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Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement
Published on: March 26, 2018
Major themes for 2009 in cardiothoracic and vascular anesthesia
J Fassl1, H Riha, H Ramakrishna
1Department of Anesthesiology and Critical Care, University of Basel; Switzerland.
Insights
Advancements in cardiac surgery include hybrid operating rooms for transcatheter therapies and new drugs for hemostasis and nephroprotection. While some interventions show promise, further trials are needed to confirm their benefits and safety.
Area of Science:
- Cardiovascular Medicine
- Surgical Innovation
- Interventional Cardiology
Background:
- The hybrid operating room facilitates transcatheter therapies, integrating cardiac surgery, cardiovascular anesthesiology, and interventional cardiology.
- Cardiac specialists are increasingly adopting endovascular techniques, exemplified by transcatheter aortic valve replacement.
- Emerging research focuses on pharmacologic and ischemic myocardial conditioning, with ongoing clinical trials.
Purpose of the Study:
- To review recent advancements in cardiac surgery, including new clinical settings, devices, and pharmacologic agents.
- To evaluate the impact of various interventions on outcomes after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).
- To discuss the potential roles of novel agents in managing bleeding, hemostasis, and nephroprotection in cardiac surgery patients.
Main Methods:
- Review of current literature and clinical trial data related to cardiac surgery and interventional cardiology.
- Analysis of factors influencing outcomes in coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).
- Evaluation of emerging pharmacologic agents for hemostasis, platelet production, and nephroprotection.
Main Results:
- Off-pump CABG may offer advantages in high-risk populations compared to on-pump CABG.
- Percutaneous coronary intervention (PCI) reduces mortality post-myocardial infarction, but evidence for intra-aortic balloon counterpulsation is less convincing.
- Newer antiplatelet agents like ticagrelor may supersede prasugrel.
- Coronary artery bypass grafting (CABG) shows superior outcomes in diabetics and the elderly for multivessel disease.
- Certain agents like hetastarch and N-acetylcysteine increase bleeding risks, while Factor VII requires further safety evaluation.
- Eltrombopag and romiplostim show potential for stimulating platelet production.
- Fenoldopam, atrial natriuretic peptide, and sodium bicarbonate demonstrate nephroprotective effects, pending further trials.
- Intensive insulin therapy provides no outcome benefit and increases hypoglycemia risk.
Conclusions:
- The past year has seen significant advancements in cardiac surgical venues, devices, and drugs.
- Ongoing research and clinical trials are crucial for validating the efficacy and safety of new interventions.
- Future developments are expected to further enhance patient care and outcomes in cardiovascular medicine.
Abstract:
The hybrid operating room is the venue for transcatheter therapy with the convergence of three specialties: cardiac surgery, cardiovascular anesthesiology, and interventional cardiology. Transcatheter aortic valve replacement is proof that cardiac specialists have embraced the endovascular revolution. Since pharmacologic and ischemic myocardial conditioning are safe and effective, they are currently the focus of multiple trials. Angiotensin blockade, anemia and endoscopic saphenous vein harvesting worsen outcome after coronary artery bypass grafting (CABG). Although off-pump CABG is equivalent to on-pump CABG, it may improve outcomes in high-risk groups. Although percutaneous coronary intervention (PCI) significantly decreases mortality after myocardial infarction, the evidence is less convincing for intra-aortic balloon counterpulsation. Even though prasugrel was recently approved for platlet blockade in PCI, it may be superceded by ticagrelor. Although PCI and CABG appear equivalent for multivessel coronary disease, CABG lowers revascularization rates and also has superior outcomes in diabetics and the elderly. Hetastarch and N-acetylcysteine both increase bleeding and transfusion in cardiac surgery. Factor VII can treat life-threatening bleeding, but its safety requires further evaluation. Since eltrombopag and romiplostim stimulate platelet production, they may have a future role in hemostasis after cardiac surgery. Even though fenoldopam, atrial natriuretic peptide and sodium bicarbonate are nephroprotective, further trials must confirm these findings. Intensive insulin therapy offers no further outcome advantage and significantly increases hypoglycemic risk. The past year has witnessed the advent of a new clinical venue, new devices, and new drugs. The coming year will most likely advance these achievements.
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