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Transcatheter edge-to-edge repair (TEER) of the mitral valve is a complex procedure requiring continuous image guidance with 2-dimensional and 3-dimensional transesophageal echocardiography. In this context, the role of the echocardiographer is of paramount importance. Training in interventional echocardiography for procedures such as TEER requires comprehending the complicated workflow of the hybrid operating room and advanced imaging skills that go beyond traditional echocardiography training to guide the procedure. Despite TEER being more commonly performed, the training structure for interventional echocardiographers is lagging, with many practitioners not having any formal training in image guidance for this procedure. In this context, novel training strategies must be developed to increase exposure and aid training. In this review, the authors present a step-wise approach to training for image guidance during TEER of the mitral valve. The authors have deconstructed this complex procedure into modular components and have incremental stages of training based on different steps of the procedure. At each step, trainees must demonstrate proficiency before advancing to the next step, thus ensuring a more structured approach to attaining proficiency in this complex procedure. [ABSTRACT FROM AUTHOR]

Intraprocedural transesophageal echocardiography imaging is an integral part of percutaneous structural heart disease (SHD) interventions. The rapid growth in the number, scope, and complexity of SHD interventions has outpaced the efforts to develop training and proficiency standards in periprocedural imaging. At the Beth Israel Deaconess Medical Center in Boston, Massachusetts, the authors have developed a 6-month duration fellowship in interventional echocardiography for SHD to address this issue. The purpose of this fellowship is to train cardiac anesthesiologists to address the unique challenges of interventional echocardiography. In this paper, the authors describe the rationale for and specific features of this training program. Their fellowship curriculum follows a multimodal integrative approach to training in SHD imaging, which includes simulation sessions, online modules, deliberate practice in the clinical setting, and interdisciplinary team-based training. In the next several years, there will be an increased need for echocardiographers who are proficient in intraprocedural SHD imaging. In this article, the authors describe their experience with a competency-based curriculum for subspecialty anesthesia training in SHD imaging. [ABSTRACT FROM AUTHOR]

To describe the current nationwide perspectives and practice regarding intraoperative oxygen titration in cardiac surgery. Prospective, observational survey. Hospitals across the United States. Cardiovascular anesthesiologists and perfusionists. Expert- and consensus-derived electronic surveys were sent to perfusionists and cardiac anesthesiologists to evaluate the current intraoperative practices around oxygen administration. Providers were asked about individual intraoperative oxygen titration practices used at different stages of cardiac surgical procedures. Anonymous responses were collected in the Research Electronic Data Capture (REDCap). A total of 3,335 providers were invited to participate, of whom 554 (317 anesthesiologists and 237 perfusionists) were included in the final analysis (17% response rate). During cardiopulmonary bypass (CPB), perfusionists reported a median (interquartile range [IQR]) target range from 150 (110-220)-to-325 mmHg (250-400), while anesthesiologists reported a significantly lower target range from 90 (70-150)-to-250 mmHg (158-400) (p values <0.0001 and 0.02, respectively). This difference was most pronounced at lower partial pressure of arterial oxygen (PaO 2) ranges. The median PaO 2 considered "too low" by perfusionists was 100 mmHg (IQR 80-125), whereas it was 60 mmHg (IQR 60-75) for anesthesiologists, who reported for both off and on bypass. The median PaO 2 considered "too high" was 375 mmHg (IQR 300-400) for perfusionists and 300 mmHg (IQR 200-400) for anesthesiologists. Anesthesiologists, therefore, reported more comfort with significantly lower PaO 2 values (p < 0.0001), and considered a higher PaO 2 value less desirable compared with perfusionists (p < 0.0001). This survey demonstrated there was wide variation in oxygen administration practices between perfusionists and anesthesiologists. Hyperoxygenation was more common while on CPB. [ABSTRACT FROM AUTHOR]

With advancements in technology and progress in interventional procedures, left-sided structural heart disease (SHD) interventions have become part of everyday clinical practice. One of the most important steps for a successful left-sided structural heart intervention is the transseptal puncture (TSP). Appropriate transesophageal echocardiographic (TEE) guidance of TSP requires extensive supervised hands-on experience prior to attaining proficiency. Whereas some TEE skills are acquired during cardiac anesthesia fellowships, continuous procedural guidance during SHD interventions requires substantial hands-on experience. Several studies have emphasized the value of advanced training in imaging for SHD interventions; however, the pathways and advanced training to ensure proficiency in interventional echocardiography have not yet been clearly established. In an effort to achieve a uniform and consistent approach to TSP imaging that is homogeneous and complementary to the component steps of the TSP procedure from an interventional point-of-view, the authors have developed a protocol for providing image guidance for TSP - the PITLOC protocol (Practice, Identification of septal puncture needle, Tracking of needle tip, Localization of needle tip in fossa ovalis, Optimizing septal indentation, and, finally, Crossing the interatrial septum under direct vision). This protocol aims to standarize image guidance for TSP while complementing the the steps of the procedure as performed and described by interventionalists. [ABSTRACT FROM AUTHOR]

To describe the current nationwide perspectives and practice regarding intraoperative oxygen titration in cardiac surgery. Prospective, observational survey. Hospitals across the United States. Cardiovascular anesthesiologists and perfusionists. Expert- and consensus-derived electronic surveys were sent to perfusionists and cardiac anesthesiologists to evaluate the current intraoperative practices around oxygen administration. Providers were asked about individual intraoperative oxygen titration practices used at different stages of cardiac surgical procedures. Anonymous responses were collected in the Research Electronic Data Capture (REDCap). A total of 3,335 providers were invited to participate, of whom 554 (317 anesthesiologists and 237 perfusionists) were included in the final analysis (17% response rate). During cardiopulmonary bypass (CPB), perfusionists reported a median (interquartile range [IQR]) target range from 150 (110-220)-to-325 mmHg (250-400), while anesthesiologists reported a significantly lower target range from 90 (70-150)-to-250 mmHg (158-400) (p values <0.0001 and 0.02, respectively). This difference was most pronounced at lower partial pressure of arterial oxygen (PaO 2) ranges. The median PaO 2 considered "too low" by perfusionists was 100 mmHg (IQR 80-125), whereas it was 60 mmHg (IQR 60-75) for anesthesiologists, who reported for both off and on bypass. The median PaO 2 considered "too high" was 375 mmHg (IQR 300-400) for perfusionists and 300 mmHg (IQR 200-400) for anesthesiologists. Anesthesiologists, therefore, reported more comfort with significantly lower PaO 2 values (p < 0.0001), and considered a higher PaO 2 value less desirable compared with perfusionists (p < 0.0001). This survey demonstrated there was wide variation in oxygen administration practices between perfusionists and anesthesiologists. Hyperoxygenation was more common while on CPB. [ABSTRACT FROM AUTHOR]

With advancements in technology and progress in interventional procedures, left-sided structural heart disease (SHD) interventions have become part of everyday clinical practice. One of the most important steps for a successful left-sided structural heart intervention is the transseptal puncture (TSP). Appropriate transesophageal echocardiographic (TEE) guidance of TSP requires extensive supervised hands-on experience prior to attaining proficiency. Whereas some TEE skills are acquired during cardiac anesthesia fellowships, continuous procedural guidance during SHD interventions requires substantial hands-on experience. Several studies have emphasized the value of advanced training in imaging for SHD interventions; however, the pathways and advanced training to ensure proficiency in interventional echocardiography have not yet been clearly established. In an effort to achieve a uniform and consistent approach to TSP imaging that is homogeneous and complementary to the component steps of the TSP procedure from an interventional point-of-view, the authors have developed a protocol for providing image guidance for TSP - the PITLOC protocol (Practice, Identification of septal puncture needle, Tracking of needle tip, Localization of needle tip in fossa ovalis, Optimizing septal indentation, and, finally, Crossing the interatrial septum under direct vision). This protocol aims to standarize image guidance for TSP while complementing the the steps of the procedure as performed and described by interventionalists. [ABSTRACT FROM AUTHOR]

Procedural guidance during structural heart disease (SHD) interventions is achieved with both two-dimensional and three-dimensional transesophageal echocardiography as well as real-time fluoroscopic imaging. Although both image the cardiac anatomy, they are based on different principles of image acquisition. In the era of multimodality imaging with coregistration of anatomic landmarks and simultaneous real-time display, it is essential to have cross-disciplinary imaging knowledge. Besides improving communication, it also enhances patient care and, possibly, outcomes. In this study, the authors used a novel fluoroscopic phantom cardiac model with enhanced structural markers to display the basic fluoroscopic images used during SHD interventions. The projected images enhance the understanding of the orientation and relationship among intracardiac structures as seen on fluoroscopy. In this study, the authors present the basic fluoroscopic views for SHD interventions and the anatomic relationship for intracardiac structures using a custom-made phantom fluoroscopic heart model. [ABSTRACT FROM AUTHOR]

Inability of home discharge occurs in nearly a third of patients undergoing cardiac surgery and is associated with increased mortality. The authors aimed to evaluate the incidence and risk factors for adverse discharge disposition (ADD) after cardiac surgery and develop a prediction tool for preoperative risk assessment. This retrospective cohort study included adult patients undergoing cardiac surgery between 2010 and 2018. The primary outcome was ADD, defined as in-hospital mortality, discharge to a skilled nursing facility, or transfer to a long-term care hospital. The authors created a prediction tool using stepwise backward logistic regression and used 5-fold and leave-one-out cross-validation. University hospital network. Adult patients living at home prior to surgery, who underwent coronary artery bypass grafting and/or valve procedures at the authors' institution. None. A total of 3,760 patients were included in the final study cohort. The observed rate of ADD was 33.3%. The prediction model showed good discrimination and accuracy, with C-statistic of 0.78 (95% confidence interval [CI] 0.76-0.79) and unmodified Brier score of 0.177 (reliability 0.001). The final model comprised 14 predictors. Patients who experienced ADD were more likely to be older, of female sex, to have had higher length of hospital stay prior to surgery, and to have undergone emergency surgery. The authors present an instrument for prediction of loss of the ability to live independently in patients undergoing cardiac surgery. The authors' score may be useful in identifying high-risk patients such that earlier coordination of care can be initiated in this vulnerable patient population. [ABSTRACT FROM AUTHOR]

Postoperative morbidity in patients undergoing lower extremity amputation (LEA) has remained high. Studies investigating the influence of the anesthetic modality on the postoperative outcomes have yielded conflicting results. The aim of our study was to assess the effects of regional anesthesia vs general anesthesia on postoperative complications for patients undergoing LEA. We systematically searched PubMed, Embase, MEDLINE, Web of Science, and Google Scholar from 1990 to 2022 for studies investigating the effect of the anesthetic modality on the postoperative outcomes after LEA. Regional anesthesia (RA) included neuraxial anesthesia and peripheral nerve blocks. The outcomes included 30-day mortality, respiratory failure (unplanned postoperative intubation, failure to wean, mechanical ventilation >24 hours), surgical site infection, cardiac complications, urinary tract infection, renal failure, sepsis, venous thrombosis, pneumonia, and myocardial infarction. Of the 25 studies identified, we included 10 retrospective observational studies with 81,736 patients, of whom 69,754 (85.3%) had received general anesthesia (GA) and 11,980 (14.7%) had received RA. In the GA group, 50,468 patients were men (63.8%), and in the RA group, 7813 patients were men (62.3%). The results of the meta-analyses revealed that GA was associated with a higher rate of respiratory failure (odds ratio, 1.38; 95% confidence interval, 1.06-1.80; P =.02) and sepsis (odds ratio, 1.21; 95% confidence interval, 1.11-1.33; P <.0001) compared with RA. No differences were found in postoperative 30-day mortality, surgical site infection, cardiac complications, urinary tract infection, renal failure, venous thrombosis, pneumonia, and myocardial infarction between the GA and RA groups. The results of our meta-analysis have shown that GA could be associated with a higher rate of respiratory failure and sepsis compared with RA for LEA. [ABSTRACT FROM AUTHOR]