Future Technology.

Mitral regurgitation is the most common valvular disease and significant (moderate/severe) mitral regurgitation is found in 2.3% of the population older than 65 years. New transcatheter minimally invasive technologies are being developed to address mitral valve disease in patients deemed too high a risk for conventional open-heart surgery. There are several features of the mitral valve (saddle-shaped noncalcified annulus with irregular leaflet geometry) that make a transcatheter approach to repair or replacing the valve more challenging compared with the aortic valve. Several devices are under investigation for transcatheter mitral valve replacement, and also for mitral valve repair targeting the mitral valve leaflets, chordae tendinae, and mitral annulus. The MitraClip device is the only Food and Drug Administration-approved device to treat mitral regurgitation by targeting the mitral leaflets. There are eight minimally invasive devices being studied in humans that target the mitral annulus, and at least two devices being studied in animal models. There are 5 devices in clinical trials for minimally invasive approaches targeting the chordae tendinae. More than 10 different transcatheter mitral valves are in various stages of development and clinical trials. These transcatheter mitral valves can be delivered either through a transseptal, transapical, transaortic, or left atriotomy approach. It seems likely that transcatheter treatment approaches to mitral valve disease will become more common, at least in the sick and elderly patient population.

ECMO in major burn patients: feasibility and considerations when multiple modes of mechanical ventilation fail.

BACKGROUND: We report two cases of acute respiratory distress syndrome in burn patients who were successfully managed with good outcomes with extra corporeal membrane oxygenation (ECMO) after failing multiple conventional modes of ventilation, and review the relevant literature. CASE PRESENTATION: The two patients were a 39-year-old male and 53-year-old male with modified Baux Scores of 79 and 78, respectively, with no known inhalation injury. After the initial modified Parkland-based fluid resuscitation and partial escharotomy, both patients developed worsening hypoxemia and acute respiratory distress syndrome. The hypoxemia continued to worsen on multiple modes of ventilation including volume control, pressure regulated volume control, pressure control, airway pressure release ventilation and volumetric diffusive ventilation. In both cases, the PaO2 ≤ 50 mm Hg on a FiO2 100% during the trial of mechanical ventilation. The deterioration was rapid (<12 h since onset of worsening oxygenation) in both cases. A decision was made to trial the patients on ECMO. Veno-Venous ECMO (V-V ECMO) was successfully initiated following cannulation-under transesophgeal echo guidance-with the dual lumen Avalon® (Maquet, NJ, USA) cannula. ECMO support was maintained for 4 and 24 days, respectively. Both patients were successfully weaned off ECMO and were discharged to rehabilitation following their complex hospital course. CONCLUSION: Early ECMO for isolated respiratory failure in the setting on maintained hemodynamics resulted in a positive outcome in our two burn patients suffered from acute respiratory distress syndrome.

Peripheral Venous Waveform Analysis for Detecting Hemorrhage and Iatrogenic Volume Overload in a Porcine Model.

BACKGROUND: Unrecognized hemorrhage and unguided resuscitation is associated with increased perioperative morbidity and mortality. The authors investigated peripheral venous waveform analysis (PIVA) as a method for quantitating hemorrhage as well as iatrogenic fluid overload during resuscitation. METHODS: The authors conducted a prospective study on Yorkshire Pigs (n = 8) undergoing hemorrhage, autologous blood return, and administration of balanced crystalloid solution beyond euvolemia. Intra-arterial blood pressure, electrocardiogram, and pulse oximetry were applied to each subject. Peripheral venous pressure was measured continuously through an upper extremity standard peripheral IV catheter and analyzed with LabChart. The primary outcome was comparison of change in the first fundamental frequency (f1) of PIVA with standard and invasive monitoring and shock index (SI). RESULTS: Hemorrhage, return to euvolemia, and iatrogenic fluid overload resulted in significantly non-zero slopes of f1 amplitude. There were no significant differences in heart rate or mean arterial pressure, and a late change in SI. For the detection of hypovolemia the PIVA f1 amplitude change generated an receiver operator curves (ROC) curve with an area under the curve (AUC) of 0.93; heart rate AUC = 0.61; mean arterial pressure AUC = 0.48, and SI AUC = 0.72. For hypervolemia the f1 amplitude generated an ROC curve with an AUC of 0.85, heart rate AUC = 0.62, mean arterial pressure AUC = 0.63, and SI AUC = 0.65. CONCLUSIONS: In this study, PIVA demonstrated a greater sensitivity for detecting acute hemorrhage, return to euvolemia, and iatrogenic fluid overload compared with standard monitoring and SI. PIVA may provide a low-cost, minimally invasive monitoring solution for monitoring and resuscitating patients with perioperative hemorrhage.

Virtual office hours using a tablet PC: E-lluminating biochemistry in an online environment.

The availability of online collaboration software has provided new opportunities for instructors to interact with students outside the classroom. This report describes how Elluminate Live!®, a particular conferencing software package, can be used with a tablet PC to conduct virtual office hours in a biochemistry course. The educational value of engaging students in an online environment, with text messaging, voice-over-internet protocol (VoIP), and application sharing is also discussed. A student perspective is provided to illustrate the advantages of conducting virtual office hours and how the combination of online collaboration software and tablet PC technology can provide an enhanced learning experience.