Leveraging the Capabilities of AI: Novice Neurology-Trained Operators Performing Cardiac POCUS in Patients with Acute Brain Injury.

BACKGROUND: Cardiac point-of-care ultrasound (cPOCUS) can aid in the diagnosis and treatment of cardiac disorders. Such disorders can arise as complications of acute brain injury, but most neurologic intensive care unit (NICU) providers do not receive formal training in cPOCUS. Caption artificial intelligence (AI) uses a novel deep learning (DL) algorithm to guide novice cPOCUS users in obtaining diagnostic-quality cardiac images. The primary objective of this study was to determine how often NICU providers with minimal cPOCUS experience capture quality images using DL-guided cPOCUS as well as the association between DL-guided cPOCUS and change in management and time to formal echocardiograms in the NICU. METHODS: From September 2020 to November 2021, neurology-trained physician assistants, residents, and fellows used DL software to perform clinically indicated cPOCUS scans in an academic tertiary NICU. Certified echocardiographers evaluated each scan independently to assess the quality of images and global interpretability of left ventricular function, right ventricular function, inferior vena cava size, and presence of pericardial effusion. Descriptive statistics with exact confidence intervals were used to calculate proportions of obtained images that were of adequate quality and that changed management. Time to first adequate cardiac images (either cPOCUS or formal echocardiography) was compared using a similar population from 2018. RESULTS: In 153 patients, 184 scans were performed for a total of 943 image views. Three certified echocardiographers deemed 63.4% of scans as interpretable for a qualitative assessment of left ventricular size and function, 52.6% of scans as interpretable for right ventricular size and function, 34.8% of scans as interpretable for inferior vena cava size and variability, and 47.2% of scans as interpretable for the presence of pericardial effusion. Thirty-seven percent of screening scans changed management, most commonly adjusting fluid goals (81.2%). Time to first adequate cardiac images decreased significantly from 3.1 to 1.7 days (p < 0.001). CONCLUSIONS: With DL guidance, neurology providers with minimal to no cPOCUS training were often able to obtain diagnostic-quality cardiac images, which informed management changes and significantly decreased time to cardiac imaging.

To Swan or Not to Swan: Indications, Alternatives, and Future Directions.

The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.

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.

Preoperative Opioid Use Disorder Is Associated With Poorer Outcomes After Coronary Bypass and Valve Surgery: A Multistate Analysis, 2007-2014.

OBJECTIVE: To determine the effect of preoperative opioid use disorder (OUD) on postoperative outcomes in patients undergoing coronary artery bypass grafting (CABG) and heart valve surgery. DESIGN: Retrospective, observational study using data from the State Inpatient Database and the Healthcare Cost and Utilization Project. SETTING: Inpatient data from Florida, California, New York, Maryland, and Kentucky between 2007 and 2014. PARTICIPANTS: A total of 377,771 CABG patients and 194,469 valve surgery patients age ≥18 years. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prevalence of OUD was 2,136 (0.57%) in the CABG group and 2,020 (1.04%) in the valve surgery group. There was no significant difference in mortality between the OUD and non-OUD groups in both surgical cohorts (both p > 0.05). On adjusted analyses, preoperative OUD was significantly associated with increased adjusted odds ratios (aORs) of 30-day hospital readmission (CABG aOR 1.47 [95% confidence interval {CI} 1.30-1.66]; valve surgery aOR 1.41 [95% CI 1.27-1.56]) and 90-day hospital readmission (CABG aOR 1.47 [95% CI 1.31-1.64]; valve surgery aOR 1.33 [95% CI 1.23-1.43]). Preoperative OUD was significantly associated with increased adjusted risk ratios (aRRs) of hospital length of stay (CABG aRR 1.13 [95% CI 1.10-1.16]; valve surgery aRR 1.63 [95% CI 1.54-1.72]) and total hospitalization charges (CABG aRR 1.05 [95% CI 1.03-1.07]; valve surgery aRR 1.28 [95% CI 1.24-1.32]). CONCLUSION: Preoperative OUD is significantly associated with poorer outcomes after cardiac surgery, including increased 30- and 90-day readmissions, hospital length of stay, and total hospitalization charges. Opioid use should be considered a modifiable risk factor in cardiac surgery, and interventions should be attempted preoperatively.

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.

The impact of hospital safety-net burden on mortality and readmission after CABG surgery.

BACKGROUND AND AIM: Safety-net hospitals (SNHs) serve high proportions of uninsured and Medicaid patients. Data conflict as to the impact of hospital safety-net status on perioperative complications. Our goal was to assess the effect of hospital safety-net burden on mortality and readmission following coronary artery bypass graft (CABG) surgery. METHODS: A retrospective analysis was performed using five State Inpatient Databases (2007-2014) for isolated CABG surgery. High, medium, and low burden hospitals were those with the highest, middle, and lowest tertiles of uninsured and Medicaid admissions, respectively. We compared patient demographics and hospital characteristics by safety-net status. Multivariable logistic regression models assessed adjusted odds of in-hospital mortality and 30- and 90-day readmission. RESULTS: About 304 080 patients were included in our analysis. On univariate analysis, high burden hospitals had higher inpatient mortality (2.06% vs 1.71%; P < .001) and 30 day- (16.3% vs 15.3%; P < .001) and 90-day readmission rates (24.6% vs 23.0%; P < .001). On multivariate analysis, high-burden status was not associated with significantly increased adjusted odds of inpatient mortality (OR, 1.047; 95% CI, 0.878-1.249), or readmission at 30 (OR, 1.035; 95% CI, 0.958-1.118) or 90 days (OR, 1.040; 95% CI, 0.968-1.117). CONCLUSION: SNHs do not have worse mortality and readmission outcomes following CABG, after adjusting for patient and hospital characteristics. These findings are reassuring regarding the quality of cardiac surgery care provided to underinsured patient groups. More research is needed to further elucidate trends in outcomes.

Social determinants of health affect unplanned readmissions following acute myocardial infarction.

Background: Low socioeconomic status predicts inferior clinical outcomes in many patient populations. The effects of patient insurance status and hospital safety-net status on readmission rates following acute myocardial infarction are unclear. Materials & methods: A retrospective review of State Inpatient Databases for New York, California, Florida and Maryland, 2007-2014. Results: A total of 1,055,162 patients were included. Medicaid status was associated with 37.7 and 44.0% increases in risk-adjusted readmission odds at 30 and 90 days (p < 0.0001). Uninsured status was associated with reduced odds of readmission at both time points. High-burden safety-net status was associated with 9.6 and 9.5% increased odds of readmission at 30 and 90 days (p < 0.0003). Conclusion: Insurance status and hospital safety-net burden affect readmission odds following acute myocardial infarction.

Methylene Blue Causing Serotonin Syndrome Following Cystocele Repair.

Methylene blue is an intravenously administered agent that may potentiate serotonin syndrome. The usage of methylene blue to evaluate ureters for injuries and patency during urological surgeries is recognized as common practice. However, there is no mention of serotonin syndrome caused by methylene blue in urological literature or for urological surgery. We report the first urological case in order to raise awareness of the risk for serotonin toxicity with utilizing methylene blue.