CPB in conscious patients — surely you’re joking

In this issue of the EJCTS, Porizka and co-workers explore whether cardiopulmonary bypass (CPB) in conscious patients is feasible using standard blood flow rates [1]. This publication is certainly provocative and raises a number of questions. Since the early days of cardiac surgery and CPB, our speciality has made enormous progress in alleviating suffering and saving lives of increasingly sicker patients. The latest EACTS Adult Cardiac Surgical Database Report revealed that the average mortality for cardiac surgery in Europe is about 3—4% [2]. Surgical innovation based on ethical considerations is important to advance our current clinical practice [3]. Alternative treatment options may become available in situations where the patient is deemed unfit for conventional surgery or conventional anaesthesia. The latest addition to our armamentarium is transcatheter aortic and mitral valve treatment. Before fast-track recovery following cardiac surgery became commonplace, the role of thoracic epidural anaesthesia was explored to facilitate earlier extubation and better pain relief. This was logical in the days before inhalational anaesthetic agents and short-acting narcotics. Adding a thoracic epidural to a general anaesthetic has been shown to be beneficial in coronary surgery [4]. Thoracic epidurals increase coronary perfusion and improve pulmonary function [5]. The safety of thoracic epidural anaesthesia under these circumstances has been amatter of concern. Coronary surgery is usually performed in patients on platelet-active medication and heparin is required during surgery. This may increase the risk of epidural haematoma formation, a feared complication that may lead to permanent neurologic damage. In a recent review, Royse stated that thoracic epidural anaesthesia is safe in patients undergoing cardiac surgery. It appears that the risk ofepiduralhaematoma isabout1 in12,000,whichaccording to the author is similar tonon-cardiac surgery [6]. However, other authors suggest a lower incidence of epidural haematoma in non-cardiac surgery [7]. Thoracic epidural anaesthesia without general anaesthesia in conscious patients has been performed in a small number of cardiac surgical procedures, mostly in off-pump coronary artery bypass (OPCAB) surgery. The largest series is