Journal of Cardiothoracic and Vascular Anesthesia
Volume 26, Issue 1 , Pages 3-10, February 2012

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2011

  • Prakash A. Patel, MD

      Affiliations

    • Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
    • ,
  • Harish Ramakrishna, MD, FASE

      Affiliations

    • Cardiac Anesthesia, Mayo Clinic, Scottsdale, AZ
    • ,
  • Michael Andritsos, MD

      Affiliations

    • Department of Anesthesiology, The Ohio State University, Columbus, OH
    • ,
  • Tygh Wyckoff, MD

      Affiliations

    • Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
    • ,
  • Hynek Riha, MD, DEAA, FCCP

      Affiliations

    • Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
    • ,
  • John G.T. Augoustides, MD, FASE, FAHA

      Affiliations

    • Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
    • Corresponding Author InformationAddress reprint requests to John G.T. Augoustides, MD, FASE, FAHA, Cardiothoracic Section, Anesthesiology and Critical Care, Dulles 680, HUP, 3400 Spruce Street, Philadelphia, PA 19104-4283

Article Outline

There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive valve surgery has shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for percutaneous coronary intervention in acute coronary syndromes but significantly reduces the risk of local vascular complications. Recent trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. The past year has witnessed major advances in cardiovascular practice with new drugs, new devices, and new guidelines. The coming year most likely will advance these achievements to enhance the care of patients.

Key Words:  factor Xa inhibitor , rivaroxaban , apixaban , direct thrombin inhibitor , dabigatran , blood conservation guidelines , aminocaproic acid , tranexamic acid , antifibrinolytics , erythropoietin , clopidogrel , platelet blockade , point-of-care testing , fresh frozen plasma , factor concentrates , leukoreduction , blood salvage , minimally invasive surgery , thoracic endovascular repair , cardiopulmonary bypass , coronary artery bypass surgery , ultrafiltration , microplegia , transcatheter mitral valve repair , transcatheter aortic valve implantation , percutaneous coronary intervention , radial artery , femoral artery , heart failure

 

THIS ARTICLE is the fourth in the annual series for the Journal of Cardiothoracic and Vascular Anesthesia.1 The authors thank the editor-in-chief, Dr Kaplan, for the opportunity to continue this series, namely the research highlights of the year that pertain to the specialty of cardiothoracic and vascular anesthesia. The introduction of this article outlines the major themes selected for 2011, each of which is then reviewed in detail in the main body of the article.

The literature highlights in the specialty of anesthesiology for 2011 begin with the rapid advances in oral anticoagulation that offer clinical alternatives to vitamin K antagonsists, such as warfarin. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been evaluated rigorously in large randomized clinical trials. As these novel anticoagulants are phased into clinical practice, they will usher in a new paradigm for perioperative anticoagulation as well.

Perioperative blood conservation in cardiac surgery has continued to receive considerable clinical attention because of concerns such as adverse outcomes associated with transfusion. The Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons recently have updated collaborative blood conservation guidelines that were first published in 2007. Their recommendations reflect a comprehensive and expert evaluation of the recent evidence that allows the perioperative clinician to even balance further the risks and benefits of transfusion.

Transcatheter mitral valve repair continues to mature with the recent publication of this technique compared with the gold standard, namely surgical mitral valve repair. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive aortic and mitral valve surgery have shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for percutaneous coronary intervention in acute coronary syndromes but is likely to reduce significantly the risk of local vascular complications. Recent landmark randomized trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. The themes selected for this fourth highlights article only have sampled the advances in anesthesiology for 2011. Many significant advances in 2011 also have been discussed in the expert review section of the Journal.

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Advances in Hematology 

The Oral Factor Xa Inhibitors 

The oral factor Xa inhibitors rivaroxaban and apixaban have received considerable clinical attention because multiple randomized trials recently have been published showing their effects in deep venous thrombois, atrial fibrillation, and acute coronary syndromes.2 These agents provide effective anticoagulation with a simple regimen with fixed dosing, a rapid onset, and no need for laboratory monitoring. Rivaroxaban in a large randomized trial (N = 3,449) showed equivalent outcomes for short-term and continued treatment of deep venous thrombosis when compared with standard therapy of subcutaneous enoxaparin followed by a vitamin K antagonist (warfarin or acenocoumarol).3 Furthermore, for thromboprophylaxis after hip arthroplasty, apixaban as compared with subcutaneous enoxaparin significantly reduced the rate of venous thromboembolism (N = 5,407: relative risk = 0.36; 95% confidence interval, 0.22-0.54; p < 0.001) without increasing the bleeding risk.4 Rivaroxaban has a half-life of 7 to 11 hours and a 66% renal clearance.2 Apixaban has a half-life of 12 hours and a renal clearance of only 25%.2 There are no clinically available reversal agents for these potent anticoagulants.

These novel agents also have ushered in a new era of anticoagulation for atrial fibrillation.5 As compared with warfarin, rivaroxaban recently was shown to be equivalent for anticoagulation in nonvalvular atrial fibrillation (N = 14,264) with significantly reduced risks of intracranial hemorrhage (0.5% v 0.7%, p = 0.02) and fatal bleeding (0.2% v 0.5%, p = 0.003).6 In contrast, apixaban was superior to warfarin for clinical anticoagulation in atrial fibrillation (n = 18,201).7 It significantly reduced the risk of systemic embolization, including stroke (hazard ratio = 0.79; 95% confidence interval 0.66-0.95; p = 0.01) as well as the risks of bleeding (hazard ratio = 0.69; 95% confidence interval 0.60-0.80; p < 0.001) and mortality (hazard ratio = 0.89; 95% confidence interval 0.80-0.99; p = 0.047).7

Although this burst of positive randomized trials holds immense therapeutic promise for these agents, they do have limitations. A recent randomized trial (N = 7,392) showed that apixaban combined with antiplatelet therapy after acute coronary syndromes worsened the risk of serious bleeding (hazard ratio = 2.59; 95% confidence interval, 1.50-4.46; p = 0.001) with no reduction of ischemic events.8 Furthermore, agents for prompt reversal of these agents in the perioperative period are not clinically available. Recent pilot studies have highlighted the role of prothrombin complex concentrate for reversal of factor Xa inhibitors because it contains high concentrations of factor X.9, 10 A recent study in healthy volunteers (N = 12) showed that prothrombin complex concentrate at a dose of 50 IUs/kg rapidly and completely reversed the effects of rivaroxaban.10 There are no more data to guide clinical reversal of the factor Xa inhibitors. It must be noted that dialysis for the prompt removal and reversal of factor Xa inhibitors has a limited role because they are highly bound to proteins with a small free fraction. As an example, rivaroxaban is about 95% bound to circulating proteins.11 These agents will be the focus of a dedicated expert review in the coming year because they likely will initiate a paradigm shift in perioperative anticoagulation.

The Oral Thrombin Inhibitors 

Dabigatran is an oral direct thrombin inhibitor with a rapid onset and with no requirement for coagulation monitoring.12 Recent prospective, randomized trials have shown the efficacy of dabigatran for the prevention of venous thromboembolism after joint replacement and for the prevention of systemic embolism in atrial fibrillation.12, 13 Because dabigatran relies on renal clearance, careful dosing is essential in patients with impaired renal function.14 Similar to factor Xa inhibitors, there is no reversal agent for dabigatran although hemodialysis can arrest life-threatening toxicity.15 Furthermore, the management of severe bleeding caused by dabigatran may require intervention with recombinant activated factor VII.15 Given the emerging perioperative importance of this novel anticoagulant, it will be examined in detail in a forthcoming expert review.16

Blood Conservation Guidelines in Cardiac Surgery 

Blood conservation in the conduct of cardiac surgery remains a priority. The Society of Cardiovascular Anesthesiologists in conjunction with the Society of Thoracic Surgeons recently published updated guidelines for blood conservation.17 This section focuses on the new recommendations since the previous guidelines were published in 2007. Full details, including the exhaustive literature review (404 references), are available in the updated guidelines.17 A recurring theme in these guidelines is the importance of a multidisciplinary blood management team as part of an effective and safe perioperative blood conservation program (class IIa recommendation, level of evidence B).17

Preoperative Interventions for Blood Conservation 

Platelet P2Y12-receptor blockers such as clopidogrel should be discontinued before coronary artery bypass graft (CABG) surgery, whether on- or off-pump. Although the interval depends on the half-life of the drug in question, it may be as short as 3 days for irreversible P2Y12 blockers such as clopidogrel (class I recommendation, level of evidence B).18, 19 Point-of-care platelet function testing may be a reasonable option to identify patients who are resistant to P2Y12 blockade to minimize operative delays (class IIb recommendation, level of evidence C). Routine P2Y12 platelet blockade is not indicated after CABG surgery except in patients with acute coronary syndromes or with recent drug-eluting coronary stents (class III recommendation, level of evidence B).

Short-term erythropoietin is a reasonable intervention to boost red cell mass before cardiac surgery in patients with or at risk for perioperative anemia and in patients who refuse transfusion, such as Jehovah's Witnesses (class IIa recommendation, level of evidence B).17, 20 Furthermore, short-term erythropoietin may be considered to augment preoperative red cell mass for the maximization of autologous donation (class IIb recommendation, level of evidence A).17 Erythropoeitin is not absolutely required as an essential component of a safe and effective preoperative autologous blood donation program in cardiac surgery.21

Antifibrinolytic Therapy for Blood Conservation 

The lysine analogs aminocaproic acid and tranexamic acid reduce bleeding and transfusion exposure in cardiac surgery (class I recommendation, level of evidence A).22, 23 A recent cost analysis showed that aminocaproic acid was as clinically effective and safe as tranexamic acid but at a fraction of the cost.22 Although it is an effective hemostatic agent, aprotinin is not indicated in clinical practice because of the increased risks of death and renal dysfunction in adult patients (class I recommendation, level of evidence A).24, 25 A recent analysis also has shown that aprotinin likely is associated with a significant risk of renal dysfunction in pediatric cardiac surgery as well (odds ratio = 4.7; 95% confidence interval, 1.1-19.5; p = 0.03).26

Antifibrinolytic agents may be poured into the surgical wound after cardiopulmonary bypass as a reasonable intervention to limit bleeding and blood transfusion (class IIa recommendation, level of evidence B).17

Blood Derivative Management for Blood Conservation 
Fresh Frozen Plasma 

Plasma transfusion is reasonable in major bleeding caused by coagulation factor deficiencies (class IIa recommendation, level of evidence B).17 Plasma transfusion is also an option in the setting of massive blood loss (class IIb recommendation, level of evidence B). Plasma is not indicated for warfarin reversal in the absence of bleeding (class III recommendation, level of evidence A). Although plasma transfusion is acceptable for urgent warfarin reversal, prothrombin complex concentrates are preferred (class IIa recommendation, level of evidence B). Plasma should not be transfused prophylactically in cardiac surgery in the absence of coagulopathy (class III Recommendation, level of evidence A).

Factor Concentrates 

Recombinant factor VIIa may be considered in the management of intractable nonsurgical bleeding after cardiac surgery with cardiopulmonary bypass (class IIb recommendation, level of evidence B).17, 27 This powerful hemostatic should not be a routine intervention because it is associated with thrombotic risks such as stroke.28, 29 Antithrombin III therapy is indicated for the management of heparin resistance because of antithrombin III deficiency before cardiopulmonary bypass (class I recommendation, level of evidence A).17 The clinical niche of antithrombin III concentrate in a blood conservation protocol in high-risk patients is not otherwise well established (class IIb recommendation, level of evidence C).17 Factor XIII concentrate may be considered for hemostasis after cardiopulmonary bypass when bleeding persists despite routine measures (class IIb recommendation, level of evidence C).17 Factor IX concentrates may be an option for cardiac surgical patients who have hemophilia B or who refuse blood transfusion (class IIb recommendation, level of evidence C).17

Blood Derivative Processing 

Transfusion with leukoreduced donor blood is a reasonable way to improve clinical outcomes in cardiac surgical patients (class IIa recommendation, level of evidence B).17, 30 Intraoperative platelet plasmapharesis is a reasonable component of a multimodality blood conservation protocol in high-risk patients (class IIa recommendation, level of evidence A).17

Blood salvage from the operative field using centrifugation is an option in adult cardiac surgical patients with known malignancy (class IIb recommendation, level of evidence B).17 Expert consensus suggests that the reinfusion of residual pump blood at the end of cardiopulmonary bypass is a reasonable intervention to minimize blood transfusion (class IIa recommendation, level of evidence C).17 Centrifugation of salvaged blood from the cardiopulmonary bypass machine is a reasonable intervention to reduce allogeneic blood transfusion (class IIa recommendation, level of evidence A).17, 31 Leukoreduction, platelet plasmapharesis, and blood salvage are all components of a multimodal approach to optimize perioperative transfusion practice.

Minimally Invasive Surgery for Blood Conservation 

Thoracic endovascular aortic repair for descending aortic diseases reduces bleeding and transfusion when compared with open procedures (class I recommendation, level of evidence B).17, 32 Off-pump CABG surgery is also a reasonable intervention for blood conservation, provided that the risk of conversion to on-pump CABG surgery is low (class IIa recommendation, level of evidence A).17, 33 It is likely that minimally invasive valve surgery also will be listed as a blood conservation measure when the guidelines are updated in the near future because multiple recent studies have shown the significant reductions in resource consumption.34, 35

Perfusion Interventions for Blood Conservation 

Minimized perfusion circuits for cardiopulmonary bypass reduce hemodilution and are indicated for blood conservation (class I recommendation, level of evidence A).17, 36 Patients with heparin-induced thrombocytopenia who require extracorporeal perfusion should be anticoagulated with alternative nonheparin anticoagulants, such as bivalirudin (class I recommendation, level of evidence C).17, 37 Biocompatible cardiopulmonary bypass circuits are an option for blood conservation (class IIb recommendation, level of evidence A).17, 38 Vacuum-assisted venous drainage in conjunction with minicircuits also may be an effective blood conservation strategy (class IIb recommendation, level of evidence C).17 Microcardioplegia may be an effective measure to limit transfusion by limiting hemodilution with crystalloid when applied as part of a multimodal blood conservation program (class IIb recommendation, level of evidence B).17

Modified ultrafiltration is a robust intervention for blood conservation for both adults and children undergoing cardiac surgery with cardiopulmonary bypass (class I recommendation, level of evidence A).17 In contrast, it is unclear whether conventional or zero-balance ultrafiltration limits bleeding and transfusion in cardiac surgery (class IIb recommendation, level of evidence A).17 Leukocyte filters are not indicated for blood conservation during cardiopulmonary bypass (class III recommendation, level of evidence B).17

In summary, the updated blood conservation guidelines provide a comprehensive evidence-based template for perioperative improvement of transfusion practice in anesthesiology.17 A recent expert consensus had identified the critical areas for future trials so that future clinical decisions for blood conservation in anesthesiology are even more evidence based.39 Furthermore, the significant variations in perioperative hematologic practice across institutions provide an opportunity for further research to identify best practices that can be adopted widely to optimize clinical outcomes for patients.40, 41

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Advances in Valve Intervention 

The Mitral Valve 

Transcatheter Mitral Repair 

Mitral valve repair for mitral regurgitation has evolved into a standard surgical technique.42 The edge-to-edge leaflet technique with an Alfieri stitch creates a double mitral valve orifice to provide an effective mitral valve repair in selected patients.43, 44 Transcatheter transseptal double-orifice repair with the MitraClip device (Abbott Laboratories, Abbott Park, IL) has shown significant improvement in mitral regurgitation in both the short- and midterm (Everest I Study: Endovascular Valve Edge-to-Edge Repair Study).45, 46

The EVEREST II study recently was completed and published.47 In this landmark trial, patients with severe mitral regurgitation (N = 279: 37 North American Centers from 2005 to 2008) were randomized in a 2:1 ratio to percutaneous repair with the MitraClip device or conventional surgery for mitral valve repair or replacement.47 The primary composite endpoint for efficacy was defined as freedom from death, mitral valve surgery, and severe mitral regurgitation at 12 months. The primary safety endpoint was defined as a composite of major adverse events at 30 days.47

Percutaneous mitral repair was significantly less effective at 12 months (55% v 73%, p = 0.007) but was significantly safer than surgery at 30 days (15% v 48%, p < 0.001).47 The decreased efficacy mostly was because of an increased risk of mitral valve surgery in the first year (20% v 2%). At 12 months, both cohorts had significantly improved symptoms, left ventricular dimensions, and quality of life. The investigators concluded that as compared with mitral surgery, percutaneous mitral repair is less effective for the reduction of mitral regurgitation but that it showed superior safety and similar outcome improvement.47

This landmark trial likely represents a stepping stone in the gradual maturation of transcatheter interventions for mitral valve repair. As highlighted in an earlier expert review article in the Journal, there are multiple transcatheter techniques in development.42 Consequently, it is likely that more pivotal trials of these transcatheter techniques compared with surgery will be undertaken in the future.42 Percutaneous mitral valve repair already has been described in a small case series as complementary to valve surgery in complex patients.48 Furthermore, it already has joined the list of possible mitral valve options that are part of the informed consent process.49

Minimally Invasive Mitral Valve Surgery 

Minimally invasive mitral valve surgery has evolved into a mainstream surgical option for mitral valve disease.50, 51 Recent trials have shown that this surgical approach can improve outcomes in high-risk patients, including the subset who have undergone previous cardiac surgery.52, 53 Furthermore, because of lower health resource utilization, minimally invasive mitral procedures are cost saving as well.50, 54 A clinical caveat is that this surgery has a higher stroke risk if arterial perfusion is retrograde (eg, femoral arterial cannula), especially in older patients.55 This stroke risk disappears in the presence of an antegrade arterial perfusion strategy.

The Aortic Valve 

Transcatheter Aortic Valve Implantation 

The development of transcatheter aortic valve implantation (TAVI) has been reviewed extensively in two prior articles for the Journal.56, 57 The landmark PARTNER (Placement of Aortic Transcatheter Valves) trials recently have been published.58, 59 In the first PARTNER trial, patients with severe aortic stenosis and with excessively high surgical risk were randomized to best medical therapy (including balloon valvuloplasty) or TAVI (N = 358: 21 medical centers around the world).58 Excessive surgical risk was defined as a predicted operative risk of death or severe disability >50%. The primary endpoint was all-cause mortality at 1 year. Mortality at 1 year was reduced significantly by TAVI (30.7% v 50.7% [hazard ratio = 0.55; 95% confidence interval, 0.40-0.74; p < 0.001).58 Furthermore, TAVI significantly decreased the risks of all-cause mortality and repeat hospitalization (42.5% v 71.6%; hazard ratio = 0.46; 95% confidence interval, 0.35-0.59; p < 0.001). In contrast, TAVI was associated with a higher perioperative stroke rate (5.0% v 1.1%, p = 0.06) and major vascular complications (16.2% v 1.1%, p < 0.001).58 The investigators concluded that despite the higher procedural risk, TAVI is superior to best medical management for severe aortic stenosis in patients considered too high risk for surgical aortic valve replacement.

In the second PARTNER trial, patients with severe aortic stenosis and with high surgical risk were randomized to surgical aortic valve replacement or TAVI (N = 699: 25 medical centers around the world).59 Excessive surgical risk was defined as a predicted operative risk of death or severe disability >10%. The primary endpoint was all-cause mortality at 1 year. The mortality at 1 year was similar between groups (24.2% for TAVI, 26.8% for surgery: p = 0.44).59 The stroke rates were similar at 30 days (3.8% for TAVI, 2.1% for surgery: p = 0.20) but tended to be higher in the TAVI cohort at 1 year (5.1% for TAVI, 2.4% for surgery: p = 0.07).59 Although TAVI was associated with a higher risk of vascular complications (11.0% v 3.2%, p < 0.001), it significantly decreased the risks of major bleeding (9.3% v 19.5%, p < 0.001) and new atrial fibrillation (8.6% v 16.0%, p = 0.006).58 The investigators concluded that despite important differences in procedural risk, TAVI was equivalent to surgical therapy for severe aortic stenosis in patients considered at high risk for surgical aortic valve replacement.59

The anesthetic technique for transfemoral TAVI also is feasible not only under general anesthesia but also local anesthesia combined with deep sedation based on titration of remifentanil and propofol.60, 61, 62 Noninvasive positive-pressure ventilation is a successful option in this technique, even in high-risk respiratory patients.60 This avoidance of general anesthesia also has been associated with significantly shorter procedural times and hospital stays.61 Furthermore, it also is compatible with transaxillary TAVI.62 These trials used transthoracic echocardiography and thus obviated the need for transesophageal echocardiography.60, 61

As TAVI technologies begin to disseminate throughout clinical practice, it is clear that TAVI is transformational.63 The successful introduction of this novel therapy will require the following components: a specialized heart center; a professional multidisciplinary team, including cardiac anesthesiologists; a specialized procedural venue, such as a hybrid operating room or a modified cardiac catheterization laboratory; participation in clinical trials to evaluate treatment outcomes and comparative effectiveness; standardized protocols for procedural excellence; and appropriate ongoing personnel training.63 The TAVI service line is a major opportunity for the cardiac anesthesiologist to play a leading and invaluable role within his/her institution at all stages of the program including planning, launch, growth, team building, crisis management, maturation, teaching, and training. Forthcoming articles on TAVI likely will explore these issues in further detail.63 The central importance of multidisciplinary collaboration has been apparent from the very beginning.64

Minimally Invasive Aortic Valve Surgery 

Minimally invasive aortic valve replacement continues to evolve. A recent trial (N = 192: 2005-2010) showed a 1.6% perioperative mortality rate with access to the aortic valve via a right anterior minithoracotomy.65 The investigators concluded that sutureless aortic valve technology would further facilitate the procedure by significantly shortening the cardiopulmonary bypass time.66, 67

Minimally invasive aortic valve surgery recently has been evaluated in a large single center series (N = 249: 1996-2009) in high-risk octogenarians with severe aortic stensosis.68 Despite a predicted operative mortality >10%, the operative mortality in this series was only 3%. The investigators pointed out that this surgical approach poses a serious alternative to TAVI. However, the question remains whether perioperative excellence at a single center represents the typical clinical outcomes of the cardiac surgical community at large.69 The clinical necessity for the precise prediction of operative risk for TAVI has prompted the ongoing development of a risk scoring system specific for TAVI.70 The serum biomarker, B-type natriuretic peptide, may feature prominently in this type of specific perioperative scoring system for aortic valve procedures.71

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Advances in Coronary Artery Disease 

Arterial Access for Percutaneous Coronary Intervention 

Major bleeding after percutaneous coronary intervention (PCI) for acute coronary syndromes has about a 2% to 5% incidence and is associated significantly with adverse clinical outcomes.72 Recent trials have suggested that radial access as compared with femoral access for PCI may reduce bleeding complications. A recent meta-analysis (N = 7,020 from 23 randomized trials: 1908-2008) confirmed that radial access significantly reduced major bleeding (0.05% v 2.3%; odds ratio = 0.27; 95% confidence interval, 0.16-0.45; p < 0.001).73 Furthermore, radial access was associated with a trend toward a reduced composite outcome of death, myocardial infarction, or stroke (2.5% v 3.8%; 95% confidence interval, 0.49-1.01; p = 0.058).73

A large multicenter trial (N = 7021: 158 medical centers from 32 countries, 2006-2010) randomized patients with acute coronary syndromes to PCI with either radial or femoral access.74 The primary outcome was a composite of death, myocardial infarction, stroke, or non-CABG major bleeding at 30 days. There was no significant difference in the defined primary outcome (3.7% for radial cohort, 4.0% for femoral cohort: hazard ratio = 0.92; 95% confidence interval, 0.72-1.17; p = 0.50).74 The radial access group had significantly fewer local vascular complications, such as large hematoma (hazard ratio = 0.40; 95% confidence interval, 0.28-0.57; p < 0.0001) and significant pseudoaneurysm (hazard ratio = 0.30; 95% confidence interval, 0.13-0.71; p = 0.006).74 The investigators concluded that both types of PCI access are safe and effective but that radial access is likely to have fewer local vascular complications.

Coronary Artery Surgery in Heart Failure 

The role of CABG surgery in patients with multivessel coronary artery disease and left ventricular systolic dysfunction has not been established clearly. A recent trial (N = 1212: 2002-2007) randomized patients with multivessel coronary artery disease and an ejection fraction below 35% to medical therapy alone or medical therapy and CABG surgery.75 The defined primary outcome was all-cause mortality. There was no significant difference in the primary outcome (hazard ratio with CABG surgery = 0.86; 95% confidence interval, 0.72-1.04; p = 0.12).75 Furthermore, in a randomized substudy of this cohort, an assessment of myocardial viability did not correlate with enhanced survival after CABG surgery as compared with medical therapy.76

The clinical implications of these two important trials are important.77 First, patients with coronary artery disease and left ventricular dysfunction benefit from optimal guideline-directed medical therapy. Second, patients with severe left main or equivalent coronary artery disease also should undergo CABG surgery as well as receive optimal medical therapy. Third, patients with angina should undergo CABG surgery as per current guidelines. It is important to remember that in these two randomized trials patients with left main disease and severe angina were excluded. A recent randomized trial showed that in patients with triple-vessel coronary artery disease, CABG surgery offers better relief from angina than PCI with drug-eluting stents.78

Fourth, patients with significant ischemic but viable myocardium in the distribution of a coronary artery with severe proximal disease should be revascularized whether by PCI or CABG surgery. Finally, patients with severe left ventricular dysfunction who have neither angina nor viable myocardium may benefit most from medical therapy with consideration of cardiac replacement therapy, such as ventricular assist device and/or heart transplantation.77, 79

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Conclusions 

There have been rapid advances in oral anticoagulation that offer clinical alternatives to vitamin K antagonists, such as warfarin. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated in pivotal randomized clinical trials. As these novel anticoagulants are phased into clinical practice, they will usher in a new paradigm for perioperative anticoagulation as well. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. Their recommendations reflect a comprehensive and expert evaluation of the recent evidence that allows the perioperative clinician to balance even further the risks and benefits of transfusion. Transcatheter mitral valve repair continues to mature with the recent publication of this technique compared with the gold standard, namely surgical mitral valve repair. TAVI for aortic stenosis has entered the clinical mainstream with randomized trials demonstrating its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive aortic and mitral valve surgery has shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for PCI in acute coronary syndromes but is likely to reduce significantly the risk of local vascular complications. Recent landmark randomized trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. These selected highlights have only sampled the advances in anesthesiology for 2011. The past year has witnessed major advances in cardiovascular practice with new drugs, new devices, and new guidelines. The coming year most likely will advance these achievements to enhance the care of patients.

Back to Article Outline

References 

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PII: S1053-0770(11)00708-7

doi:10.1053/j.jvca.2011.10.005

Journal of Cardiothoracic and Vascular Anesthesia
Volume 26, Issue 1 , Pages 3-10, February 2012

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