Journal and News Scan

Within the field of Enhanced Recovery after Thoracic and Cardiac Surgery (ERATS and ERACS, respectively), appropriate  fluid administration that avoids the detrimental effects of tissue edema on organ function and wound healing is a potentially important modifier of postoperative outcomes. This use of specific hemodynamic and other targets to provide goals of administered fluids (i.e. goal-directed therapy or GDT) has been suggested as an effective means to provide sufficient volume to facilitate cardiac flow while minimizing the potential harms of excessive fluid resuscitation.  The literature to this point, however, has been inconsistent in demonstrating improvements in clinical outcomes.  Bednarczyk and colleagues have undertaken an important and well-constructed SR/MA to determine if acute volume resuscitation using an objective measure of fluid responsiveness (stroke volume variation, pulse pressure variation, and stroke volume change with passive leg raise/fluid challenge) is associated with improved outcomes. In this analysis, the authors have concluded that the use of GDT guided assessments of fluid responsiveness was associated with reduced mortality, ICU length of stay, and time on mechanical ventilation. Further high quality clinical investigation in the cardiac critical care environment is warranted. 

The Nationwide Inpatient Sample (NIS) was queried for aortic valve replacements conducted between 2003 and 2014.  The data on a total of 166,809 patients (37% female) were analyzed with respect to outcomes in men vs. women.   Hospital mortality was 40% higher in women than men (5.6% v. 4%, p<0.001).   When isolated AVRs were analyzed and propensity-matched, hospital mortality was 14% higher in women than men (3.3% v. 2.9%, p=0.001).    The differential outcomes appear to be driven by a distinct risk profile.  

The authors conducted a double-blinded prospective, randomized clinical trial in 249 patients >60 years of age who underwent cardiac surgery with cardiopulmonary bypass to assess whether interventions based on cerebral oximetry would decrease the incidence of postoperative delirium.  Two groups were compared:  The control group, in which the results of cerebral oximetry were blinded, and the intervention group, in which an algorithm was instituted for oximetry values below 75% of baseline.  

Results:  Postop delirium occurred in 24.4%  and 24.6% of the intervention and control groups, respectively (p=0.97).  Thus, interventions based on cerebral oximetry data do not appear to alter the incidence of postop delirium.  Incidentally, a higher baseline cerebral oximetry value was associated with a lower incidence of postoperative delirium.

Duerr and colleagues describe the experimental development of a mitral anuloplasty ring, which should facilitate later transcatheter valve-in-ring implantation. Two accompanying videos demonstrate valve expansion and implantation within the ring. The article illustrates the potential importance these new technologies are expected to gain in the near future.