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Background: Open surgical repair of a failed valve-sparing aortic root replacement (VSARR) or stentless bioroot aortic root replacement (bio-ARR) entails significant operative risks. Whether valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is feasible in patients with a previous VSARR or stentless bio-ARR remains unclear, given lingering concerns about the ill-defined aortic annulus in these patients and the potential for coronary obstruction. We present our experience with patients who had a previous VSARR or stentless bio-ARR and underwent ViV-TAVR to repair a degenerated aortic valve with combined valvular disease, aortic insufficiency and aortic stenosis. Methods: In this retrospective data review, we identified and analyzed consecutive patients with a previous VSARR or stentless bio-ARR who underwent ViV-TAVR between December 1, 2014 and August 31, 2019. Results: ViV-TAVR was performed in twelve high-risk patients with previous VSARR or bio-ARR during the study period. Of these, seven received Medtronic Freestyle porcine stentless bioprosthetic aortic roots, three received homograft aortic roots, one underwent a Ross procedure and one underwent VSARR. ViV-TAVR restored satisfactory valve function in all patients, and technical success was 100%. No patient had more than mild regurgitation after implantation. No thirty-day mortality was seen. One patient had major bleeding after transapical access, one patient had a transient ischemic stroke, and one patient needed permanent pacemaker implantation. At a median last follow-up of 21.5 months (interquartile range, 9.0–69.0 months), all patients remained alive and had satisfactory valve function. Conclusions: In this study, ViV-TAVR was a clinically effective option for treating patients with a failed stentless bio-ARR or previous VSARR. Short-term and intermediate-term results after these procedures were favorable. These findings may have important implications for treating high-risk patients with structural aortic root deterioration and call for better transcatheter heart valves that are suitable for treating aortic insufficiency.

Extracorporeal membrane oxygenation (ECMO) has been used for more than 50 years as salvage therapy for patients with severe cardiopulmonary failure refractory to conventional treatment. ECMO was first used in the 1960s to treat hypoxemic respiratory failure in newborns. On the basis of its success in that population, ECMO began to be used in the early 1970s to treat adult hypoxemic respiratory failure. However, outcomes for adults were, somewhat perplexingly, quite poor. By the 1980s, use of ECMO for severe hypoxemia was rare outside of the pediatric population. ECMO technology, however, continued to evolve and improve. Multiple case reports and small series describing ECMO use as rescue for adults with severe hypoxemia from various lung pathologies have appeared in the literature over the past three decades. Adult respiratory distress syndrome (ARDS) is often the final common pathway of various pathologies affecting adults and causing hypoxemic respiratory failure. It is prevalent in intensive care units throughout the world and has, since it was first described in 1967, carried a high mortality. No specific therapy for ARDS has been found, and current care is supportive, primarily by mechanical ventilation. Results from recent randomized controlled trials, however, suggest that ECMO may have a place in the treatment of these patients. This article reviews these studies and recommends adding severe ARDS to the list of established indications for ECMO in patients with hypoxemic respiratory failure.

Thoracic endovascular aortic repair (TEVAR) is a less invasive method for treating thoracic and some thoracoabdominal aortic aneurysms, dissections of the thoracic aorta and blunt traumatic aortic injury, compared with conventional open surgery. Maximizing the likelihood of a successful outcome requires diligent multidisciplinary (surgical, critical care, nursing, pharmacy, nutrition and physical therapy) perioperative care. In this article, we discuss fundamentals for managing patients after endovascular aortic aneurysm repair. These principles focus on the transition between the operating room and the intensive care unit, prevention and management of spinal cord deficits (SCD), and vital neurological, respiratory, cardiovascular, renal, gastrointestinal and hematological concerns. The better the care team understands the expected postoperative course, the earlier that deviations can be recognized and the more likely that successful rescue can be achieved to reduce the incidence and severity of adverse outcomes. Achieving optimal results after TEVAR requires attention to detail across the preoperative, intraoperative and postoperative phases of care.

Surgery, and especially cardiac surgery, is common, costly, and entails considerable risk. Significant progress has been made in recent years to improve quality, promote patient safety, and increase value and cost-effectiveness in surgical care. Enhanced Recovery After Surgery (ERAS) initiatives are increasing in popularity, improving outcomes, and enriching patient satisfaction. First developed for abdominal surgical cases, ERAS has increasingly established itself across all surgical subspecialities, including cardiac surgery. ERAS focuses on evidence-based initiatives in the preoperative, intraoperative, and postoperative phases of care to promote patient well-being and efficient care. The deliberate, judicious incorporation of technology into surgery and the periprocedural home has tremendous, revolutionary potential in all phases of care and is consistent with ERAS principles. This technology can be harnessed by physicians and the care provider team, the healthcare system, and perhaps most importantly, by patients themselves to lead to a higher level of engagement. We will explore technology's transformational capability by concentrating on cardiac surgery because of its prevalence, costs, risks, and contribution to the healthcare system's bottom line. In addition, the role that ERAS combined with technology can play in a constructive manner will be important. We discuss the disruptive effect that the COVID-19 pandemic offers to accelerate these developments. While the human cost of the pandemic has been staggering, in the post-COVID world, the lessons learned can be vital. Finally, we seek to show that the opportunities technology provides are closely related to what both patients and the physician and provider teams want. As technology inevitably becomes more integrated into healthcare, the ability to harness technology to maximize patient outcomes and well-being while promoting more efficient healthcare delivery will be critical. © Journal of Hospital Management and Health Policy. All rights reserved.

In this review, we discuss common difficulties that clinicians may encounter while managing patients treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO). ECMO is an increasingly important tool for managing severe respiratory failure that is refractory to conventional therapies. Its overall goal is to manage respiratory failure-induced hypoxemia and hypercarbia to allow "lung rest" and promote recovery. Typically, by the time VV-ECMO is initiated, the patient's pulmonary condition requires conventional ventilator settings that are detrimental to lung recovery or that exceed the remaining functional lung's ability to maintain acceptable physiological conditions. Standard mechanical ventilation can activate inflammation and worsen the pulmonary damage caused by the underlying disease, leading to ventilator-induced lung injury. In contrast, VV-ECMO facilitates lung-protective ventilation, decreasing further ventilator-induced lung injury and allowing lung recovery. Such lung-protective ventilation seeks to avoid barotrauma (by monitoring transpulmonary pressure), volutrauma (by reducing excessive tidal volume to promote lung rest), atelectotrauma [by maintaining adequate positive end-expiratory pressure (PEEP)], and oxygen toxicity (by decreasing ventilator oxygen levels when PEEP is adequate). ECMO for adult respiratory failure was associated with overall survival of 62% in 2018, according to the Extracorporeal Life Support Organization (ELSO) January 2019 registry report. Difficulties that may arise during VV-ECMO require timely diagnosis and optimal management to achieve the most favorable outcomes. These difficulties include ventilation issues, hypoxemia (especially as related to recirculation or low ECMO-flow-to-cardiac-output ratio), sepsis, malfunctioning critical circuit components, lack of clarity regarding optimal hemoglobin levels, hematological/anticoagulation complications, and right ventricular (RV) dysfunction. A culture of safety should be emphasized to optimize patient outcomes. A properly functioning team-not only the bedside clinician, but also nurses, perfusionists, respiratory therapists, physical therapists, pharmacists, nutritionists, and other medical specialists and allied health personnel-is vital for therapeutic success.

BACKGROUND: Bleeding complications are common with extracorporeal membrane oxygenation (ECMO). We investigated whether a heparin monitoring protocol using activated partial thromboplastin time (aPTT) and thromboelastography (TEG) affected clinical outcomes. METHODS: This retrospective chart review stratified cohorts by study interval: pre-protocol (January 2016–March 2017) or post-protocol (March 2017–December 2017). The protocol defined therapeutic anticoagulation as aPTT of 60–80 seconds and a TEG reaction (TEG-R) time of 2–4× baseline; pre-protocol management used aPTT alone. The primary endpoints were the rates of bleeding and thrombotic events (clinical/device thrombosis) as defined by Extracorporeal Life Support Organization (ELSO) guidelines. Secondary endpoints included time in therapeutic aPTT range, rate of physician compliance with the protocol, time to heparin initiation, intensive care unit length of stay, mortality, and antithrombin III (ATIII) supplementation. RESULTS: The pre-protocol (n=72) and post-protocol (n=51) groups (age 60±12 years; 80% on venoarterial ECMO; average ECMO duration of 6 days) showed no difference in baseline characteristics. Major bleeding events occurred in 69% of pre-protocol patients, versus 67% of post-protocol patients (P=0.85). The post-protocol group had fewer retroperitoneal bleeds (P=0.01) and had a non-significantly lower rate of pulmonary or central nervous system (CNS) bleeding (P=0.07). Thrombotic events occurred in 21% of the pre-protocol group, versus 28% of the post-protocol group (P=0.39). Mortality during ECMO support was significantly lower in the post-protocol group (56.9% vs. 33.3%, P=0.01). The thrombosis rate was higher in patients who received ATIII than in those who did not (48.2% vs. 15.9%, P