Loss of Independent Living in Patients Undergoing Transcatheter or Surgical Aortic Valve Replacement: A Retrospective Cohort Study.

BACKGROUND: The recommendation for transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) in patients 65 to 80 years of age is equivocal, leaving patients with a difficult decision. We evaluated whether TAVR compared to SAVR is associated with reduced odds for loss of independent living in patients ≤65, 66 to 79, and ≥80 years of age. Further, we explored mechanisms of the association of TAVR and adverse discharge. METHODS: Adult patients undergoing TAVR or SAVR within a large academic medical system who lived independently before the procedure were included. A multivariable logistic regression model, adjusting for a priori defined confounders including patient demographics, preoperative comorbidities, and a risk score for adverse discharge after cardiac surgery, was used to assess the primary association. We tested the interaction of patient age with the association between aortic valve replacement (AVR) procedure and loss of independent living. We further assessed whether the primary association was mediated (ie, percentage of the association that can be attributed to the mediator) by the procedural duration as prespecified mediator. RESULTS: A total of 1751 patients (age median [quartiles; min-max], 76 [67, 84; 23-100]; sex, 56% female) were included. A total of 27% (222/812) of these patients undergoing SAVR and 20% (188/939) undergoing TAVR lost the ability to live independently. In our cohort, TAVR was associated with reduced odds for loss of independent living compared to SAVR (adjusted odds ratio [OR adj ] 0.19 [95% confidence interval {CI}, 0.14-0.26]; P < .001). This association was attenuated in patients ≤65 years of age (OR adj 0.63 [0.26-1.56]; P = .32) and between 66 and 79 years of age (OR adj 0.23 [0.15-0.35]; P < .001), and magnified in patients ≥80 years of age (OR adj 0.16 [0.10-0.25]; P < .001; P -for-interaction = .004). Among those >65 years of age, a shorter procedural duration mediated 50% (95% CI, 28-76; P < .001) of the beneficial association of TAVR and independent living. CONCLUSIONS: Patients >65 years of age undergoing TAVR compared to SAVR had reduced odds for loss of independent living. This association was partly mediated by shorter procedural duration. No association between AVR approach and the primary end point was found in patients ≤65 years of age.

Curriculum for Subspecialty Anesthesia Training in Adult Structural Heart Disease Imaging: A Single-Center Experience.

Intraprocedural transesophageal echocardiography imaging is an integral part of percutaneous structural heart disease (SHD) interventions. The rapid growth in the number, scope, and complexity of SHD interventions has outpaced the efforts to develop training and proficiency standards in periprocedural imaging. At the Beth Israel Deaconess Medical Center in Boston, Massachusetts, the authors have developed a 6-month duration fellowship in interventional echocardiography for SHD to address this issue. The purpose of this fellowship is to train cardiac anesthesiologists to address the unique challenges of interventional echocardiography. In this paper, the authors describe the rationale for and specific features of this training program. Their fellowship curriculum follows a multimodal integrative approach to training in SHD imaging, which includes simulation sessions, online modules, deliberate practice in the clinical setting, and interdisciplinary team-based training. In the next several years, there will be an increased need for echocardiographers who are proficient in intraprocedural SHD imaging. In this article, the authors describe their experience with a competency-based curriculum for subspecialty anesthesia training in SHD imaging.

Year in Review 2020: Noteworthy Literature in Cardiothoracic Anesthesiology.

The year 2020 was marred by the emergence of a deadly pandemic that disrupted every aspect of life. Despite the disruption, notable research accomplishments in the practice of cardiothoracic anesthesiology occurred in 2020 with an emphasis on optimizing care, improving outcomes, and expanding what is possible for patients undergoing cardiac surgery. This year's edition of Noteworthy Literature Review will focus on specific themes in cardiac anesthesiology that include preoperative anemia, predictors of acute kidney injury following cardiac surgery, pain management modalities, anticoagulation strategies after transcatheter aortic valve replacement, mechanical circulatory support, and future directions in research.

Cardiac arrhythmia from epinephrine overdose in epidural test dose.

Medication shortages are a clinical reality that force changes in practice patterns leading to unintended consequences. Potential solutions to any drug shortage require a thoughtful, multidisciplinary and often creative approach. Here, we report a case of unintentional epinephrine overdose leading to an unstable cardiac arrhythmia and our subsequent development of a visual cue system to prevent future errors. A 56-year-old man with a history of rectal adenocarcinoma presented for low anterior resection and creation of diverting loop ileostomy. Epidural placement was requested by the surgical team, and following administration of a second test dose (created by the physician), the patient experienced supraventricular tachycardia with heart rates of 200-210 BPM for approximately 2 minutes. This rhythm then converted to atrial fibrillation with rapid ventricular response with heart rate of 150-170 BPM. The patient was stabilized after cardioversion. Later evaluation of medication administration revealed that the second epidural test dose inadvertently contained 100 mcg epinephrine instead of the intended 10 mcg dose. The test dose had to be created because the original ampule with the kit had been utilized. Since this time, our kits have no test dose, and this shortage is concerning for increased provider error. We suggest a novel visual cue system that may prevent unintentional epinephrine overdoses in the setting of regional anesthesia.

Use of the rabbit larynx in an excised larynx setup.

OBJECTIVE: To modify the excised larynx bench apparatus to accommodate experiments with rabbit larynges. STUDY DESIGN: Methodological study using ex vivo rabbit larynges. METHODS: Rabbit larynges (n=5) were dissected and mounted on a custom-made phonatory apparatus. The arytenoids were adducted by rods, and humidified air was passed through the larynx to elicit vocal fold vibration. Acoustic, aerodynamic, electroglottographic (EGG), and videokymographic data were collected for each larynx. The same data were collected for five canine larynges for the purpose of comparison, and coefficients of variation were calculated for each parameter in both models. RESULTS: Reliable phonation was achieved in each larynx. Acoustic fundamental frequency (F(0)), percent jitter, percent shimmer, signal-to-noise ratio, pressure and flow at phonation onset and offset; and F(0), closed quotient, speed quotient, jitter, shimmer, and contact quotient, as recorded by EGG; and mucosal wave amplitude and phase difference are reported for rabbit larynges. Coefficients of variation for each parameter are similar in magnitude between the two models. CONCLUSION: We developed a method for recording reliable acoustic, aerodynamic, videokymographic, and EGG data from rabbit larynges. When data obtained from leporine larynges were compared with data from canine larynges, the intralarynx variability of rabbit larynges was found to be similar to that of canine larynges.

Comparison of conjunctival autograft transplantation and amniotic membrane transplantation for pterygium: a meta-analysis.

BACKGROUND: Conjunctival autograft transplantation (CAT) and amniotic membrane transplantation (AMT) are two widely used techniques for pterygium treatment. However, previous studies comparing the outcomes of CAT and AMT have generally had small sample sizes and conflicting results. The aim of this report was to evaluate and comment on peer-reviewed literature for evidence of effectiveness and safety of CAT and AMT for management of pterygium. METHODS: Studies comparing outcomes of CAT and AMT for pterygium treatment were identified by searching PubMed, Embase, Web of Knowledge, and a search of all references in relevant papers. Two reviewers confirmed study eligibility and extracted data independently, and data were pooled using standard meta-analysis techniques. RESULTS: Five eligible studies reporting outcomes in 538 eyes were included. The pooled hazard ratio (HR) estimate for recurrence of CAT compared to AMT was 0.30 (95% confidence interval (CI) [0.16, 0.59], p < 0.001) and 0.22 (95%CI [0.02, 2.37], p = 0.214), respectively, for primary and recurrent pterygium. For unacceptable appearance, the pooled HR estimate was 0.33 (95% CI [0.16, 0.66], p = 0.002). There were no statistically significant differences in adverse events (odds ratio (OR) = 0.96, 95% CI [0.46, 1.97], p = 0.901). CONCLUSIONS: Available trials indicate that CAT has lower recurrence risk compared to AMT for primary pterygium treatment, as well as lower risk of unacceptable appearance risk.

Interspecies comparison of mucosal wave properties using high-speed digital imaging.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to compare the vocal fold vibratory characteristics of ex vivo bovine, canine, ovine, and porcine larynges to human male and female vocal fold vibrations to determine the best model organism for laryngeal studies concerning vibratory and kinetic characteristics. STUDY DESIGN: Prospective experimental. METHODS: High-speed videos of phonation were gathered at 4,000 frames per second (fps) in the animal models and human high-speed endoscopy data were gathered at 2,000 fps. Videos were converted into kymograms, and the amplitude, oscillation frequency, and phase difference of vocal fold vibration were measured. RESULTS: No statistically significant differences were found with respect to frequency, amplitude, or phase difference between canines and humans. Porcines were not significantly different from human females but did have an oscillation frequency significantly different from human males. Ovine vibrational amplitudes were significantly different from humans, and bovine frequency and amplitude differed significantly from humans. CONCLUSIONS: Canine and porcine larynges are the most appropriate model specimens for laryngeal studies contingent on vibratory or kinetic properties of phonation.