Jesse M. Raiten

Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery.

BACKGROUND Atrial fibrillation after cardiac surgery is associated with increased rates of death, complications, and hospitalizations. In patients with postoperative atrial fibrillation who are in stable condition, the best initial treatment strategy--heart-rate control or rhythm control--remains controversial. METHODS Patients with new-onset postoperative atrial fibrillation were randomly assigned to undergo either rate control or rhythm control. The primary end point was the total number of days of hospitalization within 60 days after randomization, as assessed by the Wilcoxon rank-sum test. RESULTS Postoperative atrial fibrillation occurred in 695 of the 2109 patients (33.0%) who were enrolled preoperatively; of these patients, 523 underwent randomization. The total numbers of hospital days in the rate-control group and the rhythm-control group were similar (median, 5.1 days and 5.0 days, respectively; P=0.76). There were no significant between-group differences in the rates of death (P=0.64) or overall serious adverse events (24.8 per 100 patient-months in the rate-control group and 26.4 per 100 patient-months in the rhythm-control group, P=0.61), including thromboembolic and bleeding events. About 25% of the patients in each group deviated from the assigned therapy, mainly because of drug ineffectiveness (in the rate-control group) or amiodarone side effects or adverse drug reactions (in the rhythm-control group). At 60 days, 93.8% of the patients in the rate-control group and 97.9% of those in the rhythm-control group had had a stable heart rhythm without atrial fibrillation for the previous 30 days (P=0.02), and 84.2% and 86.9%, respectively, had been free from atrial fibrillation from discharge to 60 days (P=0.41). CONCLUSIONS Strategies for rate control and rhythm control to treat postoperative atrial fibrillation were associated with equal numbers of days of hospitalization, similar complication rates, and similarly low rates of persistent atrial fibrillation 60 days after onset. Neither treatment strategy showed a net clinical advantage over the other. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT02132767.).

Anesthetic Management of Patients Undergoing Pulmonary Vein Isolation for Treatment of Atrial Fibrillation Using High-Frequency Jet Ventilation

OBJECTIVES The aim of this study was to describe anesthetic management and perioperative complications in patients undergoing pulmonary vein isolation for the treatment of atrial fibrillation under general anesthesia using high-frequency jet ventilation. The authors also identified variables associated with longer ablation times in this patient cohort. DESIGN A retrospective observational study. SETTING The electrophysiology laboratory in a major university hospital. PARTICIPANTS One hundred eighty-eight consecutive patients undergoing pulmonary vein isolation under general anesthesia with high-frequency jet ventilation. INTERVENTIONS High-frequency jet ventilation was used as the primary mode of ventilation under general anesthesia. MEASUREMENTS AND MAIN RESULTS High-frequency jet ventilation was performed successfully throughout the ablation procedure in 175 cases of the study cohort. The remaining 13 patients had to be converted to conventional positive-pressure ventilation because of high PaCO(2) or low PaO(2) on arterial blood gas measurements. Variables associated with a shorter ablation time included a higher ejection fraction (p = 0.04) and case volume performed by each electrophysiologist in the study group (p = 0.001). CONCLUSIONS High-frequency jet ventilation is generally a safe technique that can be used in catheter ablation treatment under general anesthesia.

Atrial Fibrillation After Cardiac Surgery: Clinical Update on Mechanisms and Prophylactic Strategies

ATRIAL FIBRILLATION (AF) is a common complication after cardiac surgery and is associated with increased cost, morbidity, and mortality. Minimally invasive surgical techniques such as transcatheter aortic valve replacement (TAVR) have not substantially reduced the risk of developing AF. The development of AF after cardiac surgery remains common and significantly increases mortality, morbidity, and total hospital costs, including readmission. In an effort to reduce these adverse consequences of this complication, considerable research recently has focused on identifying prophylactic strategies for AF after cardiac surgery. A thorough understanding of the mechanisms underlying the genesis of AF in this setting may aid in designing preventative paradigms and standardizing treatment. The purpose of this expert review is to highlight the incidence, pathogenesis, and preventative strategies for AF after cardiac surgery.

Global health outreach during anesthesiology residency in the United States: a survey of interest, barriers to participation, and proposed solutions ☆

STUDY OBJECTIVE To assess the interest in and barriers to pursuing global health outreach (GHO) experiences for anesthesiology residents in the United States. DESIGN Survey instrument. SETTING Academic department of anesthesiology. SUBJECTS Anesthesiology residents who were members of the American Society of Anesthesiologists (ASA). MEASUREMENTS An online survey was administered to residents in anesthesiology via the ASA membership database. Descriptive statistics, including means, frequencies, and percentages were calculated. MAIN RESULTS 91% of participants indicated an interest in GHO, of whom fewer than half (44%) had done a GHO medical mission. Seventy-nine percent reported that GHO affected their current practice or education; 33% commented they were now less wasteful with supplies and resources. Permission from work or obtaining work coverage were the primary barriers for both those with and without previous GHO participation. Of all respondents, 78% agreed that the availability of a GHO residency track would influence their ranking of that program for training, and 71% would pursue a GHO fellowship if available. CONCLUSIONS Anesthesiology residents have an interest in residency and fellowship GHO programs. Formalization of GHO programs during training may reduce work-related barriers associated with GHO participation and broaden academic program recruitment.

The use of high-frequency jet ventilation for out of operating room anesthesia.

Purpose of review High-frequency jet ventilation is a novel technique for providing mechanical ventilation in the out of operating room (OOR) setting. Case reports and a small series of patients have shown it to be useful in patients undergoing cardiac arrhythmia ablations, interventional radiology procedures, and extracorporeal shock wave lithotripsy. Recently, interest in the technique has grown tremendously as the ability to provide superior surgical conditions may lead to improved efficiency and less side-effects in a variety of procedures. Recent findings Atrial fibrillation ablation procedures, liver tumor ablations, and extracorporeal shock wave lithotripsy are all the procedures that benefit from minimal movement of the heart, liver, and kidney, respectively, during the procedure. Although randomized controlled trials are lacking, increasing data suggest that by maintaining the thoracic and abdominal structures relatively immobile throughout the respiratory cycle, the efficiency and safety of these procedures may be improved. Summary Technological advances are allowing an increasing number of surgical procedures to be performed in the OOR setting. Such procedures often depend on the precise application of ablation catheters or shock waves. High-frequency jet ventilation facilitates the improved accuracy of catheter and shock wave placement, as well as efficiency of a variety of procedures. Improved efficiency, with fewer side-effects, has tremendous implications for the growth of such procedures in the OOR setting.

Medical intelligence article: novel uses of high frequency ventilation outside the operating room.

High frequency jet ventilation (HFJV) is a technique that is most frequently used in the intensive care unit and during tracheal and otorhinolaryngologic surgery. The utility of HFJV for procedures performed outside of the intensive care unit and operating room is currently being explored. The ability of HFJV to provide mechanical ventilation, yet achieve near static conditions of the chest and abdomen, makes it a very appealing technique for procedures such as pulmonary vein isolation and ablation for atrial fibrillation, targeted radiation therapy for lung and liver tumors, and certain diagnostic imaging techniques.

Critical care management of patients following transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) is rapidly gaining popularity as a technique to surgically manage aortic stenosis (AS) in high risk patients. TAVR is significantly less invasive than the traditional approach to aortic valve replacement via median sternotomy. Patients undergoing TAVR often suffer from multiple comorbidities, and their postoperative course may be complicated by a unique set of complications that may become evident in the intensive care unit (ICU). In this article, we review the common complications of TAVR that may be observed in the ICU, and different strategies for their management.Transcatheter aortic valve replacement (TAVR) is rapidly gaining popularity as a technique to surgically manage aortic stenosis (AS) in high risk patients. TAVR is significantly less invasive than the traditional approach to aortic valve replacement via median sternotomy. Patients undergoing TAVR often suffer from multiple comorbidities, and their postoperative course may be complicated by a unique set of complications that may become evident in the intensive care unit (ICU). In this article, we review the common complications of TAVR that may be observed in the ICU, and different strategies for their management.

“If I Had Only Known” — On Choice and Uncertainty in the ICU

After receiving a ventricular assist device, a patient experiences months of advances and setbacks in the ICU. Shes one of a new subcategory of ICU patients: the chronically critically ill. Their stories reveal shortcomings of common perspectives on medical decision making.

Management of Postoperative Atrial Fibrillation in Cardiac Surgery Patients

Postoperative atrial fibrillation (AF) is a common arrhythmia following cardiac surgery and contributes to patient morbidity, prolonged hospital stay, and increased financial costs. The risk of postoperative AF may increase based on patient characteristics or events that occur intraoperatively or postoperatively. An understanding of these risks may be helpful in identifying which patients would benefit from prevention strategies. Acute AF presentation may range from completely indolent to rapidly progressing hemodynamic instability. Patients without hemodynamic compromise can be managed conservatively with rate control or initiation of antiarrhythmic medications. Patients with significant hemodynamic instability should undergo direct current cardioversion. In the postoperative period, it is reasonable to initiate anticoagulation after 48 hours of sustained AF or frequent episodes of postoperative AF.

Lessons of the Gacaca

I exited the church memorial in Ntarama in 2006 to find a crowd gathered, immersed in discussion, an elderly man resting in the middle on a wooden stool. “It’s gacaca,” my guide said, but my mind was still focused on the racks of human skulls in the church, the rusty brown blood stains on the wall. It wouldn’t be until years later at my patient’s bedside that I would appreciate the true significance of that meeting under the acacia tree. Twenty-one years has passed since nearly 1 million people perished in Rwanda at the hands of the Interahamwe, a Hutu paramilitary group, in a genocide rooted in decades-old tension between the Hutu and Tutsi people. Twenty-one years after the bloodshed, the ghosts of the genocide live on—in the discovery of human bones behind a house, in the amputees on the streets. Yet today, Rwanda is a country that is healing, its people emerging from the shadows of the past both as individuals and as a nation, and in the process, defining the vast and abstract nature of how we heal. The practice of medicine offers a rare glimpse into the human drama—peoples’ thoughts, their struggles, their triumphs. It provides a front row seat to humanity’s extraordinary ability to heal. In 2013 I returned to Rwanda to teach critical care for the Human Resources for Health program, charged with helping to improve a health care infrastructure devastated by the genocide. On my first day teaching in the ICU, I was approached by a young nurse. We spoke of America, my job at home, my children. But when I asked about his family and his past, his eyes adjusted toward the floor, his voice deepened, he rolled his fingers nervously. At first we both hesitated, he reluctant to reveal, I unsure if I wanted to know more. What was he hiding? Was he afraid I would judge him? He was raised in the western province of Rwanda, a teenager during the genocide. My mind raced as I imagined what he had been through, what he had seen. Roughly two decades after he witnessed his country torn apart, with enthusiasm and compassion he dressed the wounds of a country healing. There are hundreds of genocide memorials across Rwanda, serving not only as reminders of a history that must never be forgotten, but as testaments to the incredible resiliency of the Rwandan people. The Murambi Genocide Memorial is located in the southern province of Rwanda. Originally a vocational school, Murambi was the site of one of the genocide’s most notorious massacres, when more than 50 000 Tutsi were herded into small classrooms and killed.1 Those classrooms became the memorial, boldly displaying hundreds of bodies that were preserved in lime, immortalized so the massacre could never be denied. The air was stagnant under the baking sun, the smell of human remains, almost 20 years later, beckoned your hand to cover your face. I exited a brick schoolroom full of the remains of women and children, unnerved by a mother whose mummified arms still clung to her infant child. As if the preceding 20 years had passed overnight, the definition of her fingernails was still visible, a black shroud of fabric covered her hair. My guide waited patiently sitting on the edge of a brick wall. “I think you’ve had enough,” he said, a wisdom in his voice that came from years of experience guiding people through the memorials. He had greeted me when I arrived at Murambi, alone behind a simple wooden desk at the end of a long stone path. I emptied my pockets into the donation jar. He bowed his head and thanked me for visiting, for remembering, for keeping history alive. Like many of the guides at the memorials across Rwanda, he had lost family in the genocide and went on to make his living by sharing his knowledge, his experience, his story. In the years following the massacres, 12 000 gacaca courts tried more than 1.2 million perpetrators of the genocide.2 Gacaca, roughly translated to “justice on the grass,” is a traditional mechanism of resolving dispute in Rwanda dating back to the 17th century. After the genocide, gacaca served to identify the truths of the events, as well as a mechanism for reconciliation, healing, and unification of the Rwandan people.3 The courts were presided over by the Inyangamugayo, elders who were selected to serve as judges based on their honesty and integrity rather than any legal expertise. In the aftermath of a genocide where friends one day turned murderers the next, the reestablishment of trust and respect among people was as central to healing as the legal process itself. The gacaca courts strived to find justice and healing through truth, respect, and forgiveness, while never denying the realities of the past. As physicians we often rely on these same principles to help our patients heal from traumatic experiences or chronic illness. I recently received an award for patient care in our intensive care unit in Philadelphia. When I reviewed the patient’s chart, I was surprised to recall the patient actually had passed away under my care. He was an elderly gentleman from China with terminal colon cancer who spent a week in our ICU as his disease progressed. I grew up in Hong Kong, close to where he had been a child, and the stories I shared with him brought joy to both of us, although he mostly just listened to me speak. Months after he died I was acknowledged by the patient’s family for my care of their father. In reality, I hadn’t done much besides listen and talk with him, knowing all along that further medical interventions were futile. Perhaps there was a sense of trust between us, a connection spurred from familiarity, from our childhoods in Hong Kong. Perhaps there was a mutual understanding of what was important to him at that A PIECE OF MY MIND