Using pulsatility responses to breath-hold maneuvers to predict readmission rates in continuous-flow left ventricular assist device patients.

BACKGROUND: Dynamic respiratory maneuvers induce heterogenous changes to flow-pulsatility in continuous-flow left ventricular assist device patients. We evaluated the association of these pulsatility responses with patient hemodynamics and outcomes. METHODS: Responses obtained from HVAD (Medtronic) outpatients during successive weekly clinics were categorized into three ordinal groups according to the percentage reduction in flow-waveform pulsatility (peak-trough flow) upon inspiratory-breath-hold, (%∆P): (1) minimal change (%∆P ≤ 50), (2) reduced pulsatility (%∆P > 50 but <100), (3) flatline (%∆P = 100). Same-day echocardiography and right-heart-catheterization were performed. Readmissions were compared between patients with ≥1 flatline response (F-group) and those without (NF-group). RESULTS: Overall, 712 responses were obtained from 55 patients (82% male, age 56.4 ± 11.5). When compared to minimal change, reduced pulsatility and flatline responses were associated with lower central venous pressure (14.2 vs. 11.4 vs. 9.0 mm Hg, p = 0.08) and pulmonary capillary wedge pressure (19.8 vs. 14.3 vs. 13.0 mm Hg, p = 0.03), lower rates of ≥moderate mitral regurgitation (48% vs. 13% vs. 10%, p = 0.01), lower rates of ≥moderate right ventricular impairment (62% vs. 25% vs. 27%, p = 0.03), and increased rates of aortic valve opening (32% vs. 50% vs. 75%, p = 0.03). The F-group (n = 28) experienced numerically lower all-cause readmissions (1.51 vs. 2.79 events-per-patient-year [EPPY], hazard-ratio [HR] = 0.67, p = 0.12), reduced heart failure readmissions (0.07 vs. 0.57 EPPY, HR = 0.15, p = 0.008), and superior readmission-free survival (HR = 0.47, log-rank p = 0.04). Syncopal readmissions occurred exclusively in the F-group (0.20 vs. 0 EPPY, p = 0.01). CONCLUSION: Responses to inspiratory-breath-hold predicted hemodynamics and readmission risk. The impact of inspiratory-breath-hold on pulsatility can non-invasively guide hemodynamic management decisions, patient optimization, and readmission risk stratification.

Cardiogenic Shock Challenges and Priorities: A Clinician Survey.

BACKGROUND: Cardiogenic shock (CS) is common and survival outcomes have not substantially improved. Australia's geography presents unique challenges in the management of CS. The challenges and research priorities for clinicians pertaining to CS identification and management have yet to be described. METHOD: We used an exploratory sequential mixed methods design. Semi-structured interviews were conducted with 10 clinicians (medical and nursing) to identify themes for quantitative evaluation. A total of 143 clinicians undertook quantitative evaluation through online survey. The interviews and surveys addressed current understanding of CS, status of cardiogenic systems and future research priorities. RESULTS: There were 143 respondents: 16 (11%) emergency, cardiology 22 (16%), 37 (26%) intensive care, 54 (38%) nursing. In total, 107 (75%) believe CS is under-recognised. Thirteen (13; 9%) of respondents indicated their hospital had existing CS teams, all from metropolitan hospitals, and 40% thought additional access to mechanical circulatory support devices was required. Five (5; 11%) non-tertiary hospital respondents had not experienced a delay in transfer of a patient in CS. All respondents felt additional research, particularly into the management of CS, was required. CONCLUSIONS: Clinicians report that CS is under-recognised and further research into CS management is required. Access to specialised CS services is still an issue and CS protocolised pathways may be of value.

Prevalence of Coronary Vasomotor Disorders in Patients With Angina and Nonobstructive Coronary Arteries: A Sydney Experience.

BACKGROUND: Patients with angina and non-obstructive coronary arteries (ANOCA) frequently have coronary vasomotor disorders (CVaD), characterised by transient pathological vasoconstriction and/or impaired microvascular vasodilatation. Functional coronary angiography is the gold standard for diagnosing CVaD. Despite recommendations, testing is only available at a limited number of Australian and New Zealand centres. This study aimed to determine the prevalence of CVaDs in an Australian ANOCA population and identify predictive factors associated with specific endotypes. METHOD: Functional coronary angiography was performed in patients with suspected ANOCA. Vasoreactivity testing was performed using intracoronary acetylcholine provocation. A pressure-temperature sensor guidewire was used for coronary physiology assessment. Comprehensive clinical data on patient characteristics, cardiac risk factors, and symptom profiles was collected before testing. RESULTS: This prospective observational study at Royal Prince Alfred and Concord Repatriation General Hospital included 110 patients (58±13 years with 63.6% women), with 81.8% (90/110) having a CVaD. Regarding specific ANOCA endotypes, microvascular angina (MVA) occurred in 31.8% (35/110) of cases, vasospastic angina (VSA) in 25.5% (28/110) and a mixed presentation of MVA and VSA in 24.5% (27/110) of patients. Patients with CVaD were found to be older (59±11 vs 51±15, p=0.024), overweight (61.1% vs 15.0%, p<0.001) and had a worse quality of life (EuroQol 5 Dimensions-5 Levels; 0.61 vs 0.67, p=0.043). MVA was associated with being overweight (odds ratio [OR] 4.2 [95% confidence interval [CI] 1.9-9.3]; p=0.015) and ischaemia on stress testing (OR 2.4 [95% CI 1.1-4.3]; p=0.028), while VSA was associated with smoking (OR 9.1 [95% CI 2.21-39.3]; p=0.007). CONCLUSIONS: Coronary vasomotor disorders are highly prevalent among ANOCA patients. This study highlights the importance of increasing national awareness and the use of functional coronary angiography to evaluate and manage this unique cohort.

A Review on Performance Improvement of Anaerobic Digestion Using Co-Digestion of Food Waste and Sewage Sludge.

Anaerobic co-digestion (AcoD) is a vital technology in the decarburization of the economy because of its ability to process organic waste, recover nutrients, and create biogas as a sustainable biofuel all at the same time. This attribute also makes this technology a viable partner in pursuing a circular economic model. However, the poor biogas output of typical substrates like sewage sludge and animal manure and the hefty installation costs limit its viability. This review paper with literature analysis provides a good grasp of the anaerobic co-digesting process with diverse food digestion methods. In this survey, we have analyzed the Anaerobic Digestion of water waste, food waste, and animal manure and the anaerobic co-digestion of animal waste with water waste and food waste with water waste. This analysis demonstrates that anaerobic co-digestion produces more methane biogas than anaerobic digestion. Also, it has been shown that by adjusting the ratio of food and animal waste to water waste, we can produce more methane. In the future, we would like to supplement anaerobic co-digestion by altering the proportion of different wastes that are mixed with water waste in order to increase methane production.

Protocolised Management of Cardiogenic Shock and Shock Teams: A Narrative Review.

Despite advances in therapy, the incidence of cardiogenic shock continues to increase, with significant mortality that has improved minimally over time. Treatment options for cardiogenic shock are complex and time-, resource-, and case volume-dependent, and involve multiple medical specialties. To provide early, more equitable, and standardised access to cardiogenic shock expertise with advanced therapies, cardiogenic shock teams with a protocolised treatment approach have been proposed. These processes have been applied across hospitals into integrated cardiogenic shock networks. This narrative review evaluates the role of cardiogenic shock teams, protocolised and regionalised shock networks, and the main individual components of protocolised shock management approaches.

Chiral Phosphoric Acid-Catalyzed Enantio- and Diastereoselective Allylboration of Aldehydes with ß,γ-Substituted Allylboronates.

The catalytic asymmetric addition of ß,γ-substituted allylboronates to aldehydes has been described. Promoted by 5 mol % chiral phosphoric acid, the reactions were broadly applicable, scalable, and efficient, allowing for the formation of 3,4-anti/syn-homoallylic alcohols bearing adjacent tertiary or quaternary stereogenic centers in a highly enantio- and diastereoselective manner (≤99% ee and dr >20:1). The rigid chairlike transition state involving the chiral phosphoric acid contributed to the highly controlled reaction.

Integrated practice units present an opportunity over siloed survivorship care settings.

Given the rapidly rising cancer burden in the USA, the need to innovate survivorship care for oncology patients is rising rapidly. The current body of empirical evidence in survivorship care has focused on care provided by general practitioners (GP) and specialists/surgeons (SS). In particular, current evaluations address cost of care, cancer recurrence, quality of life, and overall survival of patients, with results indicating no statistically significant differences in GP- and SS-led care models and little emphasis on the broader characteristics of care settings. We fill this gap in survivorship care by introducing a perspective on the potential for holistic care delivery with a multidisciplinary team approach at integrated practice units (IPUs). Additionally, we propose a comprehensive examination of survivorship care across GP-, SS-, and IPU-led settings to provide researchers and practitioners with solid ground to determine the optimal survivorship care model, considering four key characteristics: (1) operating mode and skills, (2) cost and accountability of care, (3) health outcome measurement, and (4) workflow and scheduling.

Comparative evaluation of ADVIA Centaur® XP chemiluminescence system for screening of HBV, HCV, HIV and syphilis in Indian blood donors.

BACKGROUND: The introduction of chemiluminescent immunoassay (CLIA) in blood donor screening has led to a gradual replacement of enzyme-linked-immunosorbent assay (ELISA) as the former offers automation, higher sensitivity and lower turn-around-time. However, only a few CLIA platforms are used for blood donor screening in India. The present study evaluated one such newer platform viz., Adiva Centaur XP CLIA for screening of HBV, HCV, HIV and syphilis. MATERIAL AND METHODS: Prospective comparative study wherein 4843 whole blood donors were screened for HBsAg, Anti-HCV, HIV Ag-Ab and Anti-treponemal antibodies in both Advia Centaur XP and Architect i2000SR platforms. Additional tests were performed in samples which were reactive in only one of the platforms. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, false positive rate and false negative rate of both the platforms were compared. Kappa coefficient was calculated to determine the agreement between the testing platforms. RESULTS: The sensitivity of Advia Centaur platform for HBV, HCV, HIV and syphilis detection were 94.9 %, 100 %, 100 % and 100 % respectively as compared to 96.6 %, 100 %, 100 % and 100 % in Architect i2000SR platform. The specificity of both the platforms were 99.8-99.9 % for all the four tests. The agreement between the two platforms was almost perfect for HBV, HCV and syphilis testing; and fair for HIV testing. CONCLUSION: The Advia Centaur CLIA platform was found to be comparable with the Architect CLIA platform for blood donor screening. Unexpected finding was the occurrence of HBV false negatives in both the platforms, possibly due to HBsAg mutations.

Residual risk estimates of transfusion transmissible hepatitis B, hepatitis C and human immunodeficiency virus using nucleic acid testing yield/window period model in an Indian setting.

BACKGROUND: Estimation of residual risk (RR) is necessary to understand status of blood safety with current testing strategies and need to improve it further. These estimates from India are lacking till date. Present study was aimed to estimate RR and incident rate (IR) of transfusion transmitted infectious disease (TTIDs) in Indian setting. STUDY DESIGN AND METHODS: Blood donor demographic data, serological testing results and nucleic acid testing (NAT) screening results were collected retrospectively from January 2015 to June 2017. Mathematical modelling using NAT yield/window period model was done to estimate IR and RR of TTIDs. Data was compared between different groups based on age-group, gender, donation repeatability and type of donor. RESULTS: A total 106 119 blood donors donated 109 441 units with overall TTID reactivity of 2.22%. HBV was most prevalent TTID (1.26%) with RR of 16.1 per million followed by HCV and HIV with RR of 4.4 and 3.1 per million donations, respectively. NAT testing variably reduced RR ranging from 69.4% to 96.1% depending on TTID. Younger, repeat and voluntary donors had significantly lower prevalence of TTIDs compared to older, first time and replacement donors. DISCUSSION: Gaps in the blood safety could be bridged significantly by implementing NAT testing and using quality serological assays. Comparatively high RR despite using quality serological assays and ID-NAT testing highlights need to develop long term strategies to improve blood safety by focusing on improving donor pool by recruiting regular voluntary donors among youth and imparting knowledge of healthy practices.

A comprehensive update on the structure and synthesis of potential drug targets for combating the coronavirus pandemic caused by SARS-CoV-2.

The outbreak of the coronavirus pandemic COVID-19 created by its severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) variant, known for producing a very severe acute respiratory syndrome, has created an unprecedented situation by its continual assault around the world. The crisis caused by the SARS-CoV-2 variant has been a global challenge, calling to mitigate this unprecedented pandemic that has engulfed the whole world. Since the outbreak and spread of COVID-19, many researchers globally have been grappling to find new clinically trialed active drugs with anti-COVID-19 activity, from antimalarial drugs to JAK inhibitors, antiviral drugs, immune suppressants, and so forth. This article presents a brief discussion on the activity and synthesis of some active molecules such as favipiravir, hydroxychloroquine, pirfenidone, remdesivir, lopinavir, camostat, chloroquine, baricitinib, molnupiravir, and so forth, which are under trial.

Phenotyping of Stable Left Ventricular Assist Device Patients Using Noninvasive Pump Flow Responses to Acute Loading Transients.

BACKGROUND: Although it has been established that continuous flow left ventricular assist devices are sensitive to loading conditions, the effect of acute load and postural changes on pump flow have not been explored systematically. METHODS AND RESULTS: Fifteen stable outpatients were studied. Patients sequentially transitioned from the seated position to supine, passive leg raise, and standing with transition effects documented. A modified Valsalva maneuver, consisting of a forced expiration with an open glottis, was performed in each position. A sustained, 2-handed handgrip was performed in the supine position. The pump flow waveform was recorded continuously and left ventricular end-diastolic diameter measured during each stage using transthoracic echocardiography. Transitioning from seated to supine posture produced a significant increase in the flow and the ventricular end-diastolic diameter, consistent with an increased preload. The transition from supine to standing produced a transient increase in the mean flow and decreased the flow pulsatility index. At steady state, these changes were reversed with a decrease in the mean and trough flow and increased pulsatility index, consistent with venous redistribution and possible baroreflex compensation. Four distinct patterns of standing-induced flow waveform effects were identified, reflecting varying preload, afterload, and individual compensatory effects. A sustained handgrip produced a significant decrease in flow and increase in flow pulsatility across all patients, reflecting an increased afterload pressure. A modified Valsalva maneuver produced a decrease in the flow pulsatility while seated, supine, and standing, but not during leg raise. Five patterns of pulsatility effect during Valsalva were observed: (1) minimal change, (2) pulsatility recovery, (3) rapid flatline, (4) slow flatline with delayed flow recovery, and (5) primary suction. CONCLUSIONS: Acute disturbances in loading conditions produce heterogeneous pump flow responses reflecting their complex interactions with pump and ventricular function as well as reflex compensatory mechanisms. Differences in responses and individual variabilities have significant implications for automated pump control algorithms.

Right Ventricular Dysfunction Is Common and Identifies Patients at Risk of Dying in Cardiogenic Shock.

BACKGROUND: Understanding the prognostic impact of right ventricular dysfunction (RVD) in cardiogenic shock (CS) is a key step toward rational diagnostic and treatment algorithms and improved outcomes. Using a large multicenter registry, we assessed (1) the association between hemodynamic markers of RVD and in-hospital mortality, (2) the predictive value of invasive hemodynamic assessment incorporating RV evaluation, and (3) the impact of RVD severity on survival in CS. METHODS AND RESULTS: Inpatients with CS owing to acute myocardial infarction (AMI) or heart failure (HF) between 2016 and 2019 were included. RV parameters (right atrial pressure, right atrial/pulmonary capillary wedge pressure [RA/PCWP], pulmonary artery pulsatility index [PAPI], and right ventricular stroke work index [RVSWI]) were assessed between survivors and nonsurvivors, and between etiology and SCAI stage subcohorts. Multivariable logistic regression analysis determined hemodynamic predictors of in-hospital mortality; the resulting models were compared with SCAI staging alone. Nonsurvivors had a significantly higher right atrial pressure and RA/PCWP and lower PAPI and RVSWI than survivors, consistent with more severe RVD. Compared with AMI, patients with HF had a significantly lower RA/PCWP (0.58 vs 0.66, P = .001) and a higher PAPI (2.71 vs 1.78, P < .001) and RVSWI (5.70 g-m/m2 vs 4.66 g-m/m2, P < .001), reflecting relatively preserved RV function. Paradoxically, multiple RVD parameters (PAPI, RVSWI) were associated with mortality in the HF but not the AMI cohort. RVD was more severe with advanced SCAI stage, although its prognostic value was progressively diluted in stages D and E. Multivariable modelling incorporating the RA/PCWP improved the predictive value of SCAI staging (area under the curve [AUC] 0.78 vs 0.73, P < .001), largely driven by patients with HF (AUC 0.82 vs 0.71, P < .001). CONCLUSIONS: RVD is associated with poor outcomes in CS, with key differences across etiology and shock severity. Further studies are needed to assess the usefulness of RVD assessment in guiding therapy.

Seroprevalence of SARS-Coronavirus 2 among asymptomatic healthy blood donors from healthcare and non-healthcare settings: Implications for safety of blood donors and blood collection staff during blood donation.

INTRODUCTION: SARS-Coronavirus-2 pandemic has adversely affected blood supply as potential blood donors were afraid of acquiring infection in hospital settings. We aimed to compare COVID-19 seroprevalence among asymptomatic blood donors from healthcare and non-healthcare setting to analyse the difference in exposure level of each group as well as the risk of acquiring infection during the process of blood donation. MATERIAL AND METHODS: Analysis of whole blood donors tested for SARS-CoV-2 IgG antibodies was carried out after categorizing them into healthcare workers (HCW) and non-healthcare workers (NHCW). NHCW were further categorized into residents of containment and non-containment zones and seroprevalence analyzed. Seroprevalence among different ABO blood groups was also analyzed. RESULTS: 1191 blood donors were tested for SARS-CoV-2 antibodies with 9.5 % seropositivity. Significantly lower seropositivity of 3.2 % (p < 0.001) was observed among HCW as compared to 10.9 % seropositivity in NHCW. Among NHCW no difference in seropositivity was observed based on residence in containment or non-containment zone. Significantly higher (p = 0.012) seroprevalence was observed among A blood group donors (12.5 %) as compared to O blood group donors (6.8 %). CONCLUSION: Results suggests that a blood donor, in a hospital setting is less likely to be exposed to COVID-19 disease than when participating in activities of daily living. It is postulated that the lower seroprevalence among HCW as compared to NHCW reflects differences in knowledge and practice of preventive measures among these groups. The findings should instil confidence among blood donors and motivate them to donate blood without fear.

A Narrative Review for Cardiac Anesthesiologists of the 2019 Expert Consensus on Operator and Institutional Recommendations for Transcatheter Mitral Valve Intervention.

US Food and Drug Administration approval of the edge-to-edge clip repair device (MitraClip; Abbott Laboratories, Abbott Park, IL) in 2013 led to wide adoption of the device for treatment of severe primary mitral regurgitation in patients unsuitable for surgery. Demonstration of favorable outcomes in the setting of secondary mitral regurgitation by the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial in 2019 provided an additional impetus to the transcatheter mitral interventional program. The role of the cardiac anesthesia service also is expanding to echocardiography services for these patients outside of the procedure room. Moreover, cardiac anesthesiologists serve on the multidisciplinary team that is involved in clinical decision-making pertaining to patient selection, optimization, and intervention. This document has direct implications for the cardiac anesthesiologist involved in the care of these patients because a broader understanding of pertinent issues is essential to function as an effective clinical member within the multidisciplinary team. As such, this narrative review serves to highlight the salient features of the "2019 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Mitral Valve Intervention: A Joint Report of the American Association for Thoracic Surgery, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons," focuses on issues pertinent to the cardiac anesthesiologist, and provides an outline for the clinical context and evolution of transcatheter mitral valve interventions.

Bi(cyclopentyl)diol-Derived Boronates in Highly Enantioselective Chiral Phosphoric Acid-Catalyzed Allylation, Propargylation, and Crotylation of Aldehydes.

In this study, we disclose the catalytic addition of bi(cyclopentyl)diol-derived boronates to aldehydes promoted by chiral phosphoric acids, allowing for the formation of enantioenriched homoallylic, propargylic, and crotylic alcohols (up to >99% enantiomeric excess (ee), diastereomeric ratio (dr) >20:1). These boronate substrates provided superior enantioselectivities, allowing for the reactions to proceed with low catalyst loading (0.5-5 mol %) and reduced reaction time (15 min at room temperature for aldehyde allylboration). A wide substrate scope was exhibited, and the novel boronates provided high enantiocontrol. Reactions with substituted allylboronates and aldehydes yielded vicinal stereogenic alcohols bearing ß-tertiary or quaternary carbon centers. High enantio- and diastereoselectivities were found due to the closed six-membered chair-like transition state, with backbone modifications of the boronate and its interactions with the chiral phosphoric acid being the most likely contributing factor.

Retrospective comparison between non-treponemal and treponemal tests for screening of blood donors for syphilis and their correlation with donor history in a tertiary care teaching hospital.

BACKGROUND AND OBJECTIVES: Treponemal tests provide advantage of better detection during early, late and latent stages of syphilis with equal or higher sensitivity & specificity in comparison to non-treponemal tests. The objective of the present study was to analyse the level of concordance between treponemal and non-treponemal tests for donor screening and to correlate them with donor history. MATERIALS AND METHODS: Retrospective analysis of syphilis screening by treponemal (Chemiluminescence & TPHA) and non-treponemal tests (RPR) was done and donor history for high-risk behaviour and factors associated with false positivity were collected from post-donation counselling and collected data was coded and analysed. RESULTS: Amongst the 12,000 donors screened, reactivity rate by RPR, TPHA and Chemiluminescence was 0.45%, 0.8% and 1.17% respectively. There was discordance of 62% and 32% for reactive results by RPR and TPHA respectively when compared with Chemiluminescence. History of high-risk behaviour was present in ∼ 50% and 15% of donors with discordant results by RPR and TPHA respectively. Of 34 donors who were reactive only by Chemiluminescence and were followed up, 15% had history of high-risk behaviour and 56% had factors associated with false reactivity. CONCLUSION: Treponemal tests showed high syphilis reactivity amongst blood donors as compared to non-treponemal tests most likely due to their ability to detect early, late and latent syphilis cases. This may confer added transfusion safety in centres dependent on replacement donors without NAT testing by identifying donors with high-risk history with negligible increase in discard rate due to false reactivity.

adj-Dicarbaporphyrinoid Systems: Synthesis, Spectroscopic Characterization, and Reactivity of 23-Carbabenziporphyrins.

A new family of adj-dicarbaporphyrinoids has been prepared using the "2 + 2" MacDonald methodology. Dibutylboron triflate catalyzed condensation of 3-iodo-4-methoxybenzaldehyde with an indene enamine afforded an iodofulvene aldehyde, and a related dimethoxyfulvene was similarly prepared in two steps from 2,4-dimethoxybenzaldehyde. Following protection as the corresponding dimethyl acetals, the iodofulvenes were metalated with Bu3MgLi at -100 °C and reacted with dimethylformamide to give the required fulvene dialdehyde intermediates. Acid-catalyzed condensation with three different dipyrrylmethanes afforded a series of benzo-23-carbabenziporphyrins in 52-70% yields. The proton nuclear magnetic resonance spectra for these adj-dicarbaporphyrinoids indicate that these macrocycles are slightly diatropic. Monoprotonation afforded cationic species with slightly larger aromatic ring currents, and under strongly acidic conditions, C-protonated dications were generated with substantial diatropic properties. The aromatic character of these structures was supported by nucleus-independent chemical shifts and anisotropy of induced current density calculations. The computational results indicate that the dications favor 23-atom 22π electron delocalization pathways. The benzo-23-carbabenziporphyrins were selectively oxidized with silver(I) acetate in dichloromethane-methanol to give stable nonaromatic structures with two additional methoxy substituents connected to sp3 hybridized bridging carbons. The intriguing reactivity and unique spectroscopic properties of benzo-23-carbabenziporphyrins make these novel structures promising candidates for further investigations.

ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Review of the 2017 Document for the Cardiac Anesthesiologist.

Chronic mitral regurgitation (MR) is the most prevalent valvular lesion in the adult US population. Appropriate patient selection for mitral intervention and selection of the appropriate interventional strategy and optimal periprocedural management rely on thorough clinical evaluation, accurate echocardiographic input, and in-depth understanding of chronic MR pathophysiology on the part of the cardiac anesthesiologist. The recently published Expert Consensus Decision Pathway on the management of MR was designed to provide tools to help the clinician with broad clinical decision-making, including patient referral, and the present review focuses and elaborates on the key aspects relevant to the cardiac anesthesiologist in the peri-interventional setting.

Predicting the Number of Edge-to-Edge Repair Devices Needed to Adequately Treat Mitral Regurgitation Using Transesophageal Echocardiography.

OBJECTIVES: Increased utilization and highly variable costs seen with percutaneous mitral valve edge-to-edge repair have made cost cutting strategies of significant interest. Mitral regurgitation etiology, the number of devices used, and experience all play a role in variability. Currently a paucity of data exists in predicting the number of devices. Any associations found between echocardiography parameters and the number of devices used could help with pre-procedure planning and device placement strategies, ultimately reducing variability and costs. DESIGN: In this retrospective analysis the authors evaluated the ability of established and novel three-dimensional (3D) mitral regurgitation measures, namely 3D vena contracta area and vena contracta length, to predict the number of devices used. Other factors evaluated include mitral valve area and ejection fraction. All factors were compared using the Mann Whitney rank sum tests. PARTICIPANTS: Patients over 18 years old undergoing the MitraClip procedure. SETTING: Catheterization Laboratory. MAIN RESULTS: No relationship was found between 3D parameters and the number of devices used, but mitral valve area was strongly associated with the use of multiple devices. CONCLUSION: The 3D parameters of interest were not associated with the use of multiple devices, but the mitral valve area was associated. Further studies are needed to determine if this relationship is predictive.

A Narrative Review for Perioperative Physicians of the 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants.

In 2017 the American College of Cardiology issued an Expert Consensus Decision Pathway dedicated specifically to the management of bleeding in patients on anticoagulants. The consensus document is both timely and important as indications for more novel anticoagulants expand rapidly. The document reviews in detail recommendations for interruption, management and re-initiation of anticoagulation in bleeding scenarios. Numerous points within the document are relevant to perioperative physicians managing patients on anticoagulation with either bleeding complications or undergoing surgical procedures. The intent of this narrative review is to highlight the salient points within the expert consensus for perioperative physicians.