Carbon Footprint of Total Intravenous and Inhalation Anesthesia in the Transcatheter Aortic Valve Replacement Procedure.

OBJECTIVES: To quantify and compare the emissions for deep sedation with total intravenous anesthesia (TIVA) and general anesthesia with inhaled agents during the transcatheter aortic valve replacement procedure. DESIGN: A retrospective study. SETTING: A tertiary hospital in Boston, Massachusetts. PARTICIPANTS: The anesthesia records of 604 consecutive patients who underwent the transcatheter aortic valve replacement procedure between January 1, 2018, and March 31, 2022, were reviewed and analyzed. INTERVENTIONS: Data were examined and compared in the following 2 groups: general anesthesia with inhaled agents and deep sedation with TIVA. MEASUREMENTS AND MAIN RESULTS: The gases, drugs, airway management devices, and anesthesia machine electricity were collected and converted into carbon dioxide emissions (CO2e). The carbon emissions of intravenous medications were converted with the CO2e data for anesthetic pharmaceuticals from the Parvatker et al. study. For inhaled agents, inhaled anesthetics and oxygen/air flow rate were collected at 15-minute intervals and calculated using the anesthetic gases calculator provided by the Association of Anesthetists. The airway management devices were converted based on life-cycle assessments. The electricity consumed by the anesthesia machine during general anesthesia was estimated from the manufacturer's data (Dräger, GE) and local Energy Information Administration data. The data were analyzed in the chi-squared test or Wilcoxon rank-sum test. There were no significant differences in the patients' demographic characteristics, such as age, sex, weight, height, and body mass index. The patients who received general anesthesia with inhaled agents had statistically higher total CO2e per case than deep sedation with TIVA (16.188 v 1.518 kg CO2e; p < 0.001), primarily due to the inhaled agents and secondarily to airway management devices. For deep sedation with TIVA, the major contributors were intravenous medications (71.02%) and airway management devices (16.58%). A subgroup study of patients who received sevoflurane only showed the same trend with less variation. CONCLUSIONS: The patients who received volatile anesthesia were found to have a higher CO2e per case. This difference remained after a subgroup analysis evaluating those patients only receiving sevoflurane and after accounting for the differences in the duration of anesthesia. Data from this study and others should be collectively considered as the healthcare profession aims to provide the best care possible for their patients while limiting the harm caused to the environment.

Impact of Pressure Recovery Adjustment on Aortic Valve Area Classification of Disease Severity in Transcatheter Aortic Valve Replacement Patients.

OBJECTIVES: To determine the impact of pressure recovery (PR) adjustment on disease severity grading in patients with severe aortic stenosis. The authors hypothesized that accounting for PR would result in echocardiographic reclassification of aortic stenosis severity in a significant number of patients. DESIGN: A retrospective observational study between October 2013 and February 2021. SETTING: A single-center, quaternary-care academic center. PARTICIPANTS: Adults (≥18 years old) who underwent transcatheter aortic valve implantation (TAVI). INTERVENTIONS: TAVI. MEASUREMENTS AND MAIN RESULTS: A total of 342 patients were evaluated in this study. Left ventricle mass index was significantly greater in patients who continued to be severe after PR (100.47 ± 28.77 v 90.15 ± 24.03, p = < 0.000001). Using PR-adjusted aortic valve area (AVA) resulted in the reclassification of 81 patients (24%) from severe to moderate aortic stenosis (AVA >1.0 cm2). Of the 81 patients who were reclassified, 23 patients (28%) had sinotubular junction (STJ) diameters >3.0 cm. CONCLUSION: Adjusting calculated AVA for PR resulted in a reclassification of a significant number of adult patients from severe to moderate aortic stenosis. PR was significantly larger in patients who reclassified from severe to moderate aortic stenosis after adjusting for PR. PR appeared to remain relevant in patients with STJ ≥3.0 cm. Clinicians need to be aware of PR and how to account for its effect when measuring pressure gradients with Doppler.

Preoperative Pulmonary Artery-to-Aorta Diameter Ratio as a Predictor of Postoperative Severe Right Ventricular Failure and 1-Year Mortality After Left Ventricular Assist Device Implantation.

OBJECTIVES: To evaluate the association of pulmonary artery diameter and pulmonary artery- to-aorta diameter ratio (PA/Ao) with right ventricular failure and mortality within 1 year after left ventricular assist device implantation. DESIGN: This was a retrospective observational study between March 2013 and July 2019. SETTING: The study was conducted at a single, quaternary-care academic center. PARTICIPANTS: Adults (≥18 years old) receiving a durable left ventricular assist device (LVAD). Inclusion if (1) a chest computed tomography scan was performed within 30 days before the LVAD and (2) a right and left heart catheterization was completed within 30 days before the LVAD. INTERVENTIONS: A left ventricular assist device was used for intervention. MEASUREMENTS AND MAIN RESULTS: A total of 176 patients were included in this study. Median PA diameter and PA/Ao ratio were significantly greater in the severe right ventricular failure (RVF) group (p = 0.001, p < 0.001, respectively). Receiver operating characteristic analysis revealed PA/Ao and RVF as predictors for mortality (area under the curve = 0.725 and 0.933, respectively). Logistic regression analysis-predicted probability gave a PA/Ao ratio cutoff point of 1.04 (p < 0.001). Survival probability was significantly worse in patients with a PA/Ao ratio ≥1.04 (p = 0.005). CONCLUSIONS: The PA/Ao ratio is an easily measurable noninvasive indicator that can predict RVF and 1-year mortality after LVAD implantation.

The Association Between Institutional Mortality After Coronary Artery Bypass Grafting at One Year and Mortality Rates at 30 Days.

OBJECTIVE: To assess the association between the common quality metric of 30-day mortality and mortality at 60 days, 90 days, and one year after coronary artery bypass grafting. DESIGN: A retrospective cohort study, with multivariate logistic regression to assess association among mortality outcomes. SETTING: Hospitals participating in Medicare and reporting data within the Centers for Medicare and Medicaid Services Limited Data Set between April 1, 2016, and March 31, 2017. PARTICIPANTS: A total of 37,036 patients undergoing surgery at 394 hospitals. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Mortality rates were 1.0%-to-3.1% for the top and bottom quartile of hospitals at 30 days. At one year, the top 25th percentile of hospitals had mortality rates averaging 3.9%; while hospitals below the 75th percentile had mortality rates averaging 7.6%. Twenty-three percent of hospitals in the top quartile at 30 days were no longer in the top quartile at 60 days. At one year, only 48% of hospitals that were in the top quartile at 30 days remained in the top quartile. The correlation between mortality rates at 30 days and the reported points was assessed using Spearman's rho. The R value between mortality at 30 days and mortality at one year was 0.53, which improved to 0.7 and 0.76 at 60 and 90 days. CONCLUSIONS: Mortality at 30 days correlated poorly with mortality at one year. Hospitals that were high- or low-performing at 30 days frequently were no longer within the same performance group at one year.

Myocardial Bridge or Something Else?

In this E-Challenge, the authors report on a patient with symptoms of exertional dyspnea and angina, scheduled to have surgical unroofing of an identified myocardial bridge (MB). An MB is very common in patients with hypertrophic cardiomyopathy (HCM). Intraoperative transesophageal echocardiography with provocative maneuvers revealed the patient had a systolic anterior motion of the mitral valve with septal contact and resulting outflow tract obstruction despite the notable absence of significant basal septal hypertrophy. HCM has many phenotypic variants that can make the identification of patients with latent left ventricular outflow tract obstruction difficult in the absence of a high index of suspicion. In this report, the authors discuss the association between MBs and HCM and the importance of recognizing phenotypic variants of HCM.

A Case of Transient Mitral Regurgitation: Not Everything Is Always What It Seems.

Mitral regurgitation (MR) is a common form of valvular heart disease that is associated with significant morbidity and mortality. MR can be broadly classified into 2 different categories: primary and secondary MR. Primary MR usually is caused by leaflet abnormalities, whereas secondary MR is a chronic disease secondary to geometric distortion of both the annulus and subvalvular apparatus because of left ventricular remodeling. Without acute changes in loading conditions, myocardial blood flow, or rhythm disturbances, functional MR typically is not transient. In this E-Challenge, the authors show a transient and completely reversible acute and severe form of functional MR with the use of multimodal echocardiography.

Two Tales of Cardiomyopathy: Underscore for One Health Initiative.

Hypertrophic cardiomyopathy, a common cause of sudden cardiac death, results from mutations in the cardiac sarcomere. Although there has been much scientific exploration regarding this disease, there is still much to be elucidated. This E-challenge highlights two cases of cardiomyopathy and underscores the need for future multidisciplinary collaboration as outlined by the One Health Initiative.

Skeletal Muscle Characteristics May Inform Preprocedural Risk Stratification in Transcatheter Aortic Valve Replacement Patients.

OBJECTIVES: Low psoas muscle mass previously has been associated with mortality after transcatheter aortic valve replacement (TAVR). Evidence from other clinical disciplines suggests that psoas density (PD) may be a better predictor than psoas muscle cross-sectional area indexed to body surface area (PI). The authors hypothesized that PD would be more strongly correlated with patient discharge disposition and survival after TAVR than PI. DESIGN: The authors performed a single-center, retrospective study of TAVR patients from 2013 to 2016. PI and PD were assessed at the third lumbar spine level using computed tomography imaging. Propensity-score matching was used to investigate the association of PI and PD with discharge disposition and mortality. SETTING: Tertiary university hospital PARTICIPANTS: Cohort of 245 TAVR patients. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: A total of 245 patients met inclusion criteria. Following propensity score matching, patients with PI <4 cm2/m2 and PD <25 Hounsfield units (HU) were less likely to survive and to be discharged home compared with patients with PI ≥4 cm2/m2 or PD >25 HU. After repeating the propensity score matching with PI as a covariable, PD remained associated with mortality (90 days: odds ratio [OR] 4.59; 95% confidence interval [CI] 2.96-10.31, p < 0.001, 1 year: OR 6.14; 95% CI 3.45-28.57, p = 0.01, 3 years: OR 4.55; 95% CI 2.41-40.00, p = 0.03). CONCLUSIONS: PD may be more relevant than PI in risk stratification for TAVR patients.

Tissue Doppler Imaging (E/e') and Pulmonary Capillary Wedge Pressure in Patients With Severe Aortic Stenosis.

OBJECTIVE: Although American and European consensus statements advocate using the ratio of the transmitral E velocity and tissue Doppler early diastolic mitral annular velocity (E/e') in the assessment of left-sided heart filling pressures, recent reports have questioned the reliability of this ratio to predict left atrial pressures in a variety of disease states. The authors hypothesized that there is a clinically significant correlation between E/e' and pulmonary capillary wedge pressure (PCWP) in patients with severe aortic stenosis. DESIGN: Retrospective cohort study. PARTICIPANTS: The study comprised 733 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve replacement for severe aortic stenosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PCWP and E/e'ave (average of the lateral and medial annulus tissue Doppler velocities) were measured with a pulmonary artery catheter and transthoracic echocardiography during preprocedural evaluation. Patients were grouped by left ventricular ejection fraction (LVEF) ≥50% and LVEF <50%. Spearman rank correlation, analysis of variance, and t and chi-square tests were used to analyze the data. Seventy-nine patients met the inclusion criteria. There was no significant correlation between E/e'ave and PCWP (n = 79, Spearman r = 0.096; p = 0.3994). This correlation did not improve when ventricular function was considered (LVEF <50%: n = 11, Spearman r = -0.097; p = 0.776 and LVEF ≥50%: n = 68, Spearman r = 0.116; p = 0.345). There was no statistically significant difference in mean PCWP between each range of E/e'ave. CONCLUSION: A clinically relevant relationship between E/e' and PCWP was not observed in patients with severe aortic stenosis.

The Convergent Procedure: A Unique Multidisciplinary Hybrid Treatment of Atrial Fibrillation.

The convergent procedure is a hybrid ablation treatment for atrial fibrillation. It is increasingly considered as a management option for patients with persistent and long-standing atrial fibrillation. It consists of surgical ablation of the posterior left atrium through a minimally invasive closed-chest approach followed by endocardial catheter ablation. It is increasingly performed with concurrent epicardial occlusion of the left atrial appendage with a video-assisted thoracoscopic technique to physically and electrically isolate the left atrial appendage. This article provides an overview of a multidisciplinary approach to the convergent procedure, with concurrent thoracoscopic closure of the left atrial appendage, with an emphasis on perioperative management at a single institution. It provides a literature review of procedural outcomes, current data limitations, and future considerations.

Successful use of Impella 5.5 to manage cardiogenic shock complicated by COVID-19.

BACKGROUND: Acute decompensated heart failure in patients with coronavirus disease 2019 (COVID-19) is becoming increasingly common. AIMS: In this case report, we describe the successful use of an Impella 5.5 (Abiomed) to treat cardiogenic shock refractory to inotropic therapy. MATERIALS & METHODS: Transthoracic and transesophageal echocardiography confirmed severely diminished left ventricular ejection fraction and a reverse-transcription polymerase chain reaction test revealed that the patient was COVID-19 positive during his hospital admission. RESULTS: Following initiation of inotropic therapy, we placed an Impella 5.5 for further cardiac support. The patient's LVEF and cardiac index improved after 21 days on the Impella 5.5 and was maintained following explant. DISCUSSION & CONCLUSION: The findings reported here demonstrate successful use of an Impella 5.5 to improve native heart function in refractory cardiogenic shock and further indicate its use as an option for those in acute decompensated heart failure who have tested positive for COVID-19 infection.

The Mitral/Aortic Flow Velocity Integral Ratio in Mitral Regurgitation.

The development of echocardiography was driven, in part, by a need to diagnose mitral regurgitation in patients undergoing finger fracture commissurotomy in the 1950s. Decades later, color Doppler became the cornerstone for noninvasive evaluation of mitral regurgitation. The authors present 2 cases of calcific mitral stenosis in which reliance on color Doppler in transthoracic echocardiography resulted in erroneous conclusions as to the severity of coexisting mitral regurgitation. The possible application of the Mitral to Aortic Flow Velocity Integral Ratio in such cases as a possible adjunct to grading mitral regurgitation is also discussed.

Automated Spectral Doppler Profile Tracing.

OBJECTIVE: The authors hypothesized that automated tracings of both pulsed wave (PW) and continuous wave (CW) Doppler correlate well with manual measurements performed by an experienced echocardiographer. DESIGN: The authors performed a retrospective analysis of spectral Doppler profile measurements performed by automated software and an echocardiographer. SETTING: University hospital, single institution. PARTICIPANTS: The authors reviewed transesophageal echocardiographic examinations from patients undergoing transcatheter aortic valve (AV) replacement procedures at their institution. INTERVENTIONS: No interventions were performed solely for research purposes. MEASUREMENTS AND MAIN RESULTS: PW and CW spectral envelopes at the left ventricular outflow tract (LVOT) and AV were analyzed. Blinded, a board-certified echocardiographer performed manual measurements of the identical spectral envelopes. Peak velocities, mean gradients, and velocity time integrals (VTI) were collected. A total of 33 PW as well as 33 CW Doppler spectral envelopes were evaluated. There was no significant difference between the measurements provided by the automated software and manual tracings. LVOT PW VTI automated versus manual: 18.2 cm versus 15.9 cm, p = 0.11. AV CW VTI automated versus manual: 65.8 cm versus 64.8 cm, p = 0.90. AV CW mean gradient automated versus manual: 24.3 mmHg versus 23.4 mmHg, p = 0.84. AV CW peak velocity automated versus manual: 3.00 m/s versus 2.98 m/s, p = 0.93. Correlation coefficients were all above 0.9. CONCLUSIONS: Automated measurements of peak velocities, mean gradients, and VTI of spectral Doppler correlate closely with manual measurements performed by an experienced echocardiographer.

Artificial Intelligence for the Measurement of the Aortic Valve Annulus.

OBJECTIVE: The authors aim to evaluate an automated echocardiography software as compared with computed tomography in measurement of the aortic valve annulus in patients with aortic stenosis. The authors hypothesize that aortic annular measurements by this software and computed tomography will show acceptable correlation. DESIGN: This study is an Institutional Review Board-approved, retrospective data collection of patients with aortic stenosis who underwent implantation of a transcatheter heart valve with intraprocedural transesophageal echocardiography, multidetector computed tomography, and use of the Siemens eSie Valves automated aortic valve software. SETTING: Intraprocedural in a single hospital institution. PARTICIPANTS: The participants are 47 patients who underwent implantation of an Edwards SAPIEN 3 transcatheter heart valve. INTERVENTIONS: The authors compared aortic valve annulus measurements by two-dimensional transesophageal echocardiography, computed tomography, and the automated software. MEASUREMENTS AND MAIN RESULTS: Aortic annulus measurements by the software correlated more closely to the computed tomography measurements than two-dimensional measurements. Bland-Altman analysis showed qualitative comparability of measurements performed by the automated software to computed tomography (95% limits of agreement between -4.62 mm and 1.26 mm for area-derived and -4.51 mm and 1.45 mm for perimeter-derived methods). Similarly, there was significant linear correlation with automated software use (r = 0.84, p < 0.0001 and r = 0.85, p < 0.0001). CONCLUSIONS: Periprocedural aortic valve measurement by automated echocardiographic software correlates with computed tomography in patients with severe aortic stenosis. This technology is helpful and accurate, but has limitations.

Supraglottic Airway Use for Transfemoral-Transcatheter Aortic Valve Replacement.

OBJECTIVE: Examine outcome differences in patients managed either with a supraglottic airway or an endotracheal tube for general anesthesia during transcatheter aortic valve replacement. The authors hypothesized that patients managed with a supraglottic airway would have shorter post-anesthesia care unit and hospital stays and receive fewer opioids, norepinephrine equivalents, and neuromuscular blocking agents, without an increase in 30-day major adverse cardiovascular events. DESIGN: Retrospective chart review with 1:2 supraglottic airway-to-endotracheal tube patient propensity score matching. SETTING: Single, urban, tertiary care, academic medical center. PARTICIPANTS: Patients undergoing transfemoral- transcatheter aortic valve replacement between 2017 and 2019. INTERVENTIONS: Supraglottic or endotracheal tube airway management during general anesthesia. MEASUREMENTS AND MAIN RESULTS: Thirty-one supraglottic airway patients were propensity score matched with 62 endotracheal tube patients. There was no significant difference for postanesthesia care unit (p = 0.58) or hospital (p = 0.16) lengths of stay. Supraglottic airway patients received significantly fewer neuromuscular blockers (p < 0.0001) and trended toward fewer opioids (p = 0.05), but received a similar number of norepinephrine equivalents (p = 0.76). The major adverse cardiovascular event odds ratio between groups was 1.39 (p = 0.51). The time under general anesthesia (p = 0.02) and total time in the operating room (p = 0.04) were significantly shorter for supraglottic airway patients. CONCLUSIONS: Supraglottic airway management in transcatheter aortic valve replacement was feasible without an increase in major adverse cardiovascular outcomes compared with endotracheal tube management during general anesthesia. Supraglottic airway patients trended toward receiving fewer opioids and received significantly fewer neuromuscular blockers while also having significantly shorter time under general anesthesia and total time in the operating room.

ABO Blood Group and Transfusions In the Intraoperative and Postoperative Period After LVAD Implantation.

OBJECTIVES: To assess whether blood group O patients undergoing left ventricular assist device (LVAD) insertion have higher perioperative transfusion requirements, postoperative chest tube output, and postoperative changes in hematocrit. DESIGN: Retrospective review of 116 LVAD patients from August 2015 to May 2018. SETTING: Single-institution, urban academic medical center. PARTICIPANTS: One hundred sixteen LVAD patients analyzed by blood group: group O (n = 49) versus non-O (n = 67). INTERVENTIONS: Transfusions in the combined intraoperative and postoperative period at 7 days and 90 days after LVAD implantation, chest tube output in the first 24 hours, and hematocrit change in the first 48 hours postoperatively. RESULTS: There was no difference between group O and non-O within the univariable analysis for both 7-day and 90-day transfusion rates. Adjusting for covariables, blood type O was not associated with packed red blood cells transfusion after accounting for multiple comparisons (odds ratio 1.33 [1.07-1.66], p = 0.01, where p < 0.005 was considered statistically significant as a Bonferroni correction was performed to control the familywise error rate). Additionally, there was no difference in chest tube output over the first 24 hours (1,129 v 1,057 mL, p = 0.47) or hematocrit change in the first 48 hours postoperatively (3.49 v 4.53%, p = 0.15). CONCLUSION: O blood group is not a significant predictor of transfusion requirements in the combined intraoperative and postoperative period up to 90 days after LVAD implantation.

Intraoperative Hemodynamic and Echocardiographic Measurements Associated With Severe Right Ventricular Failure After Left Ventricular Assist Device Implantation.

BACKGROUND: Severe right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation increases morbidity and mortality. We investigated the association between intraoperative right heart hemodynamic data, echocardiographic parameters, and severe versus nonsevere RVF. METHODS: A review of LVAD patients between March 2013 and March 2016 was performed. Severe RVF was defined by the need for a right ventricular mechanical support device, inotropic, and/or inhaled pulmonary vasodilator requirements for >14 days. From a chart review, the right ventricular failure risk score was calculated and right heart hemodynamic data were collected. Pulmonary artery pulsatility index (PAPi) [(pulmonary artery systolic pressure - pulmonary artery diastolic pressure)/central venous pressure (CVP)] was calculated for 2 periods: (1) 30 minutes before cardiopulmonary bypass (CPB) and (2) after chest closure. Echocardiographic data were recorded pre-CPB and post-CPB by a blinded reviewer. Univariate logistic regression models were used to examine the performance of hemodynamic and echocardiographic metrics. RESULTS: A total of 110 LVAD patients were identified. Twenty-five did not meet criteria for RVF. Of the remaining 85 patients, 28 (33%) met criteria for severe RVF. Hemodynamic factors associated with severe RVF included: higher CVP values after chest closure (18 ± 9 vs 13 ± 5 mm Hg; P = .0008) in addition to lower PAPi pre-CPB (1.2 ± 0.6 vs 1.7 ± 1.0; P = .04) and after chest closure (0.9 ± 0.5 vs 1.5 ± 0.8; P = .0008). Post-CPB echocardiographic findings associated with severe RVF included: larger right atrial diameter major axis (5.4 ± 0.9 vs 4.9 ± 1.0 cm; P = .03), larger right ventricle end-systolic area (22.6 ± 8.4 vs 18.5 ± 7.9 cm; P = .03), lower fractional area of change (20.2 ± 10.8 vs 25.9 ± 12.6; P = .04), and lower tricuspid annular plane systolic excursion (0.9 ± 0.2 vs 1.1 ± 0.3 cm; P = .008). Right ventricular failure risk score was not a significant predictor of severe RVF. Post-chest closure CVP and post-chest closure PAPi discriminated severe from nonsevere RVF better than other variables measured, each with an area under the curve of 0.75 (95% CI, 0.64-0.86). CONCLUSIONS: Post-chest closure values of CVP and PAPi were significantly associated with severe RVF. Echocardiographic assessment of RV function post-CPB was weakly associated with severe RVF.

Late Clinical Presentation of Prosthesis-Patient Mismatch Following Transcatheter Aortic Valve Replacement.

Prosthesis-patient mismatch (PPM) is relatively common after aortic valve replacement (AVR) and generally is associated with reduced regression of left ventricular (LV) mass. PPM after valve-in-valve transcatheter aortic valve replacement (TAVR) was reported to be 38%. PPM generally is manifested clinically by dyspnea and echocardiographically by high transvalvular gradients. In this E-Challenge, the authors will review a case of a late clinical presentation of PPM 1-year following a valve-in-valve TAVR.

Differences in Two- and Three-Dimensional Assessment of the Mitral Valve by Novices and Experts, Illustrated Using Anterior Mitral Valve Leaflet Length.

OBJECTIVES: In this measurement validation study, the authors evaluated agreement between 2-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE), measuring anterior mitral valve leaflet length by both novice and experienced echocardiographers. DESIGN: This was a retrospective, observational study. SETTING: Single university hospital. PARTICIPANTS: Analyses on datasets from 44 patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty datasets from 44 patients with mitral regurgitation were analyzed by 4 observers (2 novices, 2 experts). All observers measured the anterior mitral valve leaflet length from end-systolic 2D TEE images from the midesophageal longitudinal axis view and 3D software-augmented TEE images. The overall mean anterior mitral valve leaflet length was significantly shorter with 3D versus 2D TEE measurements (24.6 ± 4.5 mm v 26.2 ± 5.3 mm; p < 0.001), with novices measuring shorter leaflets than experts for both techniques (p < 0.001 and p = 0.005, respectively). Bland-Altman plots of 3D and 2D TEE measurements showed mean biases (95% limits of agreement) of -1.6 mm (-9.0 to 5.9 mm), -1.8 mm (-9.6 to 6.0 mm), and -1.3 mm (-8.4 to 5.7 mm) for all observers, novices, and experts, respectively. For 2D measurements, interobserver reliability was very strong among experts and strong among novices (Pearson's r = 0.83 v 0.66; p = 0.055). For 3D measurements, interobserver reliability was strong in experts and moderate in novices (Pearson's r = 0.69 v 0.51; p = 0.168). CONCLUSION: For both novices and experts, 3D TEE measurements of the anterior mitral valve leaflet were significantly shorter than 2D measurements. Interobserver reliability was lowest for novices making 3D TEE measurements, indicating that reliable, quantitative evaluation of 3D TEE may require a greater amount of practice.

Intraoperative Administration of 4-Factor Prothrombin Complex Concentrate Reduces Blood Requirements in Cardiac Transplantation.

OBJECTIVE: Assessing the efficacy of intraoperative 4-factor prothrombin complex concentrate (4F-PCC) use in blood product utilization, time to chest closure, intensive care unit (ICU) and hospital length of stay (LOS), thromboembolic complications, renal injury and mortality in left ventricular assist device (LVAD) patients on home anticoagulation therapy with warfarin, undergoing orthotopic heart transplantation (OHT). DESIGN: Retrospective analysis of OHT patients at Tufts Medical Center from May 2013 to October 2016. SETTING: Single-institution, university hospital setting. PARTICIPANTS: Patients with preexisting LVADs who received orthotopic heart transplants (n = 74; 32 patients 4F-PCC, 42 patients no 4F-PCC). INTERVENTIONS: Warfarin reversal using 4F-PCC in patients with LVADs undergoing orthotopic heart transplantation with the 4F-PCC dosing partitioned such that one-third was given pre-CPB and two-thirds were given post-CPB. MEASUREMENTS AND MAIN RESULTS: The 4F-PCC group required less plasma (6 [IQR 4] v 1.31 [IQR 2] U, p < 0.001), cryoprecipitate (10 [IQR 10] v 7.50 [IQR 5] U, p < 0.001), and packed red blood cells (5 [IQR 4] v 2 [IQR 1.5] U, p < 0.001) and had a shorter time to chest closure (618.8 ± 111.4 v 547.9 ± 110.1 minutes, p = 0.008). There was no difference in platelet transfusion (2 [IQR 1] v 2 [IQR 1] U, p = 0.16), ICU or hospital LOS, acute kidney injury, or mortality. No thrombotic complications occurred. CONCLUSIONS: Replacing plasma with 4F-PCC to reverse preoperative warfarin anticoagulation during OHT was associated with a shorter time to chest closure and less blood product utilization, without an increase in acute kidney injury, thromboembolic complications, or death.