Continuous PECS II block for postoperative analgesia in patients undergoing transapical transcatheter aortic valve implantation

Anesthetic Considerations in Endovascular Repair of the Ascending Aorta

Since the first endovascular aortic repair in 1990, endovascular devices and the indications for their use have significantly grown. Considerable progress has been made in endovascular devices and techniques, such that endovascular repair is now considered first-line treatment for patients with descending aortic disease. However, for patients with ascending aortic disease, open surgical repair with cardiopulmonary bypass and hypothermic cardiac arrest was the only option until recently. Although the outcomes for open surgical repair of the ascending aorta have improved over the years, approximately 30% of patients with an emergent surgical indication, such as type A aortic dissection, are considered to be too high risk for open repair. For these patients, endovascular repair of the ascending aorta offers a life-saving procedure. The ascending aorta is regarded as the final frontier for endovascular therapy. Endovascular repair of it has posed a formidable challenge thus far, due to its unique anatomy, hemodynamic forces, and lack of an appropriate stent-graft designed specifically for the ascending aorta. Although currently there are no comprehensive data from randomized clinical trials, there are several case series and case reports that have shown favorable outcomes. Improvements in available devices soon will drive an exponential increase in the number of patients undergoing endovascular ascending aortic repair. In this review, the authors discuss multiple aspects of endovascular ascending aortic repair including the unique surgical and anesthetic considerations, the devices used, and the available outcomes data, and future directions are also explored.

Anesthesia for minimally invasive cardiac surgery

Due to its potential benefits and increased patient satisfaction minimal invasive cardiac surgery (MICS) is rapidly gaining in popularity. These procedures are not without challenges and require careful planning, pre-operative patient assessment and excellent intraoperative communication. Assessment of patient suitability for MICS by a multi-disciplinary team during pre-operative workup is desirable. MICS requires additional skills that many might not consider to be part of the standard cardiac anesthetic toolkit. Anesthetists involved in MICS need not only be highly skilled in performing transesophageal echocardiography (TEE) but need to be proficient in multimodal analgesia, including locoregional or neuroaxial techniques. MICS procedures tend to cause more postoperative pain than standard median sternotomies do, and patients need analgesic management more in keeping with thoracic operations. Ultrasound guided peripheral regional anesthesia techniques like serratus anterior block can offer an advantage over neuroaxial techniques in patients on anti-platelet therapy or anticoagulation with low molecular weight or unfractionated heparin The article reviews the salient points pertaining to pre-operative assessment and suitability, intraoperative process and postoperative management of minimally invasive cardiac procedures in the operating theatre as well as the catheterization lab. Special emphasis is given to anesthetic management and analgesia techniques.

Reducing Opioid Use in Patients Undergoing Cardiac Surgery - Preoperative, Intraoperative, and Critical Care Strategies

Patients undergoing cardiothoracic surgery are exposed to opioids in the operating room and intensive care unit and after hospital discharge. Opportunities exist to reduce perioperative opioid use at all stages of care and include alternative oral and intravenous medications, novel intraoperative regional anesthetic techniques, and postoperative opioid-sparing sedative and analgesic strategies. In this review, currently used and investigational strategies to reduce the opioid burden for cardiothoracic surgical patients are explored.