Pilot Study Suggests Smartphone Application Knowledge Improves Resident Transesophageal Echocardiography Knowledge: A Randomized Controlled Trial.

OBJECTIVE: The objective of this study was to determine whether an asynchronous smartphone-based application with image-based questions would improve anesthesiology resident transesophageal echocardiography (TEE) knowledge compared with standard intraoperative teaching alone. DESIGN: Prospective, single-blinded, pilot, randomized controlled trial. SETTING: Large university teaching hospital. PARTICIPANTS: Participants were anesthesiology residents on their cardiac anesthesiology rotation. INTERVENTIONS: EchoEducator, a TEE image-based smartphone application of learning content through questions, was developed. Content was derived from the Examination of Special Competence in Basic Perioperative Transesophageal Echocardiography and the Objective Structured Clinical Examination portion of the APPLIED Examination and focused on identification of basic TEE views, cardiac structures, and pathology. Residents were randomly assigned to receive access to either the application or to standard intraoperative teaching. Thirty residents met inclusion criteria, and 18 residents completed the study. A pre-intervention assessment was given at the beginning of the rotation, and a post-intervention assessment was given after 2 weeks. MEASUREMENTS: The primary outcome was the difference between the post-test score and the pre-test score. Standard bivariate statistics and the chi-square test were used for categorical variables, and the Student t test was used for continuous variables. Tests were 2-sided, and statistical significance was set at p < 0.05. The intervention group demonstrated a greater increase in score; (+19.19% [95% confidence interval 4.14%-34.24%]; p = 0.02) compared with the control group. CONCLUSIONS: This study supports the hypothesis that use of a smartphone-based asynchronous educational application improves TEE knowledge compared with traditional modalities alone. This supports an opportunity to improve medical education by expanding the role of web-based asynchronous learning.

The "Ice Age" in Cardiac Surgery: Evolution of the "Siberian" Method of Brain Protection During Deep Hypothermic Perfusionless Circulatory Arrest.

Deep hypothermic perfusionless circulatory arrest was the first practical neuroprotective technique used for open-heart surgery. It was refined at the Novosibirsk Medical Research Center in Siberia and was actively used from the mid-1950s until 2001.This review describes the development of this technique and its contribution to our understanding of the dynamic changes in human physiology during induced hypothermia for circulatory arrest without extracorporeal perfusion. Deep hypothermic perfusionless circulatory arrest was an important stepping stone in the development of modern approaches in neuroprotection and monitoring during cardiac surgery.

Aortic Regurgitation in Acute Type-A Aortic Dissection: A Clinical Classification for the Perioperative Echocardiographer in the Era of the Functional Aortic Annulus.

The functional aortic annulus offers a clinical approach for the perioperative echocardiographer to classify the mechanisms of aortic regurgitation in acute type-A dissection. Comprehensive examination of the functional aortic annulus in this setting using transesophageal echocardiography can guide surgical therapy for the aortic root by considering the following important aspects: severity and mechanism of aortic regurgitation, extent of root dissection, and the pattern of coronary artery involvement. The final choice of surgical therapy also should take into account factors, such as patient presentation and surgical experience, to limit mortality and morbidity from this challenging acute aortic syndrome. This review explores these concepts in detail within the framework of the functional aortic annulus, detailed anatomic considerations, and the latest literature.

Stroke After Transcatheter Aortic Valve Replacement: Incidence, Definitions, Etiologies and Management Options.

Neurologic complications after transcatheter aortic valve replacement are devastating. The etiologies of stroke in this setting are best addressed in an integrated fashion during each phase of the perioperative pathway. The conduct of this triphasic approach will continue to be refined to reduce the stroke risks even further, given the major focus on aspects such as embolic protection devices and valve thrombosis. This neurologic focus in transcatheter aortic valve replacement has transformed the investigational approach to neurologic events in cardiovascular clinical trials, resulting in novel guidelines for the diagnosis and assessment of neurologic injury after cardiovascular interventions.

The theory behind, and the challenges of, conserving nature's stage in a time of rapid change.

Most conservation planning to date has focused on protecting today's biodiversity with the assumption that it will be tomorrow's biodiversity. However, modern climate change has already resulted in distributional shifts of some species and is projected to result in many more shifts in the coming decades. As species redistribute and biotic communities reorganize, conservation plans based on current patterns of biodiversity may fail to adequately protect species in the future. One approach for addressing this issue is to focus on conserving a range of abiotic conditions in the conservation-planning process. By doing so, it may be possible to conserve an abiotically diverse "stage" upon which evolution will play out and support many actors (biodiversity). We reviewed the fundamental underpinnings of the concept of conserving the abiotic stage, starting with the early observations of von Humboldt, who mapped the concordance of abiotic conditions and vegetation, and progressing to the concept of the ecological niche. We discuss challenges posed by issues of spatial and temporal scale, the role of biotic drivers of species distributions, and latitudinal and topographic variation in relationships between climate and landform. For example, abiotic conditions are not static, but change through time-albeit at different and often relatively slow rates. In some places, biotic interactions play a substantial role in structuring patterns of biodiversity, meaning that patterns of biodiversity may be less tightly linked to the abiotic stage. Furthermore, abiotic drivers of biodiversity can change with latitude and topographic position, meaning that the abiotic stage may need to be defined differently in different places. We conclude that protecting a diversity of abiotic conditions will likely best conserve biodiversity into the future in places where abiotic drivers of species distributions are strong relative to biotic drivers, where the diversity of abiotic settings will be conserved through time, and where connectivity allows for movement among areas providing different abiotic conditions.

The functional aortic annulus in the 3D era: focus on transcatheter aortic valve replacement for the perioperative echocardiographer.

The functional aortic annulus represents a sound clinical framework for understanding the components of the aortic root complex. Recent three-dimensional imaging analysis has demonstrated that the aortic annulus frequently is elliptical rather than circular. Comprehensive three-dimensional quantification of this aortic annular geometry by transesophageal echocardiography and/or multidetector computed tomography is essential to guide precise prosthesis sizing in transcatheter aortic valve replacement to minimize paravalvular leak for optimal clinical outcome. Furthermore, three-dimensional transesophageal echocardiography accurately can quantify additional parameters of the functional aortic annulus such as coronary height for complete sizing profiles for all valve types in transcatheter aortic valve replacement. Although it is maturing rapidly as a clinical imaging modality, its role in transcatheter aortic valve replacement is seen best as complementary to multidetector computed tomography in a multidisciplinary heart team model.

New frontiers in aortic therapy: focus on current trials and devices in transcatheter aortic valve replacement.

The first decade of clinical experience with transcatheter aortic valve replacement since 2002 saw the development of 2 main valve systems, namely the Edwards Sapien balloon-expandable valve series and the Medtronic self-expanding CoreValve. These 2 valve platforms now have achieved commercial approval and application worldwide in patients with severe aortic stenosis whose perioperative risk for surgical intervention is high or extreme. In the second decade of transcatheter aortic valve replacement, clinical experience and refinements in valve design have resulted in clinical drift towards lower patient risk cohorts. There are currently 2 major trials, PARTNER II and SURTAVI, that are both evaluating the role of transcatheter aortic valve replacement in intermediate-risk patient cohorts. The results from these landmark trials may usher in a new clinical paradigm for transcatheter aortic valve replacement in its second decade.