The Year in Graduate Medical Education: Selected Highlights from 2023.

This special article is the third in an annual series of the Journal of Cardiothoracic and Vascular Anesthesia that highlights significant literature from the world of graduate medical education published over the past year. Major themes addressed in this review include the potential uses and pitfalls of artificial intelligence in graduate medical education, trainee well-being and the rise of unionized house staff, the effect of gender and race/ethnicity on residency application and attrition rates, and the adoption of novel technologies in medical simulation and education. The authors thank the editorial board for again allowing us to draw attention to some of the more interesting work published in the field of graduate medical education during 2023.

Efficacy and Safety of Botulinum Toxin Type A for the Prevention of Postoperative Atrial Fibrillation.

Background: Postoperative atrial fibrillation (POAF) is associated with increased morbidity and mortality. Epicardial injection of botulinum toxin may suppress POAF.

Objectives: This study sought to assess the safety and efficacy of AGN-151607 for the prevention of POAF after cardiac surgery.

Transesophageal echocardiographic acquisition of the venous excess ultrasound exam-a case series and technical description.

Purpose: Obtaining an objective, reproducible, and accurate assessment of volume status is one of the more difficult tasks in the perioperative arena. Since its advent in 2020, the Venous Excess Ultrasound (VExUS) score has gained popularity in the minimally invasive assessment of venous congestion. The VExUS exam has been well described as an additional series of images (hepatic vein, portal vein, and intrarenal vein) obtained with a phased-array probe during a transthoracic echocardiogram.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023.

This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology.

Design and Rationale of a Phase 2 Study of NeurOtoxin (Botulinum Toxin Type A) for the PreVention of Post-Operative Atrial Fibrillation - The NOVA Study.

Background: Post-operative AF (POAF) is the most common complication following cardiac surgery, occurring in 30% to 60% of patients undergoing bypass and/or valve surgery. POAF is associated with longer intensive care unit/hospital stays, increased healthcare utilization, and increased morbidity and mortality. Injection of botulinum toxin type A into the epicardial fat pads resulted in reduction of AF in animal models, and in two clinical studies of cardiac surgery patients, without new safety observations.

Using Plasma and Prothrombin Complex Concentrates.

Surgical patients, following procedural interventions or traumatic injury, often bleed due to ongoing blood loss or coagulopathy. Volume resuscitation and transfusion management are critical for the massively bleeding patient. While transfusions may correct coagulopathy, they carry multiple risks including circulatory overload and transfusion-related acute lung injury.

Neuromodulation for the Treatment of Heart Rhythm Disorders.

There is an increasing recognition of the importance of interactions between the heart and the autonomic nervous system in the pathophysiology of arrhythmias. These interactions play a role in both the initiation and maintenance of arrhythmias and are important in both atrial and ventricular arrhythmia. Given the importance of the autonomic nervous system in the pathophysiology of arrhythmias, there has been notable effort in the field to improve existing therapies and pioneer additional interventions directed at cardiac-autonomic targets.

Association Between Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery.

Importance: The number of patients prescribed long-term opioids and benzodiazepines and complications from their long-term use have increased. Information regarding the perioperative outcomes of patients prescribed these medications before surgery is limited.

Objective: To determine whether patients prescribed opioids and/or benzodiazepines within 6 months preoperatively would have greater short- and long-term mortality and increased opioid consumption postoperatively.

Temporary autonomic modulation with botulinum toxin type A to reduce atrial fibrillation after cardiac surgery.

Background: Postoperative atrial fibrillation (POAF) frequently complicates cardiac surgery and is associated with worse outcomes. The cardiac autonomic nervous system is implicated in the pathogenesis of POAF.

Objective: The purpose of this study was to determine the efficacy and safety of selective cardiac autonomic modulation in preventing POAF.

Successful Identification of Anatomical Markers and Placement of Feeding Tubes in Critically Ill Patients via Camera-Assisted Technology with Real-Time Video Guidance.

Background: Enteral feeding via feeding tube (FT) provides essential nutrition support to critically ill patients or those who cannot intake adequate nutrition via the oral route. Unfortunately, 1%-2% of FTs placed blindly at bedside enter the airway undetected (as confirmed by x-ray), where they could result in adverse events. Misplaced FTs can cause complications including pneumothorax, vocal cord injury, bronchopleural fistula, pneumonia, and death.

Utility of Angle Correction for Hemodynamic Measurements with Doppler Echocardiography.

Objectives: The routine application angle correction (AnC) in hemodynamic measurements with transesophageal echocardiography currently is not recommended but potentially could be beneficial. The authors hypothesized that AnC can be applied reliably and may change grading of aortic stenosis (AS).

Design: Retrospective analysis.

Predictive ability of perioperative atrial fibrillation risk indices in cardiac surgery patients: a retrospective cohort study.

Purpose: The Multicenter Study of Perioperative Ischemia (McSPI) AFRisk index predicts postoperative atrial fibrillation (POAF) after cardiac surgery, but requires pre-, intra-, and postoperative data. Other more abbreviated risk indices exist, but there is no consensus on which risk index is optimal. We compared the discriminatory capacity of the McSPI AFRisk index with three indices containing only preoperative data (the CHADSVasc score, POAF score, and Kolek clinical risk prediction model), hypothesizing that the McSPI AFRisk index would have superior predictive capacity.

Stellate ganglion blockade for the treatment of refractory ventricular arrhythmias: A systematic review and meta-analysis.

Introduction: Treatment refractory ventricular arrhythmias (VAs) are often driven and exacerbated by heightened sympathetic tone. We aim to conduct a systematic review and meta-analysis of published studies of a temporary percutaneous stellate ganglion block (SGB) on VA burden and defibrillation episodes in patients with treatment refractory VAs.

Methods: Relevant studies from January 1960 through May 2017 were identified in PubMed and Google Scholar.

Bleeding risk associated with eptifibatide (Integrilin) bridging in thoracic surgery patients.

Antiplatelet use for treatment of coronary artery disease (CAD) is common amongst thoracic surgery patients. Perioperative management of antiplatelet agents requires balancing the opposing risks of myocardial ischemia and excessive bleeding. Perioperative bridging with short-acting intravenous antiplatelet agents has shown promise in preventing myocardial ischemia, but may increase bleeding.

Transorbital endotracheal intubation: a nonstandard approach to a difficult airway.

We present the case report of a 49-year-old gentleman with a history of adenoid cystic carcinoma of the left nare status post curative bifrontal craniotomy, left lateral rhinotomy and medial maxillectomy, adjuvant radiotherapy, and orbital exenteration for optic neuropathy, complicated by medial wall dehiscence. His course was also complicated by severe radiation trismus, for which he was scheduled to undergo bilateral mandibular coronoidectomies. Given his limited mouth opening, the surgeon requested a nasal endotracheal tube.

No association between donor age and recipient outcomes: transfusion of plasma in patients undergoing coronary artery bypass grafting surgery.

Background: Recent animal studies suggest that transfusion of plasma from young donors reverses age-related neurologic and cardiac changes in older recipients. Associations between age of blood product donors and corresponding outcomes in recipients have not been studied in humans. Therefore, our primary objective was to examine this relationship between donor age and recipient outcomes among patients that received plasma during and after coronary artery bypass grafting (CABG) surgery.

Intraoperative Magnesium Administration Does Not Reduce Postoperative Atrial Fibrillation After Cardiac Surgery.

Background: Hypomagnesemia has been associated with an increased risk of postoperative atrial fibrillation (POAF). Although previous studies have suggested a beneficial effect of magnesium (Mg) therapy, almost all of these are limited by small sample size and relatively low Mg dose. We hypothesized that high-dose Mg decreases the occurrence of new-onset POAF, and we tested this hypothesis by using data from a prospective trial that assessed the effect of Mg on cognitive outcomes in patients undergoing cardiac surgery.