Gastrointestinal Complications After Transesophageal Echocardiography for Mitral Valve Transcatheter Edge-to-Edge Repair: Insights From a Large Contemporary Cohort.

OBJECTIVES: Transesophageal echocardiography-related complications (TEE-RC) are higher in structural heart interventions than in traditional operative settings. In mitral valve transcatheter edge-to-edge repair (MV-TEER), the incidence of TEE-RC may be higher than in other structural interventions. However, existing reports are limited and robust data evaluating TEE safety in this patient population are lacking. The authors sought to describe the incidence and risk factors of upper gastrointestinal injuries after TEE in patients undergoing MV-TEER. DESIGN: A retrospective observational study. SETTING: A single tertiary academic hospital. PARTICIPANTS: A total of 442 consecutive patients who underwent MV-TEER, specifically with MitraClip, between December 2015 and March 2022. INTERVENTIONS: Transesophageal echocardiography was performed intraoperatively to guide all MV-TEERs. MEASUREMENTS AND MAIN RESULTS: The study's primary goal was to investigate an association between TEE procedure duration and TEE-RC risk. The contribution of demographic risk factors and intraprocedural characteristics also was investigated. Transesophageal echocardiography-RCs were observed in 17 out of 442 patients (3.8%). Dysphagia was the most common TEE-RC (n = 9/17, 53%), followed by new gastroesophageal reflux (n = 6/17, 35%) and odynophagia (n = 3/17, 18%). There were no esophageal perforations or upper gastrointestinal bleeds. History of dysphagia was the only variable associated with TEE-RCs (p = 0.008; n = 9 [2.1%] v n = 3 [18%]), with a relative risk of 8.67 (95% CI 2.57, 29.16). The TEE procedure duration was not statistically different between the 2 groups (46 minutes [39-64] in TEE-RCs v 49 minutes [36-77] in no complications). CONCLUSION: In patients undergoing MV-TEER, TEE-RCs are uncommon, and major complications are rare. The authors' outcomes reflect those of a high-volume referral center with TEEs performed by cardiac anesthesiologists.

Procedural, Short-Term, and Intermediate-Term Outcomes in Propensity-Matched Patients With Severe Mitral Valve Regurgitation Undergoing Urgent Versus Elective MitraClip Percutaneous Mitral Valve Repair.

OBJECTIVE: The study authors sought to compare outcomes in patients with severe mitral valve regurgitation (MR) undergoing urgent, as compared to elective, mitral valve repair employing MitraClip. They hypothesized that, compared to elective cases, MitraClip procedures performed for urgent indications would be associated with increased intraoperative and postoperative complications but have similar long-term outcomes. DESIGN: A retrospective chart review with 3:1 propensity score matching of elective-to-urgent cases. SETTING: A single, large-volume tertiary care academic medical center. PARTICIPANTS: All consecutive patients with severe MR who underwent elective or urgent MitraClip procedures between December 15, 2015, and October 26, 2020. INTERVENTIONS: MR repair with MitraClip. MEASUREMENTS AND MAIN RESULTS: As expected, patients in the urgent MitraClip group required a higher level of preprocedural care, and there were significant differences in baseline demographic and clinical variables as compared to the elective group. To reduce baseline characteristics heterogeneity, propensity matching was performed for age, left ventricular systolic dysfunction, congestive heart failure, chronic obstructive pulmonary disease, and smoking histories, using the nearest-neighbor matching with a caliper of 0.2 and with replacement. The final study cohort included 89 urgent and 252 matched elective cases, with a suitable alignment between the treatment groups. Propensity-matched urgent MitraClip patients experienced a longer hospital length of stay (p < 0.001), increased intensive care unit admissions (19% v 4%, p < 0.001) and mechanical ventilation (6.7% v 1.6%, p = 0.023), postprocedural atrial fibrillation (11% v 4.4%, p = 0.036), pericardial effusion (10% v 2.4%, p = 0.005), and acute kidney injury (7.9% v 2%, p = 0.016). Furthermore, patients in the urgent cohort incurred significantly higher 30-day cardiovascular mortality (6.7% v 2%, p = 0.039), increased 30-day (16% v 5.6%, p = 0.006), and 1-year (33% v 20%, p = 0.021) readmission rates. However, there were no statistically significant differences in 30-day and 1-year overall and 1-year cardiovascular mortality. CONCLUSIONS: Urgent MitraClip repairs can be performed successfully, when needed, in critically ill patients with severe MR. Despite the procedural success, patients undergoing urgent MitraClip repair remain at high risk for adverse outcomes in the short- and intermediate-term and incur increased cardiovascular mortality and morbidity. Further efforts are required to develop strategies to optimize short and intermediate outcomes in this vulnerable group of patients.

Supraglottic airway versus endotracheal tube for transesophageal echocardiography guided watchman procedures.

Context: Atrial fibrillation (AF) is the most common arrhythmia in adults. For over 90% of non-valvular AF patients, the left atrial appendage is the primary site of thrombus formation. Left atrial appendage occlusion using the FDA-approved Watchman™ device has been shown to have better clinical outcomes with minimal post-procedural complications when compared to warfarin therapy for patients with contraindications to anticoagulation. Traditionally, this procedure requires an endotracheal tube (ETT) to facilitate transesophageal echocardiography (TEE) guidance. However, recently supraglottic airway (SGA) has emerged as a feasible, non-inferior alternative to ETT for procedures requiring TEE. Aims: Compare outcomes between TEE guided Watchman™ procedures performed with a SGA versus ETT. Settings and Design: A single tertiary care academic medical center. Methods and Materials: Retrospective Observational Study comparing SGA and ETT patients. Statistical Analysis Used: 1:4 propensity score matching of SGA and ETT patients. Results: 42 SGA patients were matched with 155 ETT patients. All patients underwent procedure with TEE. SGA patients had shorter operating room time (11 min difference, P = 0.00001) and considerably shorter PACU length of stays (45 min difference, P = 0.024). Statistically significant, but clinically trivial differences were seen in procedure times (P = 0.015) and fluoroscopy times (P = 0.017). Patients in the SGA group received lower fentanyl (P < 0.00001) dosages. No significant differences were observed in postoperative complications, organ-specific morbidity or 30-day mortality. Conclusions: General anesthesia with SGA is likely a safe, feasible alternative to ETT in Watchman™ procedures requiring TEE guidance. Use of SGA was associated with significant reductions in operating room time and PACU length of stay, potentially offering advantages in terms of resource utilization.

Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Performed With General Anesthesia Using a Supraglottic Airway Versus Monitored Anesthesia Care.

OBJECTIVE: Compare general anesthesia with a supraglottic airway versus monitored anesthesia care for transfemoral transcatheter aortic valve replacement (TF-TAVR) in patients with aortic stenosis. The authors hypothesized that the supraglottic airway group would have similar operating room and procedure times, postanesthesia care unit (PACU) and hospital stays, and similar rates of intraprocedural and postprocedural complications compared with the monitored anesthesia care group. STUDY DESIGN: Retrospective chart review with 1:1 propensity score matching of supraglottic airway to monitored anesthesia care patients. SETTING: Tertiary care academic medical center. PARTICIPANTS: TF-TAVR patients between 2017 and 2019. INTERVENTIONS: Supraglottic airway or monitored anesthesia care. MEASUREMENTS AND MAIN RESULTS: One hundred forty-eight supraglottic airway patients were matched with 148 monitored anesthesia care patients. Monitored anesthesia care patients had slightly shorter operating room (p < 0.001) and procedure times (p = 0.015). No difference was observed in hospital length of stay (p = 0.34). Fewer patients in the supraglottic airway group required a PACU stay >2 hours (p < 0.001). Use of intraprocedural vasopressors (p < 0.001) and fentanyl dosage (p < 0.001) was higher in the supraglottic airway group. No differences were observed in postoperative complications or procedural success rates. CONCLUSIONS: In this, the first study to compare these 2 modalities, supraglottic airway use was demonstrated to be a safe, feasible alternative to monitored anesthesia care during TF-TAVR and did not increase organ-specific morbidity, 30-day mortality, hospital length of stay, or PACU length of stay. Even though supraglottic airway was associated with slight increases in procedure and operating room times, these were not clinically significant.

A Multi-Institutional Study to Evaluate Automated Whole Slide Scoring of Immunohistochemistry for Assessment of Programmed Death-Ligand 1 (PD-L1) Expression in Non-Small Cell Lung Cancer.

Assessment of programmed death-ligand 1 (PD-L1) expression is a critical part of patient management for immunotherapy. However, studies have shown that pathologist-based analysis lacks reproducibility, especially for immune cell expression. The purpose of this study was to validate reproducibility of the automated machine-based Optra image analysis for PD-L1 immunohistochemistry for both tumor cells (TCs) and immune cells. We compared conventional pathologists' scores for both tumor and immune cell positivity separately using 22c3 antibody on the Dako Link 48 platform for PD-L1 expression in non-small cell lung carcinoma. We assessed interpretation first by pathologists and second by PD-L1 image analysis scores. Lin's concordance correlation coefficients (LCCs) for each pathologist were measured to assess variability between pathologists and between pathologists and Optra automated quantitative scores in scoring both tumor and immune cells. Lin's LCCs to evaluate the correlation between pathologists for TC was 0.75 [95% confidence interval (CI), 0.64-0.81] and 0.40 (95% CI, 0.40-0.62) for immune cell scoring. Pathologists were highly concordant for tumor scoring, but not for immune cell scoring, which is similar to previously reported studies where agreement is higher in TCs than immune cells. The LCCs between conventional pathologists' read and the machine score were 0.80 (95% CI, 0.74-0.85) for TCs and 0.70 (95% CI, 0.60-0.76) for immune cell population. This is considered excellent agreement for TCs and good concordance for immune cells. The automated scoring methods showed concordance with the pathologists' average scores that were comparable to interpathologist scores. This suggests promise for Optra automated assessment of PD-L1 in non-small cell lung cancer.