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Mitral regurgitation (MR) is a common form of valvular heart disease that is associated with significant morbidity and mortality. MR can be broadly classified into 2 different categories: primary and secondary MR. Primary MR usually is caused by leaflet abnormalities, whereas secondary MR is a chronic disease secondary to geometric distortion of both the annulus and subvalvular apparatus because of left ventricular remodeling. Without acute changes in loading conditions, myocardial blood flow, or rhythm disturbances, functional MR typically is not transient. In this E-Challenge, the authors show a transient and completely reversible acute and severe form of functional MR with the use of multimodal echocardiography., (Copyright © 2021 Elsevier Inc. All rights reserved.)

In this E-Challenge, the authors report on a patient with symptoms of exertional dyspnea and angina, scheduled to have surgical unroofing of an identified myocardial bridge (MB). An MB is very common in patients with hypertrophic cardiomyopathy (HCM). Intraoperative transesophageal echocardiography with provocative maneuvers revealed the patient had a systolic anterior motion of the mitral valve with septal contact and resulting outflow tract obstruction despite the notable absence of significant basal septal hypertrophy. HCM has many phenotypic variants that can make the identification of patients with latent left ventricular outflow tract obstruction difficult in the absence of a high index of suspicion. In this report, the authors discuss the association between MBs and HCM and the importance of recognizing phenotypic variants of HCM., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To assess the association between the common quality metric of 30-day mortality and mortality at 60 days, 90 days, and one year after coronary artery bypass grafting., Design: A retrospective cohort study, with multivariate logistic regression to assess association among mortality outcomes., Setting: Hospitals participating in Medicare and reporting data within the Centers for Medicare and Medicaid Services Limited Data Set between April 1, 2016, and March 31, 2017., Participants: A total of 37,036 patients undergoing surgery at 394 hospitals., Intervention: None., Measurements and Main Results: Mortality rates were 1.0%-to-3.1% for the top and bottom quartile of hospitals at 30 days. At one year, the top 25th percentile of hospitals had mortality rates averaging 3.9%; while hospitals below the 75th percentile had mortality rates averaging 7.6%. Twenty-three percent of hospitals in the top quartile at 30 days were no longer in the top quartile at 60 days. At one year, only 48% of hospitals that were in the top quartile at 30 days remained in the top quartile. The correlation between mortality rates at 30 days and the reported points was assessed using Spearman's rho. The R value between mortality at 30 days and mortality at one year was 0.53, which improved to 0.7 and 0.76 at 60 and 90 days., Conclusions: Mortality at 30 days correlated poorly with mortality at one year. Hospitals that were high- or low-performing at 30 days frequently were no longer within the same performance group at one year., Competing Interests: Conflict of Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Low psoas muscle mass previously has been associated with mortality after transcatheter aortic valve replacement (TAVR). Evidence from other clinical disciplines suggests that psoas density (PD) may be a better predictor than psoas muscle cross-sectional area indexed to body surface area (PI). The authors hypothesized that PD would be more strongly correlated with patient discharge disposition and survival after TAVR than PI., Design: The authors performed a single-center, retrospective study of TAVR patients from 2013 to 2016. PI and PD were assessed at the third lumbar spine level using computed tomography imaging. Propensity-score matching was used to investigate the association of PI and PD with discharge disposition and mortality., Setting: Tertiary university hospital PARTICIPANTS: Cohort of 245 TAVR patients., Interventions: None MEASUREMENTS AND MAIN RESULTS: A total of 245 patients met inclusion criteria. Following propensity score matching, patients with PI <4 cm 2 /m 2 and PD <25 Hounsfield units (HU) were less likely to survive and to be discharged home compared with patients with PI ≥4 cm 2 /m 2 or PD >25 HU. After repeating the propensity score matching with PI as a covariable, PD remained associated with mortality (90 days: odds ratio [OR] 4.59; 95% confidence interval [CI] 2.96-10.31, p < 0.001, 1 year: OR 6.14; 95% CI 3.45-28.57, p = 0.01, 3 years: OR 4.55; 95% CI 2.41-40.00, p = 0.03)., Conclusions: PD may be more relevant than PI in risk stratification for TAVR patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Hypertrophic cardiomyopathy, a common cause of sudden cardiac death, results from mutations in the cardiac sarcomere. Although there has been much scientific exploration regarding this disease, there is still much to be elucidated. This E-challenge highlights two cases of cardiomyopathy and underscores the need for future multidisciplinary collaboration as outlined by the One Health Initiative., Competing Interests: Conflict of Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Although American and European consensus statements advocate using the ratio of the transmitral E velocity and tissue Doppler early diastolic mitral annular velocity (E/e') in the assessment of left-sided heart filling pressures, recent reports have questioned the reliability of this ratio to predict left atrial pressures in a variety of disease states. The authors hypothesized that there is a clinically significant correlation between E/e' and pulmonary capillary wedge pressure (PCWP) in patients with severe aortic stenosis., Design: Retrospective cohort study., Participants: The study comprised 733 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve replacement for severe aortic stenosis., Interventions: None., Measurements and Main Results: PCWP and E/e' ave (average of the lateral and medial annulus tissue Doppler velocities) were measured with a pulmonary artery catheter and transthoracic echocardiography during preprocedural evaluation. Patients were grouped by left ventricular ejection fraction (LVEF) ≥50% and LVEF <50%. Spearman rank correlation, analysis of variance, and t and chi-square tests were used to analyze the data. Seventy-nine patients met the inclusion criteria. There was no significant correlation between E/e' ave and PCWP (n = 79, Spearman r = 0.096; p = 0.3994). This correlation did not improve when ventricular function was considered (LVEF <50%: n = 11, Spearman r = -0.097; p = 0.776 and LVEF ≥50%: n = 68, Spearman r = 0.116; p = 0.345). There was no statistically significant difference in mean PCWP between each range of E/e' ave ., Conclusion: A clinically relevant relationship between E/e' and PCWP was not observed in patients with severe aortic stenosis., Competing Interests: Conflict of Interest The authors have no conflict of interest to declare. All co-authors have seen and agree with the contents of the manuscript and there is no financial interest to report., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The convergent procedure is a hybrid ablation treatment for atrial fibrillation. It is increasingly considered as a management option for patients with persistent and long-standing atrial fibrillation. It consists of surgical ablation of the posterior left atrium through a minimally invasive closed-chest approach followed by endocardial catheter ablation. It is increasingly performed with concurrent epicardial occlusion of the left atrial appendage with a video-assisted thoracoscopic technique to physically and electrically isolate the left atrial appendage. This article provides an overview of a multidisciplinary approach to the convergent procedure, with concurrent thoracoscopic closure of the left atrial appendage, with an emphasis on perioperative management at a single institution. It provides a literature review of procedural outcomes, current data limitations, and future considerations., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Examine outcome differences in patients managed either with a supraglottic airway or an endotracheal tube for general anesthesia during transcatheter aortic valve replacement. The authors hypothesized that patients managed with a supraglottic airway would have shorter post-anesthesia care unit and hospital stays and receive fewer opioids, norepinephrine equivalents, and neuromuscular blocking agents, without an increase in 30-day major adverse cardiovascular events., Design: Retrospective chart review with 1:2 supraglottic airway-to-endotracheal tube patient propensity score matching., Setting: Single, urban, tertiary care, academic medical center., Participants: Patients undergoing transfemoral- transcatheter aortic valve replacement between 2017 and 2019., Interventions: Supraglottic or endotracheal tube airway management during general anesthesia., Measurements and Main Results: Thirty-one supraglottic airway patients were propensity score matched with 62 endotracheal tube patients. There was no significant difference for postanesthesia care unit (p = 0.58) or hospital (p = 0.16) lengths of stay. Supraglottic airway patients received significantly fewer neuromuscular blockers (p < 0.0001) and trended toward fewer opioids (p = 0.05), but received a similar number of norepinephrine equivalents (p = 0.76). The major adverse cardiovascular event odds ratio between groups was 1.39 (p = 0.51). The time under general anesthesia (p = 0.02) and total time in the operating room (p = 0.04) were significantly shorter for supraglottic airway patients., Conclusions: Supraglottic airway management in transcatheter aortic valve replacement was feasible without an increase in major adverse cardiovascular outcomes compared with endotracheal tube management during general anesthesia. Supraglottic airway patients trended toward receiving fewer opioids and received significantly fewer neuromuscular blockers while also having significantly shorter time under general anesthesia and total time in the operating room., Competing Interests: Conflict of Interest R. Schumann receives royalties for 2 obesity-related chapters in Up-To-Date from Wolters Kluwer publishers, Alphen aan den Rijn, South Holland, Netherlands, for which he also is a reviewer., (Published by Elsevier Inc.)

The grave clinical context of the coronavirus disease 2019 (COVID-19) pandemic must be understood. Italy is immersed in the COVID-19 pandemic. Most of the world will soon follow. The United States currently has the most documented cases of COVID-19 of any nation. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated acute cardiomyopathy is common in critical care patients and is associated with a high mortality rate. Patients with COVID-19 frequently require mechanical support for adequate oxygenation. A severe shortfall of ventilators is predicted. Of equal concern is the projected shortage of trained professionals required to care for patients on mechanical ventilation. Ultrasonography is proving to be a valuable tool for identifying the pulmonary manifestations and progression of COVID-19. Lung ultrasound also facilitates successful weaning from mechanical ventilation. Ultrasonography of the lung, pleura, and diaphragm are easily mastered by experienced echocardiographers. Echocardiography has an established role for optimal fluid management and recognition of cardiac disease, including SARS-CoV-2-associated acute cardiomyopathy. Cardiologists, anesthesiologists, sonographers, and all providers should be prepared to commit their full spectrum of skills to mitigate the consequences of the pandemic. We should also be prepared to collaborate and cross-train to expand professional services as necessary. During a declared health care crisis, providers must be familiar with the ethical principles, organizational structure, practical application, and gravity of limited resource allocation., (Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess whether blood group O patients undergoing left ventricular assist device (LVAD) insertion have higher perioperative transfusion requirements, postoperative chest tube output, and postoperative changes in hematocrit., Design: Retrospective review of 116 LVAD patients from August 2015 to May 2018., Setting: Single-institution, urban academic medical center., Participants: One hundred sixteen LVAD patients analyzed by blood group: group O (n = 49) versus non-O (n = 67)., Interventions: Transfusions in the combined intraoperative and postoperative period at 7 days and 90 days after LVAD implantation, chest tube output in the first 24 hours, and hematocrit change in the first 48 hours postoperatively., Results: There was no difference between group O and non-O within the univariable analysis for both 7-day and 90-day transfusion rates. Adjusting for covariables, blood type O was not associated with packed red blood cells transfusion after accounting for multiple comparisons (odds ratio 1.33 [1.07-1.66], p = 0.01, where p < 0.005 was considered statistically significant as a Bonferroni correction was performed to control the familywise error rate). Additionally, there was no difference in chest tube output over the first 24 hours (1,129 v 1,057 mL, p = 0.47) or hematocrit change in the first 48 hours postoperatively (3.49 v 4.53%, p = 0.15)., Conclusion: O blood group is not a significant predictor of transfusion requirements in the combined intraoperative and postoperative period up to 90 days after LVAD implantation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Resolution of left ventricular outflow tract (LVOT) obstruction predicts symptom relief postmyectomy. Intraoperative measurement of LVOT gradients thus is essential for surgical guidance. We hypothesized that (1) hypertrophic cardiomyopathy patients have lower LVOT gradients when measured intraoperatively with transesophageal echocardiography (TEE) compared with preoperative measurements with transthoracic echocardiography (TTE) and that (2) intraoperative provocative testing can help evaluate the adequacy of surgical resection., Methods: We compared resting LVOT gradients on preoperative TTE to intraoperative TEE. We also compared intraoperative resting and provoked gradients pre- and postresection. Either isoproterenol 10 μg/kg/min or dobutamine 20 μg/kg/min was used. Patients with provoked LVOT gradients >30 mm Hg were considered for further resection based on LVOT/mitral valve morphology and clinical comorbidities., Results: Of 315 patients identified, 293 patients were included in the analysis. There was a statistically significant difference between preoperative TTE and intraoperative TEE resting LVOT gradients (60.9 ± 39.4 mm Hg vs 42.0 ± 30.5 mm Hg, P < .0001). Out of 197 patients who had significant resting obstruction preoperatively, 82 (41.6%) demonstrated mild or no dynamic obstruction under general anesthesia. Provocative testing with both isoproterenol and dobutamine increased peak gradients (116.8 ± 33 mm Hg isoproterenol vs 107.5 ± 33 mm Hg dobutamine, P = .03). Post-cardiopulmonary bypass, seven patients (2.3%) had LVOT gradients > 30 mm Hg at rest, while 63 patients (21.5%) had residual gradients >30 mm Hg only with provocation. Elevated gradients, persistent systolic anterior motion of the mitral valve with near contact, and/or significant mitral regurgitation with provocative testing resulted in return to cardiopulmonary bypass in 41 patients (14%)., Conclusions: Resting intraoperative TEE LVOT gradients are significantly lower than preoperative TTE gradients, with systolic anterior motion of the MV and outflow obstruction often not visualized after inducing general anesthesia. Intraoperative pharmacologic provocation can identify patients who may benefit from further surgical intervention, facilitating procedural success., (Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Objective: The authors hypothesized that automated tracings of both pulsed wave (PW) and continuous wave (CW) Doppler correlate well with manual measurements performed by an experienced echocardiographer., Design: The authors performed a retrospective analysis of spectral Doppler profile measurements performed by automated software and an echocardiographer., Setting: University hospital, single institution., Participants: The authors reviewed transesophageal echocardiographic examinations from patients undergoing transcatheter aortic valve (AV) replacement procedures at their institution., Interventions: No interventions were performed solely for research purposes., Measurements and Main Results: PW and CW spectral envelopes at the left ventricular outflow tract (LVOT) and AV were analyzed. Blinded, a board-certified echocardiographer performed manual measurements of the identical spectral envelopes. Peak velocities, mean gradients, and velocity time integrals (VTI) were collected. A total of 33 PW as well as 33 CW Doppler spectral envelopes were evaluated. There was no significant difference between the measurements provided by the automated software and manual tracings. LVOT PW VTI automated versus manual: 18.2 cm versus 15.9 cm, p = 0.11. AV CW VTI automated versus manual: 65.8 cm versus 64.8 cm, p = 0.90. AV CW mean gradient automated versus manual: 24.3 mmHg versus 23.4 mmHg, p = 0.84. AV CW peak velocity automated versus manual: 3.00 m/s versus 2.98 m/s, p = 0.93. Correlation coefficients were all above 0.9., Conclusions: Automated measurements of peak velocities, mean gradients, and VTI of spectral Doppler correlate closely with manual measurements performed by an experienced echocardiographer., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The authors aim to evaluate an automated echocardiography software as compared with computed tomography in measurement of the aortic valve annulus in patients with aortic stenosis. The authors hypothesize that aortic annular measurements by this software and computed tomography will show acceptable correlation., Design: This study is an Institutional Review Board-approved, retrospective data collection of patients with aortic stenosis who underwent implantation of a transcatheter heart valve with intraprocedural transesophageal echocardiography, multidetector computed tomography, and use of the Siemens eSie Valves automated aortic valve software., Setting: Intraprocedural in a single hospital institution., Participants: The participants are 47 patients who underwent implantation of an Edwards SAPIEN 3 transcatheter heart valve., Interventions: The authors compared aortic valve annulus measurements by two-dimensional transesophageal echocardiography, computed tomography, and the automated software., Measurements and Main Results: Aortic annulus measurements by the software correlated more closely to the computed tomography measurements than two-dimensional measurements. Bland-Altman analysis showed qualitative comparability of measurements performed by the automated software to computed tomography (95% limits of agreement between -4.62 mm and 1.26 mm for area-derived and -4.51 mm and 1.45 mm for perimeter-derived methods). Similarly, there was significant linear correlation with automated software use (r = 0.84, p < 0.0001 and r = 0.85, p < 0.0001)., Conclusions: Periprocedural aortic valve measurement by automated echocardiographic software correlates with computed tomography in patients with severe aortic stenosis. This technology is helpful and accurate, but has limitations., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Chronic postthoracotomy pain (CPTP) is a persistent, occasionally debilitating pain lasting >2 months following thoracic surgery. This study investigates for the first time the prevalence and clinical impact of CPTP in patients who have undergone a transapical transcatheter aortic valve replacement (TA-TAVR)., Design: This was a single-institution, prospective observational survey and a retrospective chart review., Setting: The study was conducted in the University Hospital., Participants: Patients., Materials and Methods: A survey of 131 participants with either a previous TA TAVR or transfemoral (TF) TAVR procedure was completed. A telephone interview was conducted at least 2 months following TAVR; participants were asked to describe their pain using the Short-Form McGill Pain Questionnaire., Measurements and Main Results: Odds ratio (OR) was calculated using the proportions of questionnaire responders reporting "sensory" descriptors in the TA-TAVR versus the TF-TAVR groups. Results were then compared to individual Kansas City Cardiomyopathy Questionnaire (KCCQ12) scores and 5-min walk test (5MWT) distances. A total of 119 participants were reviewed (63 TF, 56 TA). Among TA-TAVR questionnaire responders (n = 16), CPTP was found in 64.3% of participants for an average duration of 20.5-month postprocedure (OR = 10, [confidence interval (CI) 95% 1.91-52.5];P = 0.003). TA-TAVR patients identified with CPTP had significant reductions in 5MWT distances (-2.22 m vs. 0.92 m [P = 0.04]) as well as trend toward significance in negative change of KCCQ12 scores OR = 18.82 (CI 95% 0.85-414.99;P = 0.06) compared to those without CPTP., Conclusions: CPTP occurs in patients undergoing TA-TAVR and is possibly associated with a decline quality of life and overall function., Competing Interests: None

Background: Severe right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation increases morbidity and mortality. We investigated the association between intraoperative right heart hemodynamic data, echocardiographic parameters, and severe versus nonsevere RVF., Methods: A review of LVAD patients between March 2013 and March 2016 was performed. Severe RVF was defined by the need for a right ventricular mechanical support device, inotropic, and/or inhaled pulmonary vasodilator requirements for >14 days. From a chart review, the right ventricular failure risk score was calculated and right heart hemodynamic data were collected. Pulmonary artery pulsatility index (PAPi) [(pulmonary artery systolic pressure - pulmonary artery diastolic pressure)/central venous pressure (CVP)] was calculated for 2 periods: (1) 30 minutes before cardiopulmonary bypass (CPB) and (2) after chest closure. Echocardiographic data were recorded pre-CPB and post-CPB by a blinded reviewer. Univariate logistic regression models were used to examine the performance of hemodynamic and echocardiographic metrics., Results: A total of 110 LVAD patients were identified. Twenty-five did not meet criteria for RVF. Of the remaining 85 patients, 28 (33%) met criteria for severe RVF. Hemodynamic factors associated with severe RVF included: higher CVP values after chest closure (18 ± 9 vs 13 ± 5 mm Hg; P = .0008) in addition to lower PAPi pre-CPB (1.2 ± 0.6 vs 1.7 ± 1.0; P = .04) and after chest closure (0.9 ± 0.5 vs 1.5 ± 0.8; P = .0008). Post-CPB echocardiographic findings associated with severe RVF included: larger right atrial diameter major axis (5.4 ± 0.9 vs 4.9 ± 1.0 cm; P = .03), larger right ventricle end-systolic area (22.6 ± 8.4 vs 18.5 ± 7.9 cm; P = .03), lower fractional area of change (20.2 ± 10.8 vs 25.9 ± 12.6; P = .04), and lower tricuspid annular plane systolic excursion (0.9 ± 0.2 vs 1.1 ± 0.3 cm; P = .008). Right ventricular failure risk score was not a significant predictor of severe RVF. Post-chest closure CVP and post-chest closure PAPi discriminated severe from nonsevere RVF better than other variables measured, each with an area under the curve of 0.75 (95% CI, 0.64-0.86)., Conclusions: Post-chest closure values of CVP and PAPi were significantly associated with severe RVF. Echocardiographic assessment of RV function post-CPB was weakly associated with severe RVF.

Prosthesis-patient mismatch (PPM) is relatively common after aortic valve replacement (AVR) and generally is associated with reduced regression of left ventricular (LV) mass. PPM after valve-in-valve transcatheter aortic valve replacement (TAVR) was reported to be 38%. PPM generally is manifested clinically by dyspnea and echocardiographically by high transvalvular gradients. In this E-Challenge, the authors will review a case of a late clinical presentation of PPM 1-year following a valve-in-valve TAVR., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Assessing the efficacy of intraoperative 4-factor prothrombin complex concentrate (4F-PCC) use in blood product utilization, time to chest closure, intensive care unit (ICU) and hospital length of stay (LOS), thromboembolic complications, renal injury and mortality in left ventricular assist device (LVAD) patients on home anticoagulation therapy with warfarin, undergoing orthotopic heart transplantation (OHT)., Design: Retrospective analysis of OHT patients at Tufts Medical Center from May 2013 to October 2016., Setting: Single-institution, university hospital setting., Participants: Patients with preexisting LVADs who received orthotopic heart transplants (n = 74; 32 patients 4F-PCC, 42 patients no 4F-PCC)., Interventions: Warfarin reversal using 4F-PCC in patients with LVADs undergoing orthotopic heart transplantation with the 4F-PCC dosing partitioned such that one-third was given pre-CPB and two-thirds were given post-CPB., Measurements and Main Results: The 4F-PCC group required less plasma (6 [IQR 4] v 1.31 [IQR 2] U, p < 0.001), cryoprecipitate (10 [IQR 10] v 7.50 [IQR 5] U, p < 0.001), and packed red blood cells (5 [IQR 4] v 2 [IQR 1.5] U, p < 0.001) and had a shorter time to chest closure (618.8 ± 111.4 v 547.9 ± 110.1 minutes, p = 0.008). There was no difference in platelet transfusion (2 [IQR 1] v 2 [IQR 1] U, p = 0.16), ICU or hospital LOS, acute kidney injury, or mortality. No thrombotic complications occurred., Conclusions: Replacing plasma with 4F-PCC to reverse preoperative warfarin anticoagulation during OHT was associated with a shorter time to chest closure and less blood product utilization, without an increase in acute kidney injury, thromboembolic complications, or death., (Copyright © 2018. Published by Elsevier Inc.)

HeartWare is a third-generation continuous flow left ventricular assist device (LVAD) and generates centrifugal pattern of blood flow. In the perioperative setting, interrogating the HeartWare devices is very difficult due to the interference of the Doppler by the impeller frequency and generation of the waterfall artifact. We present a case where using color Doppler a view "inside" the impeller can be seen which corresponds to the centrifugal flow of blood. With time, these images can be looked into in pathological states such as pump thrombosis, to come to a more meaningful conclusion regarding the flow of blood within the centrifugal chamber. Newer technologies are constantly evolving to give us more meaningful insights into the flow of blood within the heart chambers. We believe similar technologies can be applied to see the flow of blood inside the LVAD devices.

Objective: To determine whether the ratio of peak systolic-to-nadir diastolic velocity (S/D ratio) measured using Doppler at the left ventricular assist device (LVAD) inflow and outflow cannulae is associated with pump thrombosis and to determine whether there is an absolute decrease in the diastolic cannula velocities in LVAD thrombosis., Design: Retrospective chart review., Setting: University hospital., Participants: Patients who underwent LVAD exchange., Interventions: None., Measurements and Main Results: Transesophageal echocardiograms were reviewed from all patients with the HeartMate II device (Thoratec Corporation, Pleasanton, CA) over a 6-year period and who underwent LVAD exchange for pump thrombosis. The following 3 time points were evaluated: (1) initial LVAD placement (prethrombosis), (2) thrombosis, and (3) exchanged LVAD placement (postthrombosis). Systolic and diastolic flow velocities were examined using pulse-wave spectral Doppler at the inflow and outflow cannulae, and the S/D ratio for each was determined. Statistical analysis was performed with SAS, version 9.4 (SAS Institute, Cary, NC), using 2-tailed tests and alpha = 0.05. Thirteen patients were included in the study. Significant differences were observed in S/D ratios among the 3 phases at both the inflow (p = 0.0234) and outflow (p = 0.0047) cannulae. Pairwise tests of the inflow cannulae showed that the mean S/D ratio at the time of thrombosis (mean ± standard deviation [SD], 4.29 ± 1.74) was significantly greater than the prethrombosis ratio (2.49 ± 0.65; p = 0.0069). Among outflow measurements, the mean S/D ratio at thrombosis (3.94 ± 1.34) was significantly higher than both the prethrombosis (2.63 ± 0.56; p = 0.0025) and postthrombosis (2.74 ± 0.83) (p = 0.0093) ratios. Decreases in diastolic velocities were not statistically significant at the inflow cannula. At the outflow cannula, there was a significant difference in diastolic velocity among the phases (p = 0.0233). Specifically, the postthrombosis diastolic measurements (41.50 ± 9.94) were significantly higher than both the prethrombosis (26.85 ± 10.13; p = 0.0140) and thrombosis (26.7 ± 15.35; p = 0.0151) values., Conclusions: An increased S/D ratio measured with Doppler at the LVAD inflow and outflow cannulas may be associated with pump thrombosis. Decreased diastolic cannula velocities were not observed in LVAD thrombosis., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: In patients with mitral regurgitation (MR), the effective regurgitant orifice area can be estimated by measuring the vena contracta area (VCA). We hypothesize that the VCA has characteristic temporal dynamics related to the underlying mechanism of functional mitral regurgitation (FMR) versus degenerative mitral valve disease (DMVD)., Methods: VCA measurements obtained by planimetry of the proximal jet from 3D transesophageal echocardiographic (TEE) color flow Doppler data sets were acquired in 42 cardiac surgical patients, including 22 with FMR and 20 with DMVD. Serial VCAs were measured throughout systole for each patient to evaluate variation in the effective regurgitant orifice area. Tercile averages were compared within and between the FMR and DMVD groups using repeated measures analysis of variance. Pairwise tests were Bonferroni-corrected for the number of comparisons., Results: Normalized average VCA values in patients with FMR revealed a biphasic pattern compared with a monophasic pattern in patients with DMVD. Among FMR patients, normalized average VCA values in early (1.10 ± 0.32 cm2) and late systole (1.11 ± 0.33 cm2) were similar but were both significantly greater compared with mid-systole (0.79 ± 0.22 cm; P = 0.0144 and P = 0.0106, respectively). Among DMVD patients, normalized average VCA values in mid-systole (1.37 ± 0.15 cm2) were significantly greater than those in early (0.53 ± 0.14 cm2) and late systole (1.09 ± 0.18 cm2; P < 0.0001 for both). An analysis of normalized average VCAs also revealed significant differences between the FMR and the DMVD groups during early (1.10 ± 0.32 cm vs 0.53 ± 0.14 cm2) and mid-systole (0.79 ± 0.22 cm2 vs 1.37 ± 0.15 cm2; P < 0.0001 for both)., Conclusions: VCA dynamics are governed by the mechanism of MR and are observed in FMR patients primarily as a biphasic temporal pattern compared with a monophasic temporal pattern in patients with DMVD.

Introduction: Transapical transcatheter aortic valve replacement is an option for patients who are not candidates for traditional aortic valve surgery but have severe aortic stenosis and unfavorable ileo-femoral anatomy. Epidural analgesia in these cases has been associated with improved morbidity and mortality. The following manuscript presents the findings of an initial clinical experience employing paravertebral analgesia for patients undergoing transapical transcatheter aortic valve replacement., Methods: A retrospective review was performed of 61 transapical transcatheter aortic valve replacement cases over a two-year period from November 2012 through July 2014. Paravertebral analgesia was provided as left sided single injections covering 1-3 dermatome levels using 0.2% ropivicaine with supplemental clonidine to 48 patients. The following outcome metrics were collected: 1) peri-operative opiate administration, 2) rate of extubation in the operating room, 3) new atrial fibrillation, 4) duration of intensive care stay, 5) 30-day mortality., Results: The mean opiate administration was less in patients with paravertebral analgesia (128.65mcg vs. 163.46mcg fentanyl, p value 0.05) and these patients were more frequently extubated in the operating room (83.3% vs. 46.2%, p-value 0.0107). Incidence of atrial fibrillation was less in patients who received paravertebral analgesia (18.8% vs. 75.0%, p-value 0.0048). There was a non-significant trend towards decreased intensive care stay in patients who received paravertebral analgesia (58.3 hrs vs 75.8 hrs, p value 0.35). There was no difference in 30-day mortality. No complications resulted from paravertebral analgesia., Conclusions: This is the first reported case series of paravertebral blockade in transapical transcatheter aortic valve replacement  patients. The findings suggest that paravertebral single shot blocks are both safe and practical for use in this patient population. A formal prospective investigation of paravertebral analgesia in these patients is warranted.

Background: Functional mitral regurgitation (FMR) occurs as a consequence of left ventricular remodeling and is an independent predictor of adverse outcome. FMR is assessed qualitatively with two-dimensional echocardiography, but accurate quantitation of the actual degree of mitral valve (MV) coaptation is not possible with this method. We evaluated a novel three-dimensional (3D) approach to quantify the MV coaptation zone in patients with FMR. We hypothesized that measuring the 3D MV coaptation zone is feasible and would correlate with FMR severity when indexed to MV area., Methods: Data were gathered on 25 patients with FMR undergoing cardiac operations, and included a comprehensive two-dimensional and 3D examination with intraoperative transesophageal echocardiography. Using available 3D MV quantification software, offline analysis of end-systolic MV coaptation zone and MV area was performed. A novel MV coaptation index was calculated by the following formula: [3D end-systolic MV coaptation zone/3D MV area]. FMR severity was described as trace, mild, moderate, and severe using the integrative approach recommended by official guidelines., Results: Analysis of variance demonstrated that the coaptation index was associated with the severity of FMR (F = 20.5, r(2) = 0.75, p < 0.0001). There was also a correlation between 2D vena contracta and the coaptation index (r = -0.74, p < 0.0003)., Conclusions: We describe a novel 3D approach to direct assessment of the MV coaptation zone. When indexed to the MV area, the 3D MV coaptation zone is closely associated with FMR severity. Assessment of the mitral coaptation may be a potentially powerful tool in the perioperative evaluation of the competency of the MV., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)