Discover the most talked about and latest scientific content & concepts.

Journal: Seminars in cardiothoracic and vascular anesthesia


Hypoplastic left heart syndrome is a congenital heart defect characterized by hypoplasia of left heart structures. Over the past 3 decades, there have been advances in techniques and management in the care of these patients. We discuss shunt selection, operative strategies, transplantation, and outline various facets of management at the University of Florida. This is a review of the literature highlighting some of the technical aspects of the preoperative, operative, and postoperative care that are important in today’s management of hypoplastic left heart syndrome.

Concepts: Medical terms, Heart, Down syndrome, Congenital heart defect, Congenital heart disease, Hypoplastic left heart syndrome, Optic nerve hypoplasia, Hypoplasia


Cardiopulmonary bypass has revolutionized the practice of cardiac surgery and allows safe conduct of increasingly complex cardiac surgery. A brief review of the bypass circuit is undertaken in this review. A more thorough review of the anesthetic management is accomplished including choice of anesthetic medications and their effects. The inflammatory response to cardiopulmonary bypass is reviewed along with interventions that may help ameliorate the inflammation.

Concepts: Inflammation, Blood vessel, Endothelium, Anti-inflammatory, Review, Cardiopulmonary bypass, The Practice


Temporary pacemakers are used in a variety of critical care settings. These life-saving devices are reviewed in 2 major categories in this review: first, the insertion and management of epicardial pacemakers after and during cardiac surgery; and second, the insertion of transvenous temporary pacemakers for the emergent treatment of bradyarrhythmias. Temporary epicardial pacemakers are used routinely in patients recovering from cardiac surgery. Borrowing from advances in cardiac resynchronization therapy there are many theoretical and untested benefits to pacing the postoperative cardiac surgery patient. Temporary transvenous pacing is traditionally an emergency procedure to stabilize patients suffering from hemodynamically unstable bradyarrhythmia. We review the traditional and expanding use of transvenous pacemakers inside and outside the operating room.

Concepts: Patient, Hospital, Physician, Review, Tradition, Artificial pacemaker, Transcutaneous pacing, Bradycardia


Acute kidney injury (AKI) is a serious postoperative complication following cardiac surgery. Despite the incidence of AKI requiring temporary renal replacement therapy being low, it is nonetheless associated with high morbidity and mortality. Therefore, preventing AKI associated with cardiac surgery can dramatically improve outcomes in these patients. The pathogenesis of AKI is multifactorial and many attempts to prevent or treat renal injury have been met with limited success. In this article, we will discuss the incidence and risk factors for cardiac surgery associated AKI, including the pathophysiology, potential biomarkers of injury, and treatment modalities.

Concepts: Renal failure, Kidney, Nephrology, Epidemiology, Medical statistics, Organ, Acute kidney injury, Hazard prevention


Anesthesia providers are frequently exposed to radiation during routine patient care in the operating room and remote anesthetizing locations. Eighty-two percent of anesthesiology residents (n = 57 responders) at our institution had a “high” or “very high” concern about the level of ionizing radiation exposure, and 94% indicated interest in educational materials about radiation safety. This article highlights key learning points related to basic physical principles, effects of ionizing radiation, radiation exposure measurement, occupational dose limits, considerations during pregnancy, sources of exposure, factors affecting occupational exposure such as positioning and shielding, and monitoring. The principle source of exposure is through scattered radiation as opposed to direct exposure from the X-ray beam, with the patient serving as the primary source of scatter. As a result, maximizing the distance between the provider and the patient is of great importance to minimize occupational exposure. Our dosimeter monitoring project found that anesthesiology residents (n = 41) had low overall mean measured occupational radiation exposure. The highest deep dose equivalent value for a resident was 0.50 mSv over a 3-month period, less than 10% of the International Commission on Radiological Protection occupational limit, with the eye dose equivalent being 0.52 mSv, approximately 4% of the International Commission on Radiological Protection recommended limit. Continued education and awareness of the risks of ionizing radiation and protective strategies will reduce exposure and potential for associated sequelae.

Concepts: Ionizing radiation, X-ray, Surgery, Neutron, Radiobiology, Radiation poisoning, Background radiation, Gray


The superior cavopulmonary connection (SCPC) or “bidirectional Glenn” is an integral, intermediate stage in palliation of single ventricle patients to the Fontan procedure. The procedure, normally performed at 3 to 6 months of life, increases effective pulmonary blood flow and reduces the ventricular volume load in patients with single ventricle (parallel circulation) physiology. While the SCPC, with or without additional sources of pulmonary blood flow, cannot be considered a long-term palliation strategy, there are a subset of patients who require SCPC palliation for a longer interval than the typical patient. In this article, we will review the physiology of SCPC, the consequences of prolonged SCPC palliation, and modes of failure. We will also discuss strategies to augment pulmonary blood flow in the presence of an SCPC. The anesthetic considerations in SCPC patients will also be discussed, as these patients may present for noncardiac surgery from infancy to adulthood.


Introduction. Cardiac Surgery Score (CASUS) was introduced in 2005 as the first postoperative scoring system specific for patients who had cardiac surgery. Prior to this, European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used preoperatively, while Intensive Care National Audit and Research Centre Score (ICNARC) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, which are widely used in general intensive care unit population, have been used to score cardiac patients postoperatively. The development of CASUS by Hekmat and colleagues for use in postoperative cardiac patients aims to change this. We wanted to validate CASUS against the well-established preoperative Logistic EuroSCORE, and postoperative APACHE II and ICNARC scores. Method. Institutional approval for this study was granted by the Audit and Clinical Governance Committee. We analyzed prospectively collected data of patients who had cardiac surgery in Castle Hill Hospital between January 2016 and September 2018. All patients who underwent surgery in the unit would have had Logistic EuroSCORE, APACHE, and ICNARC scores calculated as standard. CASUS was then calculated for these patients based on their day 1 postoperative variables. The scoring systems were compared and data presented as area under the receiver operating characteristic curve. Result. Our study shows that CASUS is the best predictor of mortality followed by ICNARC, Logistic EuroSCORE, and APACHE II. ICNARC score remains the most accurate predictor of renal and pulmonary complication followed by CASUS. Conclusion. CASUS is a useful scoring system in post-cardiac surgery patients. The accuracy of CASUS and ICNARC scores in predicting mortality, pulmonary, and renal complications are comparable.


Unexpectedly decreased left ventricular global systolic function can be difficult to manage, even for patients undergoing elective cardiac surgery, and should prompt a multidisciplinary discussion. Therefore, in this review, we discuss the evidence describing key perioperative variables expected to influence left ventricular systolic function to facilitate this discussion.


A patient with coronary artery fistula should be considered as high risk for intraoperative hemodynamic decompensation. In this article, we report the case of a 70-year-old man affected by a complex congenital coronary artery fistula defect. The patient underwent general anesthesia for spine surgery with permissive hypotension. The development of sudden intraoperative tachyarrhythmia with hemodynamic instability required immediate resuscitation and interruption of surgery. The claim advanced is that in patients with a coronary artery fistula permissive hypotension might be considered an option only if strictly necessary and real-time cardiac monitoring including transesophageal echocardiography is available to immediately detect and treat acute cardiac impairment.


Persistent left superior vena cava (PLSVC) is a rare abnormality with incidence reported as 0.3% to 0.5% in the general population and about 10 times higher in patients with congenital heart disease. The diagnosis of PLSVC in native or donor hearts of patients undergoing heart transplants has been reported in surgical journals. However, this rare finding has not been described in similar heart transplant settings in anesthesia literature. This case describes a 44-year-old male orthotopic heart transplant recipient who was incidentally diagnosed with PLSVC in his native heart on transesophageal echocardiogram after a central venous catheter placement. The particular position of the central venous catheter, in our case, raised the suspicion of PLSVC but needed further verification. With the help of images and videos, we demonstrate that transesophageal echocardiogram can be instrumental in diagnosing PLSVC. Furthermore, the case highlights the importance of effectively communicating with the surgeon about such a finding so that the surgical plan can be modified in a timely manner.