Mich., USA Bernard Canaud, Montpellier, France Vincenzo Cantaluppi, Turin, Italy Gianbattista Capasso, Naples, Italy Charles Chazot, Tassin, France Rosanna Coppo, Turin, Italy Mario Cozzolino, Milan, Italy Carlo Crepaldi, Vicenza, Italy Dinna N. Cruz, Vicenza, Italy Andrew Davenport, London, UK Thomas A. Depner, Sacramento, Calif., USA Dieter Falkenhagen, Krems, Austria Ken Farrington, Stevenage, UK Mariano Feriani, Mestre, Italy Enrico Fiaccadori, Parma, Italy Maurizio Gallieni, Milan, Italy Laurie J. Garred, Thunder Bay, Ont., Canada L. Gesualdo, Foggia, Italy Noel Gibney, Edmonton, Alta., Canada Hyo Wook Gil, Cheonan, Republic of Korea Stuart L. Goldstein, Houston, Tex., USA Mikko Haapio, Hus/Helsinki, Finland Michael Haase, Berlin, Germany Olof Heimbürger, Stockholm, Sweden W.L. Henrich, San Antonio, Tex., USA Nicholas A. Hoenich, Newcastle upon Tyne, UK

It is apparent that the increasing complexity of cardiothoracic surgical (CTS) cases requires a new level of critical care performance. Although the cardiothoracic (CT) surgeon has traditionally provided this care with the assistance of residents and fellows, the organization of critical care is changing. A new system of multidisciplinary CTS critical care is emerging, for reasons described below. I believe that the CT surgeon is uniquely positioned to have a leadership role on the multidisciplinary team and to coordinate this new system of care. With the changes in house staff working hours and the corresponding decreasing role of surgical residents and fellows in the care of CTS patients, physician assistants and nurse practitioners are having a greater role in minute-to-minute clinical decision making and protocol development. It is important that this valuable participation of paramedical personnel be properly integrated into CTS critical care programs. The surgeon is uniquely qualified to coordinate and to assist in the training and certification of paramedical personnel as they assume this expanded role in the critical care of CTS patients. The situation, however, is more complicated in several regards. The relative roles of CT surgeons and intensivists in the CTS critical care unit have become unclear. Safety remains an issue in health care and includes the field of critical care. New protocols have been instituted to address safety issues in the intensive care unit.1Curtis J.R. Cook D.J. Wall R.J. Angus D.C. Bion J. Kacmarek R. et al.Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team.Crit Care Med. 2006; 34: 211-218Crossref PubMed Scopus (262) Google Scholar A variety of studies in the critical care literature have led to new concepts of management with improvements in mortality and morbidity. Examples include the treatment of sepsis,2Dellinger R.P. Carlet J.M. Masur H. Gerlach H. Calandra T. Cohen J. et al.Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.Crit Care Med. 2004; 32: 858-873Crossref PubMed Scopus (2442) Google Scholar the management of patients with ventilator-associated pneumonia,3American Thoracic SocietyGuidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.Am J Respir Crit Care Med. 2005; 171: 338-416Google Scholar and the use of lung-protective ventilation strategies in acute lung injury.4Brower R.G. Rubenfeld G. Lung-protective ventilation strategies in acute lung injury.Crit Care Med. 2003; 31: S312-S316Crossref PubMed Google Scholar Some concepts such as the importance of tight glucose control in the critical care patient have appeared in the CT literature as well.5Carr J.M. Sellke F.W. Fey M. Doyle M.J. Krempin J.A. de la Torre R. et al.Implementing tight glucose control after coronary artery bypass surgery.Ann Thorac Surg. 2005; 80: 902-909Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar It is clearly important that the new developments in the general field of critical care be applied to patients receiving intensive care after CT surgery. Overall, as has been widely recognized, it is important that the latest scientific studies be applied correctly, using what has been described as “evidence-based medicine.” In a sense, CTS critical care is inherent to the specialty of CT surgery. The CT surgeon provides critical care to his or her patients because of the nature of the surgery. This is the case for a substantial proportion of patients, as reflected in their receiving care early postoperatively in intensive care units. From the beginning of a surgeon’s training in this specialty, experience providing critical care is an integral part of the residency or fellowship program. However, with the increasing complexity of such care and the involvement of critical care physicians and allied health care professionals, the question arises whether the critical care of CTS patients is appropriately considered part of general critical care or whether it is, indeed, a specialty itself, distinct from general critical care. In support of the latter, it is noted that the clinical situations of CT surgery, including cardiopulmonary bypass, cardiac reconstructive procedures, pulmonary resections, and esophageal surgery, create unique physiologic changes that require special considerations. In addition, complications associated with CT procedures are indeed unique in medical practice. Accordingly, in my opinion, CTS critical care qualifies as a specialty within the frameworks of CT surgery and critical care. It is clear from clinical practice that CTS critical care requires a detailed knowledge of multiple medical and surgical disciplines. Correspondingly, a team of health care professionals provides CTS critical care. They include CT surgeons, critical care physicians and anesthesiologists, interventionists, other subspecialty physicians, critical care nurses, physician assistants, nurse practitioners, perfusionists, respiratory therapists, nutritionists, and pharmacists. Therefore, in defining the breadth of the specialty, to provide for its growth and the education of the entire team, it is important to recognize that the specialty is, indeed, multidisciplinary. In this era, the increased acuity of patients undergoing CT surgery and the range and complexity of the procedures involved place increasing and changing demands on the expertise of the CTS critical care team. For example, average patient age has progressively increased, and patients, accordingly, continue to have more associated medical conditions. In many cases, the disease for which the patient undergoes operation is more advanced than those in earlier experiences in the specialty of CT surgery. Another factor that challenges the expertise of the CTS health care team is the ongoing evolution in maximally supportive technology used both during and after the operation. This technology includes advanced ventilation systems, extracorporeal life support,6Hemmila M.R. Rowe S.A. Boules T.N. Miskulin J. McGillicuddy J.W. Schuerer D.J. et al.Extracorporeal life support for severe acute respiratory distress syndrome in adults.Ann Surg. 2004; 240: 595-605PubMed Google Scholar ventricular assist devices, and continuous renal replacement therapies.7Ronco C. Bellomo R. Homel P. Brendolan A. Dan M. Piccini P. et al.Effects of different doses in continuous veno–venous haemofiltration on outcomes of acute renal failure: a prospective randomized trial.Lancet. 2000; 356: 26-30Abstract Full Text Full Text PDF PubMed Google Scholar The complexity of the equipment and the on-going improvements in design demand detailed protocols and knowledgeable, experienced bedside professionals. In a sense, the technological environment of the CT operating room has been extended to the CTS intensive care unit. An additional challenge to the CTS critical care team is the integration of new pharmaceutical agents and combinations of pharmaceuticals into management protocols. Examples of evolving approaches to important clinical issues in CTS critical care include the use of inhaled prostacyclin and nitric oxide for severe pulmonary hypertension8Fattouch K. Sbraga F. Bianco G. Speziale G. Gucciardo M. Sampognaro R. et al.Inhaled prostacyclin, nitric oxide, and nitroprusside in pulmonary hypertension after mitral valve replacement.J Card Surg. 2005; 20: 171-176Crossref PubMed Scopus (81) Google Scholar and the use of arginine vasopressin for postcardiotomy vasodilatory shock.9Morales D.L.S. Gregg D. Helman D.N. Williams M.R. Naka Y. Landry D.W. et al.Arginine vasopressin in the treatment of 50 patients with postcardiotomy vasodilatory shock.Ann Thorac Surg. 2000; 69: 102-106Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar New pharmaceuticals have the potential for greater specificity and greater potency. On the other hand, new products, with their own idiosyncrasies, challenge the team to provide a safe introduction of the associated management protocols. New bedside technologies available for CTS critical care further challenge the CTS team. Some of these new devices and techniques importantly enhance diagnosis and increase the safety of care. Examples are the use of advanced hemodynamic catheter devices, impedance cardiography, and bedside portable ultrasonography. The latter two technologies provide valuable information in the critical care unit while having the advantages for the patient of being noninvasive. Overall, new technologies provide the means to extend the inherent precision of CT surgery from the operating room to the critical care unit. Given the complexity of the field of CTS critical care and the multidisciplinary nature of the critical care team, it is important that the members of the team share a broad understanding of the field, including its latest advances. This approach of ensuring that members of the team are “on the same page” provides the optimal environment for coordination and implementation of management procedures and protocols. In this regard, successful annual “Cardiothoracic Surgical Critical Care” conferences focused on the specialty were instituted in 2004. CT surgeons have played an important role in creating and planning the conferences and participating as faculty. The central goal of the conferences has been to provide the means for a dialogue among members of CTS critical care teams, including experts and world authorities, to further advance knowledge and expertise in this complex field. Topics have been chosen to highlight new concepts, innovative technologies, and current issues and controversies in CTS critical care. The programs have included symposiums dedicated to the important issues of “patient safety” and “the critical care environment” for the patient and the health care professional. As part of the development of these conferences, a multidisciplinary board of advisors, now composed of 33 multidisciplinary specialists, 9 of whom are CT surgeons, has been created to guide and participate in the program agendas of the conferences. It is clear that the CT surgeon should have an important leadership role on the multidisciplinary team. It is key that one of the leaders of the team caring for a CTS patient understands the details of the individual’s operation and the anticipated response to the procedure(s). The surgeon has the best perspective of this. It is fundamental that the patient has placed his life in the hands of the CT surgeon and, accordingly, expects the surgeon to have an important role in the postoperative care, working closely with critical care specialists. This approach preserves the essential element of continuity of care. It is important for thoracic surgeons to stay in the forefront as leaders in the specialty of CTS critical care. Multidisciplinary conferences provide an opportunity for CT surgeons to stay updated in this rapidly evolving field and support their leadership role on the multidisciplinary team. This perspective gives CT surgeons the background to have an important role in the coordination and training of critical care personnel. A number of established CT surgeons are expressing an interest in making a transition to the specialty of CTS critical care as a supplementary or primary professional activity. Questions have been raised about the need for certification. It would seem that a CT surgeon who has been certified by the American Board of Thoracic Surgery is qualified to provide the critical care of CTS patients, as this is inherent in the discipline. Nevertheless, with evolving critical care knowledge and technology, there is the need for updates of knowledge and expertise and perhaps additional certifications. In my opinion, the formal study of CTS critical care should be a part of thoracic surgery training programs. Such training should come from CT surgeons as well as from anesthesiologists and critical care specialists in the multidisciplinary setting. In regard to the recent interest on the part of a number of certified CT surgeons to obtain certification in critical care, I would suggest that the American Board of Thoracic Surgery consider offering certification in the specialty of CTS critical care, as well as in classic thoracic surgery. In summary, a new specialty of CTS critical care has emerged as a reflection and a result of the unique physiologic changes and unique complications associated with CT surgery and the rapid evolution in the care of CTS patients. The specialty crosses the disciplines of medicine and surgery and involves a spectrum of health care professionals. CT surgeons have an important leadership role in the specialty as they maintain continuity of patient care and work closely with the multidisciplinary team.

Pulmonary hypertension with an elevated pulmonary vascular resistance was observed during the immediate recovery period in patients who underwent mitral valve surgery. In eight such patients, intravenous infusion of CGS-13080, imidazo(1,5-a)pyridine-5-hexanoic acid (a thromboxane synthetase inhibitor), at a dose range of 0.08-0.1 mg/kg/hr, effectively reduced pulmonary hypertension (from a mean pulmonary arterial pressure of 36 2 to 31 2 torr) and pulmonary vascular resistance (from 339 38 to 238 + 37 dynes * sec * cm 5) within 30 minutes and remained reduced for the entire infusion period (48 hours in five patients and 18 hours in three patients). Mean arterial pressure or systemic vascular resistance were not significantly affected by the drug infusion. Serum thromboxane B2 levels (a stable metabolic product of thromboxane A2) were significantly reduced after administration of the compound, with the maximum effect of greater than 90% reduction. All patients tolerated the drug infusion without significant side effects. (Circulation 1988;78(suppl I):I-44-I-50)

PURPOSE: Descending mediastinal infections are usually associated with acute fulminant processes. Origins of infection include odontogenic, pharyngeal or cervical infections. Disease spreads into the mediastinum via fascial planes. Delays in diagnosis and management are frequent and may be associated with poorer outcomes. Ideal management varies according to acuity of presentation.

PURPOSE: With the introduction of highly active antiretroviral therapy (HAART), human immunodeficiency virus (HIV) infection has become a more chronic disease with improved survival. Thoracic surgeons are increasingly involved in surgical procedures in this patient population. Surgical indications and outcomes are important variables in treating these patients.