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Objective: In minimally invasive surgical ablation for atrial fibrillation during video-assisted thoracoscopy surgery, one-lung ventilation (OLV) with a double- lumen tube is commonly employed. In contrast with the majority of thoracic procedures, the patient lies supine; thus, the protective effect of gravity is lost and intrapulmonary shunt remains high. To decrease intrapulmonary shunt and to increase oxygenation, many strategies are utilized: high inspiratory fraction of oxygen (F I O 2 ), positive end-expiratory pressure on the ventilated lung, and continuous positive airway pressure (CPAP) on the deflated lung., Design: The authors performed a prospective, single- center, randomized study to evaluate the effect of additional CPAP in the nonventilated lung on oxygen delivery during surgical ablation for atrial fibrillation via video-assisted thoracoscopy in the supine position., Setting: University hospital Centro Cardiologico Monzino IRCCS, Milano, Italy., Participants: Twenty-two patients scheduled for minimally invasive surgical ablation for atrial fibrillation., Interventions: The patients underwent pressure-controlled ventilation, adjusting inspiratory pressure to obtain a tidal volume of 7 mL/kg while keeping F I O 2 constantly 1.0, a respiratory rate to maintain arterial partial pressure of carbon dioxide (PaCO 2 ) between 35 and 40 mmHg, and positive end-expiratory pressure of 5 cmH 2 O. During OLV, inspiratory pressure was reduced to obtain a tidal volume of 5 mL/kg, maintaining F I O 2 of 1.0, a respiratory rate to maintain PaCO 2 between 35 and 40 mmHg with capnothorax of 10 cmH 2 O. The patients were then randomized into the CPAP group (CPAP 10 cmH 2 0 on deflated lung) and NO CPAP group. Inotropic agents (dopamine or dobutamine) were used if cardiac index fell below 1.5 L/min/m 2 ., Measurements and Main Results: Twenty-two patients were enrolled, randomized, and completed the study. Median age was 62 years. The difference in arterial partial pressure of oxygen between the 2 groups was shy of significance, p = 0.16. Cardiac index progressively increased during OLV until the end of the procedure in both groups (p < 0.01) and was maintained above 1.5 mL/min/m 2 during the whole study time. Arterial oxygen content remained stable during the entire procedure in both groups (p = 0.27). Oxygen delivery index (DO 2 I) increased significantly during the procedure (p < 0.01); nevertheless, the difference in DO 2 I between the CPAP and NO CPAP group was nonsignificant (p = 0.61). Intrapulmonary shunt (Q s /Q t ) increased during OLV (p < 0.01 for the time effect) and remained high until total lung ventilation was reintroduced. No difference in Q s /Q t was observed between the CPAP and NO CPAP groups (p = 0.98). Similarly, mean pulmonary artery pressure increased significantly during OLV and remained high at the end of the procedure in both groups (time effect p < 0.01)., Conclusions: During OLV for atrial fibrillation surgical ablation in the supine position, CPAP on the deflated lung seemed to be ineffective to reduce Q s /Q t or to increase arterial partial pressure of oxygen and DO 2 I, provided cardiac output was maintained above 1.5 L/min/m 2 ., Competing Interests: Conflict of Interest The authors declare no conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Patients with Disorders of consciousness, are persons with extremely low functioning levels and represent a challenge for health care systems due to their high needs of facilitating environmental factors. Despite a common Italian health care pathway for these patients, no studies have analyzed information on how each region have implemented it in its welfare system correlating data with patients' clinical outcomes., Materials and Methods: A multicenter observational pilot study was realized. Clinicians collected data on the care pathways of patients with Disorder of consciousness by asking 90 patients' caregivers to complete an ad hoc questionnaire through a structured phone interview. Questionnaire consisted of three sections: sociodemographic data, description of the care pathway done by the patient, and caregiver evaluation of health services and information received., Results: Seventy-three patients were analyzed. Length of hospital stay was different across the health care models and it was associated with improvement in clinical diagnosis. In long-term care units, the diagnosis at admission and the number of caregivers available for each patient (median value = 3) showed an indirect relationship with worsening probability in clinical outcome. Caregivers reported that communication with professionals (42%) and the answer to the need of information were the most critical points in the acute phase, whereas presence of Non-Governmental Organizations (25%) and availability of psychologists for caregivers (21%) were often missing during long-term care. The 65% of caregivers reported they did not know the UN Convention on the Rights of Persons with Disabilities., Conclusion: This study highlights relevant differences in analyzed models, despite a recommended national pathway of care. Future public health considerations and actions are needed to guarantee equity and standardization of the care process in all European countries.

Objective: To compare, in terms of clinical effectiveness and safety, patients who underwent transcatheter aortic valve implantation (TAVI) with those who underwent surgical aortic valve replacement (S-AVR) for the treatment of severe aortic stenosis during the same period., Methods: One hundred and eighty-seven consecutive patients were included: 81 with S-AVR and 106 with TAVI. Primary and secondary outcomes were reported in accordance with published reporting guidelines for valve surgery. A propensity matching model was computed in the attempt to reduce confounding effects of covariates., Results: Thirty-day mortality and morbidity, as well as follow-up events, did not differ between the two therapeutic options, except for ICU stay, in favor of TAVI, and occurrence of pleural effusions, in favor of S-AVR. TAVI accomplished significant mean aortic gradient reduction (better than S-AVR in the immediate postoperative and at least comparable at follow-up) and improvement in valve area and functional class (always higher than S-AVR). Although for the first year, survival was at least comparable between TAVI and S-AVR (both whole and matched groups); at later times, TAVI all-cause and noncardiac mortality was higher in the whole sample, as expected from age and comorbidities of TAVI patients. At later follow-up, in the matched subsamples, 1-year mortality rates were replicated, with a significantly higher incidence of cardiac deaths in S-AVR patients., Conclusion: TAVI morbidity and mortality registered in this series are lower than those estimated for conventional surgery in high-risk patients and compare to those associated with S-AVR in good surgical candidates.

A new generation of transoesophageal echocardiographic probes with a novel matrix array technique has been recently introduced, allowing three-dimensional (3D) presentation of cardiac structures in real-time. This new tool may potentially provide fast and complete 3D information about cardiac structures improving spatial orientation and overcoming limitations of offline 3D technologies. The aim of this study was to demonstrate the feasibility and usefulness of real-time 3D transoesophageal echocardiography (TOE) for the intraoperative evaluation of cardiac surgery procedures. One-hundred patients underwent transoesophageal echocardiographic examination during cardiac surgery as a part of their routine clinical practice. In the intraoperative pre- and post-cardiopulmonary bypass periods complete 2D and 3D transoesophageal examinations were performed. Feasibility and duration of examinations, and immediate additional anatomical value of 3D versus 2D-TOE were annotated intraoperatively. Image quality, additional clinical value of 3D- compared to standard 2D-TOE and the accuracy in the description of mitral valve pathology by a surgeon and an echocardiographer were evaluated off-line. No complications related to transoesophageal examination occurred and successful intubation was achieved in all 100 patients. Therefore, 200 examinations were performed and analysed considering the pre- and post-cardiopulmonary bypass periods. The mean number of acquisitions per patient was 16 +/- 14, including 3D real-time, zoom, full-volume and colour full volume modalities. The duration of the 3D examination was 16 +/- 10 min and the mean image quality score 2.8 +/- 0.7 (in a scale 1-4). In 36 out of 100 cases (36%) 3D-TOE provided additional anatomical information. The surgeon evaluated 3D images easier and more accurately than 2D images (88% vs. 76% in the evaluation of mitral valve scallop). Real-time 3D TOE may be used routinely for the intraoperative evaluation of cardiac surgery. Imaging with this new probe facilitates intraoperative evaluation of several surgical procedures with an additional clinical value in selected cases.