Cardiac thoracic vascular & perfusion (CTVP): Overview

Abstract
This systematic review and meta-analysis evaluated the impact of opioid-sparing versus opioid-based anesthesia in adult patients undergoing cardiac surgery. A comprehensive literature search was conducted across major databases from 2015 to 2025. Eligible studies included randomized controlled trials and observational cohorts reporting at least one of the following outcomes: opioid consumption (in morphine milligram equivalents [MME]), intensive care unit (ICU) length of stay, mechanical ventilation duration, pain scores, and mortality. A total of 27 studies (8 randomized controlled trials and 19 observational studies), including 58,998 patients, were analyzed. Opioid-sparing protocols, involving multimodal analgesia and regional anesthesia, were significantly associated with reduced intraoperative and postoperative opioid consumption. The pooled mean difference in opioid consumption was -2.48 MME (95% confidence interval [CI]: -2.60 to -2.35, p < 0.001). Opioid-sparing strategies were also associated with shorter ICU length of stay (odds ratio [OR]: 1.32, 95% CI: 1.14-1.51), reduced duration of mechanical ventilation (OR: 1.46, 95% CI: 1.24-1.72), and lower postoperative pain scores at 12 hours (OR: 1.18, 95% CI: 1.07-1.30). No significant difference was observed in postoperative mortality (OR: 0.20; 95% CI: 0.04-1.14). Narrative outcomes such as persistent opioid use, postoperative nausea, early mobilization, and patient satisfaction generally favored opioid-sparing anesthesia, although reporting was inconsistent. Adverse events related to nonopioid adjuncts were inconsistently reported. The overall risk of bias was low to moderate, and heterogeneity was moderate across most outcomes. These findings support opioid-sparing strategies in selected cardiac surgery patients as part of multimodal, enhanced recovery protocols, but highlight the need for standardized definitions and prospective trials with rigorous safety reporting.

Abstract
Objectives: Nonhome discharge (NHD) after cardiac surgery has increased in Australia and New Zealand, but its effect on long-term survival is unclear. This study aimed to assess whether NHD, compared with home discharge (HD), was associated with decreased survival up to 4 years after surgery. Additional objectives included evaluating the effects of discharge location, age, surgery types, and emergency status on long-term survival.

Design: We conducted a retrospective, multicenter, registry-based study (2018-2023).

Setting: We included 74 intensive care units (ICUs) across Australia and New Zealand that submitted data to the Australia New Zealand Intensive Care Society Adult Patient Database.

Participants: Adults (≥16 years) who underwent valvular surgery, coronary artery bypass grafting, or both and survived hospital discharge.

Interventions: None.

Measurements and main results: The study involved 92,865 patients, of whom 13,444 (14.5%) experienced NHD. NHD locations comprise rehabilitation centers, aged care facilities, mental health units, acute hospitals, and other settings. Survival up to 4 years was analyzed using Cox proportional hazards models. NHD was associated with reduced survival compared with HD (hazard ratio, 1.91; 95% confidence interval, 1.75-2.09), with the strongest association within the first 12 months after discharge. The association between NHD and reduced survival was notably greater for patients younger than 65 years (hazard ratio, 2.58; 95% confidence interval, 2.20-3.03) compared with those 65 years or older (hazard ratio, 1.71; 95% confidence interval, 1.54-1.89; pinteraction < 0.001). No significant differences existed between the NHD locations. Survival rates after NHD, compared with HD, were lower across all included surgery types, including emergency and elective procedures.

Conclusions: NHD after cardiac surgery is associated independently with decreased long-term survival, with the highest risk observed within the first year.

Abstract
Background: Transplantation of livers obtained from donors after circulatory death is associated with an increased risk of nonanastomotic biliary strictures. Hypothermic oxygenated machine perfusion of livers may reduce the incidence of biliary complications, but data from prospective, controlled studies are limited.

Methods: In this multicenter, controlled trial, we randomly assigned patients who were undergoing transplantation of a liver obtained from a donor after circulatory death to receive that liver either after hypothermic oxygenated machine perfusion (machine-perfusion group) or after conventional static cold storage alone (control group). The primary end point was the incidence of nonanastomotic biliary strictures within 6 months after transplantation. Secondary end points included other graft-related and general complications.

Results: A total of 160 patients were enrolled, of whom 78 received a machine-perfused liver and 78 received a liver after static cold storage only (4 patients did not receive a liver in this trial). Nonanastomotic biliary strictures occurred in 6% of the patients in the machine-perfusion group and in 18% of those in the control group (risk ratio, 0.36; 95% confidence interval [CI], 0.14 to 0.94; P = 0.03). Postreperfusion syndrome occurred in 12% of the recipients of a machine-perfused liver and in 27% of those in the control group (risk ratio, 0.43; 95% CI, 0.20 to 0.91). Early allograft dysfunction occurred in 26% of the machine-perfused livers, as compared with 40% of control livers (risk ratio, 0.61; 95% CI, 0.39 to 0.96). The cumulative number of treatments for nonanastomotic biliary strictures was lower by a factor of almost 4 after machine perfusion, as compared with control. The incidence of adverse events was similar in the two groups.

Conclusions: Hypothermic oxygenated machine perfusion led to a lower risk of nonanastomotic biliary strictures following the transplantation of livers obtained from donors after circulatory death than conventional static cold storage. (Funded by Fonds NutsOhra; DHOPE-DCD ClinicalTrials.gov number, NCT02584283.).

Abstract
Despite improvements in surgical techniques and perioperative care, cardiac surgery still is burdened by relatively high mortality and frequent major postoperative complications, including myocardial dysfunction, pulmonary complications, neurologic injury, and acute kidney injury. Although the surgeon's skills and volume and patient- and procedure-related risk factors play a major role in the success of cardiac surgery, there is growing evidence that also optimizing perioperative care may improve outcomes significantly. The present review focuses on the aspects of perioperative care that are strictly related to the anesthesia regimen, with special reference to volatile anesthetics and neuraxial anesthesia, whose effect on outcome in adult cardiac surgery has been investigated extensively.

Key points:
• The rate of fluid accumulation relative to pericardial stretch and the presence or absence of compensatory mechanisms are crucial in the development of cardiac tamponade.
• The pathophysiology of tamponade entails exaggerated variations in the normal haemodynamic changes that occur during respiration.
• Echocardiography is key to the diagnosis of pericardial effusions and tamponade.
• The primary goal in the management of tamponade is to relieve the effect of the fluid or clot on cardiac pressures and restore forward flow.
• Perioperative goals are to maintain preload and systemic vascular resistance; and to avoid bradycardia and myocardial depression.

The ISCHEMIA trial randomised over 5000 patients with moderate to severe stable coronary artery disease to compare initial invasive therapy with conservative medical treatment. The was a trend to a higher event rate in the invasive group at 6 months and a lower event rate in the invasive group at 5 years however overall the trial did not find any significant difference between the groups.

Early aortic valve replacement versus conservative care was compared in a randomised trial of 145 asymptomatic, very severe aortic stenosis patients. This study found significant and dramatic reduction in mortality in the early surgery compared to the conservative care group.

Koponen et al review the Vasoactive-Inotropic Score (VIS) as a tool to predict risk of mortality and morbidity after cardiac surgery and demonstrate the validity as an independent predictor for adults up to 1 year post cardiac surgery.

Khoche et al have published the fourth in a series of annual review articles on perioperative echocardiography “selected highlights from 2019”. This article reviews recent advances in echo topics such as quantification of RV function and RV diastolic function, the latest on Aortic Valve stenosis severity in the operating room, 3D echo of the tricuspid valve and more.