Impact of leaflet splitting on coronary access after redo-TAVI for degenerated supra-annular self-expanding platforms.

BACKGROUND: Coronary access (CA) is a major concern in redo-transcatheter aortic valve implantation (TAVI) for failing supra-annular self-expanding transcatheter aortic valves (TAVs). AIMS: This ex vivo study evaluated the benefit of leaflet splitting (LS) on subsequent CA after redo-TAVI in anatomies deemed at high risk of unfeasible CA. METHODS: Ex vivo, patient-specific models were printed three-dimensionally. Index TAVI was performed using ACURATE neo2 or Evolut PRO (TAV-1) at the standard implant depth and with different degrees of commissural misalignment (CMA). Redo-TAVI was performed using the balloon-expandable SAPIEN 3 Ultra (TAV-2) at different implant depths with commissural alignment. Selective CA was attempted for each configuration before and after LS in a pulsatile flow simulator. The leaflet splay area was assessed on the bench. RESULTS: In matched comparisons of 128 coronary cannulations across 64 redo-TAVI configurations, the overall feasibility of CA significantly increased after LS (60.9% vs 18.7%; p<0.001). The effect of LS varied according to the sinotubular junction height, TAV-1 design, TAV-1 CMA, and TAV-2 implant depth, given TAV-2 alignment. LS enabled CA for up to CMA 45° with the ACURATE neo2 TAV-1 and up to CMA 30° with the Evolut PRO TAV-1. The combination of LS and a low TAV-2 implant provided the highest feasibility of CA after redo-TAVI. The leaflet splay area ranged from 25.60 mm2 to 37.86 mm2 depending on the TAV-1 platform and TAV-2 implant depth. CONCLUSIONS: In high-risk anatomies, LS significantly improves CA feasibility after redo-TAVI for degenerated supra-annular self-expanding platforms. Decisions on redo-TAVI feasibility should be carefully individualised, taking into account the expected benefit of LS on CA for each scenario.

A bench study of balloon-expandable valves for the treatment of self-expanding valve failure.

BACKGROUND: Coronary obstruction and access are concerns in patients undergoing redo transcatheter aortic valve implantation (TAVI). AIMS: We sought to assess the neoskirt height, leaflet overhang, leaflet deflection,and transcatheter heart valve (THV) expansion and performance, at 2 different implant depths, of the SAPIEN 3 Ultra (S3U) within the ACURATE neo2 (ACn2) THV. METHODS: An in vitro study was performed with a 23 mm S3U deployed within a small (S) ACn2 and a 26 mm S3U deployed within a medium (M) and a large (L) ACn2. The S3U outflow was positioned at the top of the ACn2 crown (low implant) and at the base of the commissural post of the ACn2 (high implant). Testing was performed under physiological conditions as per ISO-5840-3 standard. RESULTS: The neoskirt height was shorter when the S3U outflow was positioned at a low implantation depth (S: 9.6 mm, M: 12.2 mm, L: 13.8 mm vs S: 15.2 mm, M: 15.1 mm, L: 17.8 mm ACn2 for high implants). Hydrodynamic performance was acceptable for all configurations. Leaflet overhang was <50% for all configurations except the low implant of the 26 mm S3U in the L ACn2 (77.6%). There was a gap from the side of the neoskirt to the outer border of the THV frame which was >2 mm for all configurations. The S3U was underexpanded for all configurations, and the achieved area was 77.9%-92.9% of the expected nominal area. CONCLUSIONS: Redo TAVI with an S3U within an ACn2 has favourable hydrodynamics and moderate leaflet overhang. Importantly, the design of the ACn2 results in a neoskirt that is not deflected all the way to the outer dimensions of the THV, hence creating a space that facilitates coronary flow and access.

Primer of COVID-19 Vaccines for the Perioperative Physician.

Dr. Emanuel Papper, the founding chairman of the Department of Anesthesiology at Columbia University, was passionate about research, training, and innovation. At an event held in his honor on March 20, 2021, experts came together to discuss the coronavirus disease 2019 (COVID-19) pandemic and its myriad challenges. Dr. Wellington Sun, MD, of Vaxcellerant LLC, an expert in infectious disease and vaccine research and development, presented a "Primer of COVID-19 vaccines for the perioperative physician." Operation Warp Speed was successful in producing multiple efficacious and safe vaccines for use in the United States and around the globe. Their development and authorization for emergency use occurred in an unprecedented timespan of <1 year. Technology such as V-SAFE has helped to accrue extensive postdevelopment safety data that will be utilized for licensure of these vaccines. The COVID-19 vaccine success is tempered by the knowledge that severe acute respiratory syndrome coronavirus 2 continues its natural selection of variants that threaten the efficacy of vaccines. Important questions remain regarding the future of the COVID-19 pandemic, severe acute respiratory syndrome coronavirus 2 variants, successful vaccination strategies, and preparedness for future pandemics.

COVID-19 Impact on Resident Mental Health and Well-Being.

Columbia University's Papper Symposium, a virtual event held on March 20, 2021, was dedicated to the coronavirus disease-2019 (COVID-19) pandemic. This article summarizes a lecture by Dr. Roberta Hines, Nicholas M. Greene Professor of Anesthesiology and Department Chair and Chief of Anesthesiology at Yale-New Haven Hospital titled "The impact of COVID-19 on trainees: lessons learned and unanticipated opportunities," in addition draws from experiences at Columbia University Irving Medical Center and a focused review of the literature on the toll of the pandemic on trainee well-being and mental health. Early research has demonstrated that rates of burnout and acute stress were higher among health care providers who cared for COVID-19 patients than those who did not and that COVID-19 frontline health care providers are at high risk for common psychological disorders, including depression, anxiety, and post-traumatic stress disorder. Trainees working on the frontlines may be at particularly high risk for these mental health disorders and are less likely to access resources available to them. Program directors and hospital graduate medical education leaders should be aware of the threats to physiological and psychological safety and take action to prevent further detrimental effects. The rates of burnout and mental health disorders among trainees are expected to rise as a result of the pandemic, making screening programs and increased access to mental health treatment an essential feature of all residency and fellowship programs.

The Impact of COVID-19 on Trainees: Lessons Learned and Unanticipated Opportunities.

Dr. Emanuel Martin Papper was a Professor and Department Chair at Columbia University whose top passion was training the next generation of anesthesiologists. As such, a fitting topic for discussion at Columbia University Department of Anesthesiology's Papper Symposium was the "The Impact of the COVID-19 Pandemic on Trainees: Lessons Learned and Unanticipated Opportunities," presented by Dr. Roberta L. Hines, Nicholas M. Greene Professor of Anesthesiology and Department Chair and Chief of Anesthesiology at Yale-New Haven Hospital. The pandemic led to abrupt changes at the national, hospital, and training program levels, all of which impacted trainees in anesthesiology and other disciplines. Nationally, there were sweeping regulatory changes that helped to shape the coronavirus disease-2019 response by medical front line workers. At each individual hospital, coronavirus disease-2019 units were created and teams were restructured to keep up with patient care demands. Educational programs adapted their curricula and trainees lost valuable clinical and academic opportunities. The innovative educational responses, including a pivot to virtual learning and virtual recruitment, provided a silver lining to the health care crisis. Another bright spot was that anesthesiology as a specialty rose to the forefront of patient care. Anesthesiologists displayed impactful leadership during the pandemic, paving the way for future growth and broadened reach of our specialty.

Pediatric surgeons and anesthesiologists expand the dialogue on the neurotoxicity question, rationale for early and delayed surgeries, and practice changes while awaiting definitive evidence.

The Pediatric Anesthesia NeuroDevelopment Assessment team at Columbia University Medical Center Department of Anesthesiology convened its fourth biennial Symposium to address unresolved issues concerning potential neurotoxic effects of anesthetic agents and sedatives on young children and to assess study findings to date. Dialogue initiated at the third Symposium was continued between anesthesiologists, researchers, and a panel of expert pediatric surgeons representing general surgery and dermatology, orthopedic, and urology specialties. The panel explored the need to balance benefits of early surgery using improved technologies against potential anesthetic risks, practice changes while awaiting definitive answers, and importance of continued interprofessional dialogue.

Postoperative cognitive function following general versus regional anesthesia: a systematic review.

The effect of anesthetic technique on postoperative outcomes remains in question. This systematic review compares the role of regional versus general anesthesia, with a particular focus on postoperative cognitive function. Potentially relevant articles were identified by searching publicly available computerized databases for this systematic review. Any surgical procedure was accepted with the exception of cardiac, carotid, and neurosurgical procedures. Any regional anesthetic technique was accepted unless combined with a general anesthetic or in conjunction with propofol as a sedative. Any measure of postoperative cognitive function was accepted as long as it was performed no sooner than 7 days postoperatively. Sixteen studies met inclusion criteria and were included in the final analysis. Three studies showed some difference in cognitive function between regional and general anesthesia, whereas the remaining 13 showed no difference between regional and general anesthesia on postoperative cognitive function.

Changes in impairment level, functional status, and use of assistive devices by older people with depressive symptoms.

OBJECTIVE: We sought to understand how functional status, impairment level, and use of assistive devices change over 3 years for older adults with depressive symptoms. We further explored factors that predict change in severity of depressive symptoms. METHOD: This study used data from the Rehabilitation Engineering Research Center on Aging Consumer Assessment Study, a longitudinal study of coping strategies of elders with disabilities. Seventy-three participants with depressive symptoms were interviewed at baseline and 3 years later. RESULTS: During 3 years, participants experienced increased physical disability (p = .001), a decline in severity of depressive symptoms (p = .03), and an increase in the total number of assistive devices owned. CONCLUSION: A significant number of older adults will experience a decrease in depressive symptoms over 3 years, despite an increase in physical disability. They also will obtain more assistive devices as they age.

Implementing clinical supervision: Part 1: laying the ground work.

Australia, like other countries, is experiencing a crisis in the recruitment and retention of nurses. Clinical supervision has been suggested as a potential strategy to enhance retention. However, there is a paucity of literature regarding the successful implementation of clinical supervision. The aim of this study is to explore and evaluate ways of implementing clinical supervision as undertaken in a rural health-care organization in Victoria. Qualitative methodology was used including a documentation audit and individual interviews with the staff responsible for implementation. The findings demonstrate that the successful implementation had occurred in five interrelated stages. This paper, one in a series of three, focuses on the preimplementation phase leading up to initial implementation. The main themes identified during these stages were: organizational culture, exploring the possibilities, leadership and education and training which will be examined. These issues were essential in laying the foundation for the systematic introduction of clinical supervision.

Implementation of clinical supervision in action: Part 2: implementation and beyond.

This paper presents the second part of the findings of an Australian study examining the implementation of clinical supervision in a rural mental health service. A qualitative, exploratory approach was adopted, which included the auditing of relevant documentation and interviews with the nurses who oversaw the implementation process. Within this organization, implementation happened through five stages. The first two stages (preimplementation) were described in Part 1 of this paper. Part 2 describes stages 3-5, including: the strategic plan; implementing the strategic plan; and reflecting on the past and moving forward. The implementation model developed as a result of this research is presented in Part 3. The main findings from these stages included: the role of the implementation committee; the need for a strategic approach; the necessity of education and training; the ongoing importance of assessing organizational culture and considering the sustainability of clinical supervision.

Implementation of clinical supervision in action: Part 3: the development of a model.

Implementation has been observed to be crucial to the successful introduction of clinical supervision. Despite its importance, there is limited literature which articulates principles or process to guide it. The first and second parts of this three-part paper present findings of a qualitative exploration of the implementation of clinical supervision in a rural mental health service. The findings were discussed in light of the Driscoll model of implementation. While this model provided a valuable tool to interpret some aspects of the findings, its focus was primarily on the preimplementation stage, particularly in terms of assessing the workplace culture and the recognition of the pushing and resisting forces in relation to clinical supervision. This paper presents a new model of implementation with interrelated and dynamic stages. The model was developed in a rural mental health service context. An overview of this research-based model is presented in this paper.

Using activity theory to evaluate and improve K-12 school and university partnerships.

This article reports on an evaluation methodology development study for K-12 school and university partnerships. The method is based on Engeström's (1987). Learning by expanding: An activity-theoretical approach to developmental research. Helsinki: Orienta-Konsultit Oy activity systems analysis that allows researchers to examine qualitative datasets of complex human interactions. This study was designed for participants to evaluate partnership relations and activities. We investigated how the use of activity systems analysis in K-12 school and university partnership evaluation meetings affected participant communication processes. In this study, during a 1-day retreat K-12 school staff and university staff used a modified activity systems model to identify persisting institutional tensions in their program that often trigger miscommunications and strain their relations. During the discussion sessions, study participants collaboratively examined their partnership relations and identified strategies for overcoming difficulties. Additionally, in subsequent monthly partnership meetings during the school year, participants examined findings from the evaluation to design and implement improvement strategies. The results from this methodology development and implementation study provided researchers and partnership participants a new means to (a) evaluate partnership activities, (b) identify institutional barriers, (c) plan future activities, and (d) listen to and incorporate the ideas of less vocal staff members into the planning of future activities.

An evaluation of an educational program for clinical supervision.

Clinical supervision for mental health nurses has become an area of priority since the implementation of the Enterprise Bargaining Agreement of August 2000 in Victoria. Clinical supervision has been identified as a strategy to improve both the job satisfaction of nurses and the quality of care provided to consumers. A review of the literature suggests that adequate education for supervisors is crucial if this strategy is to prove successful. In response to this identified need, the Centre for Psychiatric Nursing Research and Practice developed the "Clinical Supervision for Health Professionals" program. The evaluation of participants from the first 2 years of the program (n = 63) are mentioned here. The findings suggest a high level of satisfaction with the education provided and that it has been successful in improving participants' attitudes towards, and level of confidence in providing, clinical supervision.