Transcaval transcatheter aortic valve replacement (TC-TAVR) is an alternative approach to transcatheter aortic valve replacement involving deployment of the bioprosthetic valve via a conduit created ...from the inferior vena cava to the descending aorta in patients for whom the traditional transfemoral approach is not feasible. By analyzing the largest known cohort of TC-TAVR patients, the authors wished to compare hospital length of stay and post-procedure outcomes between patients who underwent the procedure under deep sedation (DS) and patients who underwent general anesthesia with an endotracheal tube.
Retrospective, single-center study.
Henry Ford Hospital in Detroit, MI.
Patients undergoing TC-TAVR from 2015 to 2018.
Seventy-nine patients were included in the analysis, which consisted of 38 under general anesthesia with an endotracheal tube and 41 under DS. The sample was divided into a general anesthesia (GA) group and DS group. There were no significant differences in implant success rate or post-procedure outcomes, including in-hospital mortality (p = 0.999) and major vascular complication rate (p = 0.481), between the two groups. Patients in the GA group stayed a median of 24 hours longer in the intensive care unit (ICU) (p < 0.001) and one day longer in the hospital (p = 0.046) after the procedure compared to patients in the DS group. The median procedure time was significantly lower (135 minutes) in the DS group compared to the GA group (167 minutes, p < 0.001).
Patients undergoing TC-TAVR under DS had similar postoperative outcomes and shorter post-procedure hospital and ICU lengths of stay compared to general anesthesia. In the authors’ experience, DS is the preferred anesthetic technique for TC-TAVR.
The purposes of this study were to establish whether implementing a curriculum of perioperative point-of-care ultrasound (POCUS) of the heart and lungs for current in-training anesthesia residents ...during their required month of cardiac anesthesia was feasible and whether an evaluation tool would demonstrate improvement in the residents’ baseline knowledge of POCUS.
Single-center, prospective, cohort, and observational study.
A tertiary-care, university-affiliated hospital.
The study comprised 16 anesthesia residents on their third postgraduate training year during their required cardiac anesthesia rotation.
The implementation of a curriculum to educate anesthesia residents in perioperative POCUS of the heart and lungs on patients undergoing elective cardiothoracic procedures that included both theoretical and practical approaches. A 21-question, multiple-choice, electronic-generated test was developed to gauge performance improvement from before (“pretest”) to after (“posttest”) the 4-week period.
Of the 16 residents, 13 (81.3%) showed improved scores between the pretest and posttest periods after the 4-week rotation. The difference between pretest and posttest mean score was 5 (p = 0.001).
This study demonstrates that integrating a curriculum dedicated to perioperative POCUS of the heart and lungs as part of the goals and objectives during the rotation of cardiac anesthesia is feasible and that anesthesia residents who received the training proposed by the authors improved their cognitive and technical skills.
Many quorum sensing microbes produce more than one chemical signal and detect them using interconnected pathways that crosstalk with each other. While there are many hypotheses for the advantages of ...sensing multiple signals, the prevalence and functional significance of crosstalk between pathways are much less understood. We explore the effect of intracellular signal crosstalk using a simple model that captures key features of typical quorum sensing pathways: multiple pathways in a hierarchical configuration, operating with positive feedback, with crosstalk at the receptor and promoter levels. We find that crosstalk enables activation or inhibition of one output by the non-cognate signal, broadens the dynamic range of the outputs, and allows one pathway to modulate the feedback circuit of the other. Our findings show how crosstalk between quorum sensing pathways can be viewed not as a detriment to the processing of information, but as a mechanism that enhances the functional range of the full regulatory system. When positive feedback systems are coupled through crosstalk, several new modes of activation or deactivation become possible.
Abnormalities of the coronary vascular branches and cardiac hemangiomas represent together unusual clinical entities, with an incidence difficult to establish for the former as the vast majority of ...the patients with these anomalous vascular connections are usually asymptomatic and 2.8% for the latter. Symptomatic patients may develop dyspnea on exertion or chest pain secondary to a "coronary steal" phenomenon as part of the underlying pathophysiology of the disease. The authors report a case of a patient with concomitant cardiac capillary hemangioma with multiple coronary to pulmonary artery fistula connections that was successfully treated with surgical resection of the tumor and ligation of the fistula tracts. A comprehensive and balanced anesthesia management aimed to preserve tight hemodynamic stability to avoid increased myocardial demand and worsening of the coronary steal becomes essential in these patients.
Pro: Virtual Fellowship Interviews are Here to Stay Sanders, Joseph; Morrissey, Candice
Journal of cardiothoracic and vascular anesthesia,
April 2022, 2022-04-00, 20220401, Volume:
36, Issue:
4
Journal Article
Abstract
Left ventricular assist devices (LVAD) are mechanical pumps that have become a standard treatment for end-stage heart failure. As patients with LVAD are living longer, the number of ...noncardiac surgeries performed in these patients is rising. However, these patients present a unique set of risk factors, some of which include acquired coagulopathies, anticoagulation status, and hemodynamic instability. Thus, performing noncardiac surgeries in patients with an LVAD requires a precise and complex surgical strategy with optimal communication among the surgical team. Therefore, knowledge of best perioperative approaches for patients with LVAD is urgently needed. Here, we present a detailed perioperative surgical approach in the case of a brain tumor resection for a 62-year-old patient with an LVAD whose course was complicated with a brain hematoma. Critical details include key aspects of monitoring patient hemodynamic stability and handling of anesthesia, patient positioning, and antiplatelet and anticoagulation drug therapy. This case highlights the importance for anesthesiologists to be well informed about perioperative LVAD management, as well as common complications that they may encounter.
The Architecture of William Nichols: Building the Antebellum South in North Carolina, Alabama, and Mississippiis the first comprehensive biography and monograph of a significant yet overlooked ...architect in the American South. William Nichols designed three major university campuses--the University of North Carolina, the University of Alabama, and the University of Mississippi. He also designed the first state capitols of North Carolina, Alabama, and Mississippi. Nichols's architecture profoundly influenced the built landscape of the South but due to fire, neglect, and demolition, much of his work was lost and history has nearly forgotten his tremendous legacy.
In his research onsite and through archives in North Carolina, Alabama, Louisiana, and Mississippi, Paul Hardin Kapp has produced a narrative of the life and times of William Nichols that weaves together the elegant work of this architect with the aspirations and challenges of the Antebellum South. It is richly illustrated with over two hundred archival photographs and drawings from the Historic American Building Survey.
The twin goals of any litigation are to arrive at a correct outcome and provide the parties with a sense that they were treated justly, even if they do not prevail. Adversarial proceedings are often ...perceived to be superior to inquisitorial proceedings with respect to the second goal but inferior with respect to the first. This is especially the case when proceedings involve expert testimony. In this essay, we discuss several relatively minor changes to typical adversarial processes that offer the potential of improving trial accuracy without disrupting the overall structure of adversarial proceedings. These changes include 1) alterations to the organization of the trial, including concurrent expert testimony; 2) alterations to the role of the jury, including taking notes, asking questions, and receiving written expert reports; and 3) formal expert witness codes of conduct designed to better arm experts to resist the adversarial pressures that lead to biased testimony.
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