Automatic tablet-based monoplane quantification of stroke volume and left ventricular ejection fraction: A comparative assessment against computer-based biplane and monoplane tools.

BACKGROUND: Point-of-care cardiovascular left ventricle ejection fraction (LVEF) quantification is established, but automatic tablet-based stroke volume (SV) quantification with handheld ultrasound (HAND) devices is unexplored. We evaluated a tablet-based monoplane LVEF and LV volume quantification tool (AutoEF) against a computer-based tool (Tomtec) for LVEF and SV quantification. METHODS: Patients underwent HAND scans, and LVEF and SV were quantified using AutoEF and computer-based software that utilized either apical four-chamber views (Auto Strain-monoplane [AS-mono]) or both apical four-chamber and apical two-chamber views (Auto Strain-biplane [AS-bi]). Correlation and Bland-Altman analysis were used to compare AutoEF with AS-mono and AS-bi. RESULTS: Out of 43 participants, eight were excluded. AutoEF showed a correlation of .83 [.69:.91] with AS-mono for LVEF and .68 [.44:.82] for SV. The correlation with AS-bi was .79 [.62:.89] for LVEF and .66 [.42:.81] for SV. The bias between AutoEF and AS-mono was 4.88% [3.15:6.61] for LVEF and 17.46 mL [12.99:21.92] for SV. The limits of agreement (LOA) were [-5.50:15.26]% for LVEF and [-8.02:42.94] mL for SV. The bias between AutoEF and AS-bi was 6.63% [5.31:7.94] for LVEF and 20.62 mL [16.18:25.05] for SV, with LOA of [-1.20:14.47]% for LVEF and [-4.71:45.94] mL for SV. CONCLUSION: LVEF quantification with AutoEF software was accurate and reliable, but SV quantification showed limitations, indicating non-interchangeability with neither AS-mono nor AS-bi. Further refinement of AutoEF is needed for reliable SV quantification at the point of care.

Worry as Important "Feelers" in Clinical Anesthesia Practice: A Mixed-Methods Study.

PURPOSE: Worry is an intuitive sense that goes beyond logical reasoning and is valuable in situations where patients' conditions are rapidly changing or when objective data may not fully capture the complexity of a patient's situation. Nurse anesthetists' subjective reasons for worry are quite vague as they are valued inconsistently and not accurately expressed. This study aimed to identify factors playing a role in the emergence of worry during anesthesia practice to clarify its concept. DESIGN: Mixed-methods design consisting of quantitative online surveys followed by qualitative focus group interviews including Dutch nurse anesthetists. METHODS: Both quantitative and qualitative thematic analyses were performed, followed by data and methodological triangulation to enhance the validity and credibility of findings and mitigate the presence of bias. FINDINGS: Surveys (N = 102) were analyzed, and 14 nurse anesthetists participated in the focus group interviews. A total of 89% of the survey respondents reported that at least once have had the feeling of worry, of which 92% use worry during clinical anesthesia practice. Worry was mentioned to be a vital element during anesthesia practice that makes it possible to take precautionary actions to change the anesthetic care plan in a changing situation or patient deterioration. CONCLUSIONS: While a clear definition of worry could not be given, it is a valuable element of anesthesia practice as it serves as a catalyst for critical thinking, problem-solving, clinical reasoning, and decision-making. Use of the feeling of worry alongside technological systems to make an informed decision is crucial. Technology has significantly improved the ability of health care providers to detect and respond to patient deterioration promptly, but it is crucial for nurse anesthetists to use their feeling of worry or intuition alongside technological systems and evidence-based practice to ensure quick assessments or judgments based on experience, knowledge, and observations in clinical practice.

New Hemodynamic Parameters in Peri-Operative and Critical Care-Challenges in Translation.

Hemodynamic monitoring technologies are evolving continuously-a large number of bedside monitoring options are becoming available in the clinic. Methods such as echocardiography, electrical bioimpedance, and calibrated/uncalibrated analysis of pulse contours are becoming increasingly common. This is leading to a decline in the use of highly invasive monitoring and allowing for safer, more accurate, and continuous measurements. The new devices mainly aim to monitor the well-known hemodynamic variables (e.g., novel pulse contour, bioreactance methods are aimed at measuring widely-used variables such as blood pressure, cardiac output). Even though hemodynamic monitoring is now safer and more accurate, a number of issues remain due to the limited amount of information available for diagnosis and treatment. Extensive work is being carried out in order to allow for more hemodynamic parameters to be measured in the clinic. In this review, we identify and discuss the main sensing strategies aimed at obtaining a more complete picture of the hemodynamic status of a patient, namely: (i) measurement of the circulatory system response to a defined stimulus; (ii) measurement of the microcirculation; (iii) technologies for assessing dynamic vascular mechanisms; and (iv) machine learning methods. By analyzing these four main research strategies, we aim to convey the key aspects, challenges, and clinical value of measuring novel hemodynamic parameters in critical care.

Identifying adverse drug reactions from free-text electronic hospital health record notes.

BACKGROUND: Adverse drug reactions (ADRs) are estimated to be the fifth cause of hospital death. Up to 50% are potentially preventable and a significant number are recurrent (reADRs). Clinical decision support systems have been used to prevent reADRs using structured reporting concerning the patient's ADR experience, which in current clinical practice is poorly performed. Identifying ADRs directly from free text in electronic health records (EHRs) could circumvent this. AIM: To develop strategies to identify ADRs from free-text notes in electronic hospital health records. METHODS: In stage I, the EHRs of 10 patients were reviewed to establish strategies for identifying ADRs. In stage II, complete EHR histories of 45 patients were reviewed for ADRs and compared to the strategies programmed into a rule-based model. ADRs were classified using MedDRA and included in the study if the Naranjo causality score was ≥1. Seriousness was assessed using the European Medicine Agency's important medical event list. RESULTS: In stage I, two main search strategies were identified: keywords indicating an ADR and specific prepositions followed by medication names. In stage II, the EHRs contained a median of 7.4 (range 0.01-18) years of medical history covering over 35 000 notes. A total of 318 unique ADRs were identified of which 63 were potentially serious and 179 (sensitivity 57%) were identified by the rule. The method falsely identified 377 ADRs (positive predictive value 32%). However, it also identified an additional eight ADRs. CONCLUSION: Two key strategies were developed to identify ADRs from hospital EHRs using free-text notes. The results appear promising and warrant further study.

Correlation of Carotid Doppler Blood Flow With Invasive Cardiac Output Measurements in Cardiac Surgery Patients.

OBJECTIVE: Carotid Doppler ultrasound has been a topic of recent interest, as it may be a promising noninvasive hemodynamic monitoring tool. In this study, the relation between carotid artery blood flow and invasive cardiac output (CO) was evaluated. DESIGN: A prospective, observational study. SETTING: A single-institution, tertiary referral hospital. PARTICIPANTS: Eighteen elective cardiac surgery patients. INTERVENTIONS: CO was measured by calibrated pulse contour analysis. Simultaneously, carotid artery pulsed-wave Doppler measurements were obtained in the operating room in three clinical settings: after induction of anesthesia (T1), after a passive leg raise maneuverer (T2), and at the end of surgery (T3). MEASUREMENTS AND MAIN RESULTS: Correlation and trending between carotid artery blood flow and invasive CO were evaluated. Furthermore, two Bland-Altman plots were constructed to evaluate the level of agreement between carotid artery-derived CO and invasive CO measurements. Carotid artery blood flow correlated moderately with invasive CO (ρ = 0.67, 95% confidence interval 0.56-0.76, p < 0.05). Concordance between the percentage change of carotid artery blood flow and invasive CO from T1 to T3 was 72%. The level of agreement between carotid artery-derived CO and invasive CO was ±2.29; ±2.57 L/min, with a bias of 0.1; -0.54 L/min, and mean error of 50% and 48%, for the two Bland-Altman analyses, respectively. Intraexamination precision was acceptable. CONCLUSIONS: In cardiac surgery patients, carotid artery blood flow correlated moderately with invasive CO measurements. However, the trending ability of carotid artery blood flow was poor, and carotid artery-derived CO tended not to be interchangeable with invasive CO.

Clinical validation of a computerized algorithm to determine mean systemic filling pressure.

Mean systemic filling pressure (Pms) is a promising parameter in determining intravascular fluid status. Pms derived from venous return curves during inspiratory holds with incremental airway pressures (Pms-Insp) estimates Pms reliably but is labor-intensive. A computerized algorithm to calculate Pms (Pmsa) at the bedside has been proposed. In previous studies Pmsa and Pms-Insp correlated well but with considerable bias. This observational study was performed to validate Pmsa with Pms-Insp in cardiac surgery patients. Cardiac output, right atrial pressure and mean arterial pressure were prospectively recorded to calculate Pmsa using a bedside monitor. Pms-Insp was calculated offline after performing inspiratory holds. Intraclass-correlation coefficient (ICC) and assessment of agreement were used to compare Pmsa with Pms-Insp. Bias, coefficient of variance (COV), precision and limits of agreement (LOA) were calculated. Proportional bias was assessed with linear regression. A high degree of inter-method reliability was found between Pmsa and Pms-Insp (ICC 0.89; 95%CI 0.72-0.96, p = 0.01) in 18 patients. Pmsa and Pms-Insp differed not significantly (11.9 mmHg, IQR 9.8-13.4 vs. 12.7 mmHg, IQR 10.5-14.4, p = 0.38). Bias was -0.502 ± 1.90 mmHg (p = 0.277). COV was 4% with LOA -4.22 - 3.22 mmHg without proportional bias. Conversion coefficient Pmsa âž” Pms-Insp was 0.94. This assessment of agreement demonstrates that the measures Pms-Insp and the computerized Pmsa-algorithm are interchangeable (bias -0.502 ± 1.90 mmHg with conversion coefficient 0.94). The choice of Pmsa is straightforward, it is non-interventional and available continuously at the bedside in contrast to Pms-Insp which is interventional and calculated off-line. Further studies should be performed to determine the place of Pmsa in the circulatory management of critically ill patients. ( www.clinicaltrials.gov ; TRN NCT04202432, release date 16-12-2019; retrospectively registered).Clinical Trial Registration www.ClinicalTrials.gov , TRN: NCT04202432, initial release date 16-12-2019 (retrospectively registered).

Intelligent checklists improve checklist compliance in the intensive care unit: a prospective before-and-after mixed-method study.

BACKGROUND: We examined whether a context and process-sensitive 'intelligent' checklist increases compliance with best practice compared with a paper checklist during intensive care ward rounds. METHODS: We conducted a single-centre prospective before-and-after mixed-method trial in a 35 bed medical and surgical ICU. Daily ICU ward rounds were observed during two periods of 8 weeks. We compared paper checklists (control) with a dynamic (digital) clinical checklist (DCC, intervention). The primary outcome was compliance with best clinical practice, measured as the percentages of checked items and unchecked critical items. Secondary outcomes included ICU stay and the usability of digital checklists. Data are presented as median (interquartile range). RESULTS: Clinical characteristics and severity of critical illness were similar during both control and intervention periods of study. A total of 36 clinicians visited 197 patients during 352 ward rounds using the paper checklist, compared with 211 patients during 366 ward rounds using the DCC. Per ICU round, a median of 100% of items (94.4-100.0) were completed by DCC, compared with 75.1% (66.7-86.4) by paper checklist (P=0.03). No critical items remained unchecked by the DCC, compared with 15.4% (8.3-27.3) by the paper checklist (P=0.01). The DCC was associated with reduced ICU stay (1 day [1-3]), compared with the paper checklist (2 days [1-4]; P=0.05). Usability of the DCC was judged by clinicians to require further improvement. CONCLUSIONS: A digital checklist improved compliance with best clinical practice, compared with a paper checklist, during ward rounds on a mixed ICU. CLINICAL TRIAL REGISTRATION: NCT03599856.

Acute isotonic hyponatremia after single dose histidine-tryptophan-ketoglutarate cardioplegia: an observational study.

INTRODUCTION: Histidine-tryptophan-ketoglutarate cardioplegia is used for prolonged myocardial protection in complex cardiac surgery. Administration leads to acute hyponatremia in a majority of patients, because of its low sodium concentration (15 mmol/L). However, histidine-tryptophan-ketoglutarate solution's osmolality is slightly hypertonic (310 mOsm/kg). Hypothesized was that acute isotonic hyponatremia will be induced, which does not need to be corrected with hypertonic saline. METHODS: Cardiac surgery patients who received histidine-tryptophan-ketoglutarate cardioplegia were included in this prospective single center study. Serial blood samples were taken from each patient at five different time points: after induction of anesthesia (T1) and 10 minutes (T2), 6 hours (T3), 12 hours (T4), and 18 hours (T5) after administration of histidine-tryptophan-ketoglutarate cardioplegia, respectively. Blood samples were analyzed for sodium concentration, osmolality, and acid-base balance. RESULTS: Twenty-five patients were included. Median blood sodium levels decreased from 140 [138-141] at T1 to 128 [125-130] mmol/L at T2 (p < 0.001). At T3, T4, and T5, median blood sodium concentrations were 136 [134-138], 139 [137-140], and 140 [137-142] mmol/L, respectively. Median osmolality was 289 [286-293] at T1 and increased to 296 [291-299] mOsm/kg (p < 0.001) at T2. At T3, T4, and T5, osmolality was 298 [292-302], 298 [294-304], and 300 [297-306] mOsm/kg, respectively. Median pH decreased from 7.38 [7.36-7.40] at T1 to 7.30 [7.27-7.32] at T2 (p < 0.001). CONCLUSION: Administration of histidine-tryptophan-ketoglutarate cardioplegia during cardiac surgery leads to acute moderate to severe isotonic hyponatremia, which resolves spontaneously in the first 18 hours perioperatively. Correction with hypertonic saline is not necessary.

Modulation of Pulse Propagation and Blood Flow via Cuff Inflation-New Distal Insights.

In standard critical care practice, cuff sphygmomanometry is widely used for intermittent blood pressure (BP) measurements. However, cuff devices offer ample possibility of modulating blood flow and pulse propagation along the artery. We explore underutilized arrangements of sensors involving cuff devices which could be of use in critical care to reveal additional information on compensatory mechanisms. In our previous work, we analyzed the response of the vasculature to occlusion perturbations by means of observations obtained non-invasively. In this study, our aim is to (1) acquire additional insights by means of invasive measurements and (2) based on these insights, further develop cuff-based measurement strategies. Invasive BP experimental data is collected downstream from the cuff in two patients monitored in the OR. It is found that highly dynamic processes occur in the distal arm during cuff inflation. Mean arterial pressure increases in the distal artery by 20 mmHg, leading to a decrease in pulse transit time by 20 ms. Previous characterizations neglected such distal vasculature effects. A model is developed to reproduce the observed behaviors and to provide a possible explanation of the factors that influence the distal arm mechanisms. We apply the new findings to further develop measurement strategies aimed at acquiring information on pulse arrival time vs. BP calibration, artery compliance, peripheral resistance, artery-vein interaction.

Fully automated postoperative ventilation in cardiac surgery patients: a randomised clinical trial.

BACKGROUND: Ensuring that lung-protective ventilation is achieved at scale is challenging in perioperative practice. Fully automated ventilation may be more effective in delivering lung-protective ventilation. Here, we compared automated lung-protective ventilation with conventional ventilation after elective cardiac surgery in haemodynamically stable patients. METHODS: In this single-centre investigator-led study, patients were randomly assigned at the end of cardiac surgery to receive either automated (adaptive support ventilation) or conventional ventilation. The primary endpoint was the proportion of postoperative ventilation time characterised by exposure to predefined optimal, acceptable, and critical (injurious) ventilatory parameters in the first three postoperative hours. Secondary outcomes included severe hypoxaemia (Spo2 <85%) and resumption of spontaneous breathing. Data are presented as mean (95% confidence intervals [CIs]). RESULTS: We randomised 220 patients (30.4% females; age: 62-76 yr). Subjects randomised to automated ventilation (n=109) spent a 29.7% (95% CI: 22.1-37.4) higher mean proportion of postoperative ventilation time receiving optimal postoperative ventilation after surgery (P<0.001) compared with subjects receiving conventional postoperative ventilation (n=111). Automated ventilation also reduced the proportion of postoperative ventilation time that subjects were exposed to injurious ventilatory settings by 2.5% (95% CI: 1-4; P=0.003). Severe hypoxaemia was less likely in subjects randomised to automated ventilation (risk ratio: 0.26 [0.22-0.31]; P<0.01). Subjects resumed spontaneous breathing more rapidly when randomised to automated ventilation (hazard ratio: 1.38 [1.05-1.83]; P=0.03). CONCLUSIONS: Fully automated ventilation in haemodynamically stable patients after cardiac surgery optimised lung-protective ventilation during postoperative ventilation, with fewer episodes of severe hypoxaemia and an accelerated resumption of spontaneous breathing. CLINICAL TRIAL REGISTRATION: NCT03180203.

Interfascial Plane Blocks Reduce Postoperative Pain and Morphine Consumption in Thoracic Outlet Decompression.

BACKGROUND: Postoperative analgesia in patients undergoing transaxillary thoracic outlet decompression (TATOD) is challenging because of the invasive surgery, the complex innervation of the axillary region, and the preoperative use of opioids by many patients. Commonly, postoperative pain is managed with additional opioids that introduce well-known sideeffects. To investigate the analgesic efficacy of 2 novel regional anesthesia techniques, we performed a retrospective study comparing the combined pectoral block type 1 and erector spinae block (PECS 1 + ESB) and the pectoral block type 2 (PECS 2) and systemic intravenous opioids regimen (no block) in patients undergoing TATOD. MATERIALS AND METHODS: We performed 10 PECS 1 + ESB and 10 PECS 2 blocks in patients undergoing TATOD. Twenty patients were randomly selected as controls. The primary endpoint was pain. Secondary endpoints were opioid use, nausea, and vomiting. RESULTS: Postoperative maximal numeric rating scale scores on recovery were significantly lower in patients receiving either a PECS 1 + ESB or a PECS 2 block compared with controls without block (no block: median 6.00, interquartile range [IQR] 3.00; PECS 1 + ESB: median 4.50, IQR 4.00; PECS 2: median 4.00, IQR 5.00; P = 0.031). Postoperative intravenous morphine consumption was 43% lower in the PECS 1 + ESB group and 56% lower in the PECS 2 group compared with the group with no block (oral morphine equivalents; no block: mean 16.05 ± SD 6.79 mg; PECS 1 + ESB mean 9.05 ± SD 6.24 mg; PECS 2: mean 7.00 ± SD 6.16; P = 0.03 and P = 0.003, respectively). There was no statistical difference in both nausea and vomitus (no block 45% nausea and 30% vomitus, PECS 1 + ESB 40% nausea and 20% vomitus, PECS 2 10% nausea and 0% vomitus, P = 0.17 and P = 0.14, respectively). CONCLUSIONS: There was a significant reduction in postoperative pain and opioid consumption for patients treated with either the PECS 1 + ESB block or PECS 2.

Safety of moderate-to-deep sedation performed by sedation practitioners: A national prospective observational study.

BACKGROUND: In the Netherlands, a significant proportion of moderate-to-deep sedation is performed by sedation practitioners under the indirect supervision of an anaesthesiologist but there are limited safety data available. OBJECTIVE: To estimate the rate of sedation-related adverse events and patient relevant outcomes (PRO). DESIGN: This was a prospective national observational study. Data were collected with a modified adverse event reporting tool from the International Sedation Task Force of the World Society of Intravenous Anaesthesia. SETTING: A total of 24 hospitals in the Netherlands where moderate-to-deep sedation was performed by sedation practitioners from the 1 February 2015 to 1 March 2016. PATIENTS: Consecutive adults undergoing moderate-to-deep sedation for gastrointestinal, pulmonary and cardiac procedures. INTERVENTION: Observation: Analysis included descriptive statistics and a multivariate logistic regression model for an association between adverse events and PRO. MAIN OUTCOME MEASURES: The primary outcome was the rate of unfavourable PRO (admission to ICU, permanent neurological deficit, pulmonary aspiration or death). Secondary outcome was the rate of moderate-to-good PRO (unplanned hospital admission or escalation of care). Composite outcome was the sum of all primary and secondary outcomes. RESULTS: A total of 11 869 patients with a median age of 64 years [interquartile range 51 to 72] were included. ASA physical score distribution was: first, 19.1%; second, 57.6%; third, 21.6%; fourth, 1.2%. Minimal adverse events occurred in 1517 (12.8%), minor adverse events in 113 (1.0%) and major adverse events in 80 instances (0.7%). PRIMARY OUTCOME: Five (0.04%) unfavourable PRO were observed; four patients needing admission to the intensive care unit; and one died. Secondary outcome: 12 (0.1%) moderate-to-good PRO were observed. Moderate and major adverse events were associated with the composite outcome [3.7 (95% confidence interval 1.1 to 11.9) and 40.6 (95% confidence interval 11.0 to 150.4)], but not minimal or minor adverse events. CONCLUSION: Moderate-to-deep sedation performed by trained sedation practitioners has a very low rate of unfavourable outcome.

Irreversible electroporation for nonthermal tumor ablation in the clinical setting: a systematic review of safety and efficacy.

PURPOSE: To provide an overview of current clinical results of irreversible electroporation (IRE), a novel, nonthermal tumor ablation technique that uses electric pulses to induce cell death, while preserving structural integrity of bile ducts and vessels. METHODS: All in-human literature on IRE reporting safety or efficacy or both was included. All adverse events were recorded. Tumor response on follow-up imaging from 3 months onward was evaluated. RESULTS: In 16 studies, 221 patients had 325 tumors treated in liver (n = 129), pancreas (n = 69), kidney (n = 14), lung (n = 6), lesser pelvis (n = 1), and lymph node (n = 2). No major adverse events during IRE were reported. IRE caused only minor complications in the liver; however, three major complications were reported in the pancreas (bile leak [n = 2], portal vein thrombosis [n = 1]). Complete response at 3 months was 67%-100% for hepatic tumors (93%-100% for tumors o 3 cm). Pancreatic IRE combined with surgery led to prolonged survival compared with control patients (20 mo vs 13 mo) and significant pain reduction. CONCLUSIONS: In cases where other techniques are unsuitable, IRE is a promising modality for the ablation of tumors near bile ducts and blood vessels. This articles gives an extensive overview of the available evidence, which is limited in terms of quality and quantity. With the limitations of the evidence in mind, IRE of central liver tumors seems relatively safe without major complications, whereas complications after pancreatic IRE appear more severe. The available limited results for tumor control are generally good. Overall, the future of IRE for difficult-to-reach tumors appears promising.

Impact of postoperative renal replacement therapy on long-term outcome after cardiac surgery increases with age.

BACKGROUND AND AIM OF THE STUDY: In the present study, we investigated the survival of patients who received postoperative renal replacement therapy (RRT) after cardiac surgery. We specifically focused on factors predicting long-term outcome in elderly patients. METHODS: Data of all patients that received unintentional renal replacement therapy following cardiac surgery between 2004 and 2010 were analyzed. Logistic- and Cox regression analyses were performed to detect the predictors of early and late mortality, respectively. RESULTS: During the study period, 11,899 patients underwent cardiac surgery in our center. Post-operative RRT was performed in 138 patients (1.2%). In this group of patients, 30-day mortality included 72 patients (52%) and the total overall mortality included 107 patients (77.5%). Regression analyses revealed that age predicted 30-day mortality (odds ratio = 1.08 [1.03 to 1.12]) as well as late mortality (odds ratio = 1.05 [1.02 to 1.07]. CONCLUSIONS: Patients requiring RRT after cardiac surgery have a poor prognosis with a high mortality. Older age predicted both 30-day and late mortality in these patients.

Patient's Preference for Same-Day Discharge or Hospitalization After Bariatric Surgery.

PURPOSE: Enhanced Recovery After Bariatric Surgery protocols have proven to be effective in reducing complication rates and length of stay. Guidelines do not include a recommendation on the length of hospital stay whereas same-day discharge is currently widely investigated on safety and feasibility. However, none of these studies takes patient preferences into account. The study aimed to reveal the patient's preference for outpatient surgery (OS) in patients who underwent primary bariatric surgery. MATERIALS AND METHODS: A single-center preference-based randomized trial was performed between March and December of 2021. Adult patients planned for primary bariatric surgery were able to choose their care pathway, either OS with remote heart and respiratory rate monitoring by a wearable data logger or standard care with at least one-night hospitalization. RESULTS: Out of the 202 patients, nearly everyone (98.5%) had a preference. Of 199 patients, 99 (49.7%) chose inpatient surgery. Of the 100 with a preference for OS, 23 stayed in the hospital due to medical reasons and 12 patients changed their preference. Based on both initial preference and changed preference, there were no differences between sex, age, body mass index, and co-morbidities such as diabetes mellitus, hypertension, and atrial fibrillation, nor in the use of anticoagulants or type of surgery. CONCLUSION: Patients seemed to have a strong preference for their stay after a bariatric procedure. The preference is equally divided between outpatient and inpatient surgery and is not influenced by any patient characteristics.

Is the Corrected Carotid Flow Time a Clinically Acceptable Surrogate Hemodynamic Parameter for the Left Ventricular Ejection Time?

OBJECTIVE: The corrected left ventricular ejection time (cLVET) comprises the phase from aortic valve opening to aortic valve closure corrected for heart rate. As a surrogate measure for cLVET, the corrected carotid flow time (ccFT) has been proposed in previous research. The aim of this study was to assess the clinical agreement between cLVET and ccFT in a dynamic clinical setting. METHODS: Twenty-five patients with severe aortic valve stenosis (AS) were selected for transcatheter aortic valve replacement (TAVR). The cLVET and ccFT were derived from the left ventricular outflow tract (LVOT) and the common carotid artery (CCA), respectively, using pulsed wave Doppler ultrasound. Bazett's (B) and Wodey's (W) equations were used to calculate cLVET and ccFT. Measurements were performed directly before (T1) and after (T2) TAVR. Correlation, Bland-Altman and concordance analyses were performed. RESULTS: Corrected LVET decreased from T1 to T2 (p < 0.001), with relative reductions of 11% (B) and 9% (W). Corrected carotid flow time decreased (p < 0.001), with relative reductions of 12% (B) and 10% (W). The correlation between cLVET and ccFT was strong for B (ρ = 0.74, p < 0.001) and W (ρ = 0.81, p < 0.001). The bias was -39 ms (B) and -37 ms (W), and the upper and lower levels of agreement were 19 and -98 ms (B) and 5 and -78 ms (W), respectively. Trending ability between cLVET and ccFT was good (concordance 96%) for both B and W. CONCLUSION: In TAVR patients, the clinical agreement between cLVET and ccFT was acceptable, indicating that ccFT could serve as a surrogate measure for cLVET.

Predictive modeling of perioperative patient deterioration: combining unanticipated ICU admissions and mortality for improved risk prediction.

OBJECTIVE: This paper presents a comprehensive analysis of perioperative patient deterioration by developing predictive models that evaluate unanticipated ICU admissions and in-hospital mortality both as distinct and combined outcomes. MATERIALS AND METHODS: With less than 1% of cases resulting in at least one of these outcomes, we investigated 98 features to identify their role in predicting patient deterioration, using univariate analyses. Additionally, multivariate analyses were performed by employing logistic regression (LR) with LASSO regularization. We also assessed classification models, including non-linear classifiers like Support Vector Machines, Random Forest, and XGBoost. RESULTS: During evaluation, careful attention was paid to the data imbalance therefore multiple evaluation metrics were used, which are less sensitive to imbalance. These metrics included the area under the receiver operating characteristics, precision-recall and kappa curves, and the precision, sensitivity, kappa, and F1-score. Combining unanticipated ICU admissions and mortality into a single outcome improved predictive performance overall. However, this led to reduced accuracy in predicting individual forms of deterioration, with LR showing the best performance for the combined prediction. DISCUSSION: The study underscores the significance of specific perioperative features in predicting patient deterioration, especially revealed by univariate analysis. Importantly, interpretable models like logistic regression outperformed complex classifiers, suggesting their practicality. Especially, when combined in an ensemble model for predicting multiple forms of deterioration. These findings were mostly limited by the large imbalance in data as post-operative deterioration is a rare occurrence. Future research should therefore focus on capturing more deterioration events and possibly extending validation to multi-center studies. CONCLUSIONS: This work demonstrates the potential for accurate prediction of perioperative patient deterioration, highlighting the importance of several perioperative features and the practicality of interpretable models like logistic regression, and ensemble models for the prediction of several outcome types. In future clinical practice these data-driven prediction models might form the basis for post-operative risk stratification by providing an evidence-based assessment of risk.

Evaluation of the image quality and validity of handheld echocardiography for stroke volume and left ventricular ejection fraction quantification: a method comparison study.

Bedside quantification of stroke volume (SV) and left ventricular ejection fraction (LVEF) is valuable in hemodynamically compromised patients. Miniaturized handheld ultrasound (HAND) devices are now available for clinical use. However, the performance level of HAND devices for quantified cardiac assessment is yet unknown. The aim of this study was to compare the validity of HAND measurements with standard echocardiography (SE) and three-dimensional echocardiography (3DE). Thirty-six patients were scanned with HAND, SE and 3DE. LVEF and SV quantification was done with automated software for the HAND, SE and 3DE dataset. The image quality of HAND and SE was evaluated by scoring segmental endocardial border delineation (2 = good, 1 = poor, 0 = invisible). LVEF and SV of HAND was evaluated against SE and 3DE using correlation and Bland-Altman analysis. The correlation, bias, and limits of agreement (LOA) between HAND and SE were 0.68 [0.46:0.83], 1.60% [- 2.18:5.38], and 8.84% [- 9.79:12.99] for LVEF, and 0.91 [0.84:0.96], 1.32 ml [- 0.36:4.01], 15.54 ml [- 18.70:21.35] for SV, respectively. Correlation, bias, and LOA between HAND and 3DE were 0.55 [0.6:0.74], - 0.56% [- 2.27:1.1], and 9.88% [- 13.29:12.17] for LVEF, and 0.79 [0.62:0.89], 6.78 ml [2.34:11.21], 12.14 ml [- 26.32:39.87] for SV, respectively. The image quality scores were 9.42 ± 2.0 for the apical four chamber views of the HAND dataset and 10.49 ± 1.7 for the SE dataset and (P < 0.001). Clinically acceptable accuracy, precision, and image quality was demonstrated for HAND measurements compared to SE. In comparison to 3DE, HAND showed a clinically acceptable accuracy and precision for LVEF quantification.

The Prognostic Role of Global Longitudinal Strain and NT-proBNP in Heart Failure Patients Receiving Cardiac Resynchronization Therapy.

BACKGROUND: We aimed to evaluate whether baseline GLS (global longitudinal strain), NT-proBNP, and changes in these after cardiac resynchronization therapy (CRT) can predict long-term clinical outcomes and the echocardiographic-based response to CRT (defined by 15% relative reduction in left ventricular end-systolic volume). METHODS: We enrolled 143 patients with stable ischemic heart failure (HF) undergoing CRT-D implantation. NT-proBNP and echocardiography were obtained before and 6 months after. The patients were followed up (median: 58 months) for HF-related deaths and/or HF hospitalizations (primary endpoint) or HF-related deaths (secondary endpoint). RESULTS: A total of 84 patients achieved the primary and 53 the secondary endpoint, while 104 patients were considered CRT responders and 39 non-responders. At baseline, event-free patients had higher absolute GLS values (p < 0.001) and lower NT-proBNP serum levels (p < 0001) than those achieving the primary endpoint. A similar pattern was observed in favor of CRT responders vs. non-responders. On Cox regression analysis, baseline absolute GLS value (HR = 0.77; 95% CI, 0.51-1.91; p = 0.002) was beneficially associated with lower primary endpoint incidence, while baseline NT-proBNP levels (HR = 1.55; 95% CI, 1.43-2.01; p = 0.002) and diabetes presence (HR = 1.27; 95% CI, 1.12-1.98; p = 0.003) were related to higher primary endpoint incidence. CONCLUSIONS: In HF patients undergoing CRT-D, baseline GLS and NT-proBNP concentrations may serve as prognostic factors, while they may predict the echocardiographic-based response to CRT.