Efficacy of nasal continuous positive airway pressure as a preferred airway management during intravenous sedation of patients undergoing transcatheter aortic valve replacement.

Background: As the incidence of aortic stenosis is increasing in correlation with the aging population, symptomatic patients commonly require valve replacement procedures. If left untreated, symptomatic aortic stenosis can lead to death in 2 to 3 years. Often, transcatheter aortic valve replacement (TAVR) procedures are performed with the assistance of oxygenation via nasal cannula. However, oxygenation achieved through a nasal continuous positive airway pressure (nCPAP) device could be a more optimized strategy for patients without any sacrifice in efficacy compared to nasal cannula. Methods: A retrospective chart review was conducted on 28 patients at Baylor University Medical Center who presented to the operating room for a TAVR between January and October 2021. Fourteen patients received oxygenation via nasal cannula (control group) and 14 received oxygenation with nCPAP. Information gathered included method of oxygenation, length of stay, episodes of hypoxia (defined as sustained oxygen saturation <92% for at least 1 minute), paravalvular leak, pacemaker placement, and mean atrial valve (AV) gradient before and after the procedure. Results: In the nCPAP group, the average length of stay was 2.79 days vs 2.71 days in the nasal cannula group. In the nCPAP group, no patient required a permanent pacemaker, while the nasal cannula group had a 40% rate of permanent pacemaker placement. The average preprocedure AV gradient was 51.14 in the nCPAP group and 42.57 in the nasal cannula group. The average postprocedure AV gradient was 8.5 in the nCPAP group and 5.36 in the nasal cannula group. Both groups had an intensive care unit admission rate of 0%. The rate of paravalvular leak was 35.7% in the nCPAP group and 28.6% in the nasal cannula group. The nCPAP group had an average of 0 episodes of hypoxia and the nasal cannula group had an average of 0.93 episodes of hypoxia. Conclusion: The findings demonstrate the viability of nCPAP as an effective method of oxygenation during intravenous sedation of TAVR patients when compared to oxygenation achieved via nasal cannula during TAVRs.

Iatrogenic Arteriovenous Fistula Secondary to Percutaneous Coronary Intervention Causing Severe Decompensated Heart Failure.

Congestive heart failure has long been a well-known cause of both morbidity and mortality for thousands of people worldwide. Consequences of decompensated heart failure are systemic and widespread, including but not limited to pulmonary edema, dyspnea, hypoxia, peripheral edema, and end-organ hypoperfusion. Common etiologies of congestive heart failure include systemic hypertension, coronary artery disease, longstanding alcohol abuse, valvular dysfunctions, and myocarditis. While the vast majority of congestive heart failure cases are secondary to one of these common etiologies, there is a subset of cases that cannot be traced to any of these causes and are most often grouped under the category of idiopathic. One rarely seen etiology of decompensated heart failure is an arteriovenous fistula, whether naturally occurring or iatrogenic. We report a case of an iatrogenic AV fistula secondary to percutaneous coronary intervention causing severe decompensated heart failure that was successfully treated with surgical ligation.

Nasal Continuous Positive Airway Pressure as a Preferred Airway Management During IV Sedation of Obese Patients With Obstructive Sleep Apnea Undergoing Functional Luminal Imaging Probe Panometry.

The functional luminal imaging probe (FLIP) utilizes high-resolution planimetry to provide information regarding esophagogastric junction (EGJ) diameter, EGJ distensibility, and reactive contractile patterns of the esophageal body. This is an FDA-approved measurement tool utilized to both diagnose and measure various upper gastrointestinal disorders. While patients are sedated during FLIP panometry, significant respiratory variations can affect the quality of FLIP panometry results. Nasal continuous positive airway pressure (CPAP) can be utilized to prevent intraoperative or postoperative hypoxia in obese patients as well as those with obstructive sleep apnea (OSA). In this retrospective chart review, we compared obese patients with a diagnosis of OSA who underwent FLIP panometry utilizing nasal CPAP as airway management against a group who underwent the same procedure with a nasal cannula to evaluate the incidence of hypoxia, hypercapnia, variation in cardiovascular dynamics, and the quality of FLIP panometry readings.

Combined Tricuspid Valve Repair and Orthotopic Liver Transplantation in a Patient With Severe Tricuspid Regurgitation and Pulmonary Hypertension.

Severe pulmonary hypertension and severe tricuspid regurgitation are often considered strict contraindications for orthotopic liver transplantation. A combined approach of tricuspid repair and subsequent liver transplantation could provide a novel approach for patients with severe pulmonary hypertension and tricuspid regurgitation to undergo orthotopic liver transplantation. A 62-year-old male with a history of end-stage renal disease on hemodialysis, cirrhosis, and third-degree atrioventricular heart block status post single lead pacemaker insertion presented for an orthotopic liver transplant. However, after placement of a Swan-Ganz catheter by the anesthesia team, the patient's central venous pressure was found to be high, and his mean pulmonary artery pressure was 40 mmHg. His case was canceled due to concern for poor postoperative outcomes after a subsequent transesophageal echocardiogram revealed a severely dilated right heart and 4+ tricuspid regurgitation with flow reversal into the hepatic veins. After discussion among the hospital's transplant committee, the patient was planned to have a tricuspid valve repair, liver transplant, and kidney transplant surgery several months later. The patient successfully underwent tricuspid valve repair and orthotopic liver transplant and then kidney transplant the following day.

Enhancing plasticity in central networks improves motor and sensory recovery after nerve damage.

Nerve damage can cause chronic, debilitating problems including loss of motor control and paresthesia, and generates maladaptive neuroplasticity as central networks attempt to compensate for the loss of peripheral connectivity. However, it remains unclear if this is a critical feature responsible for the expression of symptoms. Here, we use brief bursts of closed-loop vagus nerve stimulation (CL-VNS) delivered during rehabilitation to reverse the aberrant central plasticity resulting from forelimb nerve transection. CL-VNS therapy drives extensive synaptic reorganization in central networks paralleled by improved sensorimotor recovery without any observable changes in the nerve or muscle. Depleting cortical acetylcholine blocks the plasticity-enhancing effects of CL-VNS and consequently eliminates recovery, indicating a critical role for brain circuits in recovery. These findings demonstrate that manipulations to enhance central plasticity can improve sensorimotor recovery and define CL-VNS as a readily translatable therapy to restore function after nerve damage.