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Mufarrih SH, Mahmood F, Qureshi NQ, Yunus R, Quraishi I, Baribeau V, Sharkey A, Matyal R, Khabbaz KR. Three-Dimensional Printing of Patient-Specific Heart Valves: Separating Facts From Fiction and Myth From Reality. J Cardiothorac Vasc Anesth 2021; 36:2643-2655. [PMID: 34654635 DOI: 10.1053/j.jvca.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/05/2021] [Accepted: 09/08/2021] [Indexed: 11/11/2022]
Abstract
The development of prosthetic heart valves by Dr. Charles Hufnagel in 1952 was a major clinical innovation; however, it was not an ideal solution. Mechanical prosthetic heart valves are rigid, immunogenic, require anticoagulation, do not grow with the patient, and have a finite life.1 An ideal prosthetic valve should overcome all these limitations. Considering the prevalence of valvular heart disorders, there is considerable interest in the creation of patient-specific heart valves. Following the introduction of three-dimensional (3D) printing in 1986 by Chuck Hill, rapid advances in multimodality 3D imaging and modeling have led to a generation of tangible replicas of patient-specific anatomy. The science of organogenesis has gained importance for a multitude of valid reasons: as an alternate source of organs, for realistic drug testing, as an alternative to animal testing, and for transplants that grow with the patient. What scientists imagined to be seemingly impossible in the past now seems just a step away from becoming a reality. However, due to the disruptive nature of this technology, often there are commercially-motivated claims of originality and overstatement of the scope and applicability of 3D printing. It often is difficult to separate fact from fiction and myth from reality. In this manuscript, the authors have reviewed the historic perspective, status of the basic techniques of organogenesis with specific reference to heart valves, and their potential.
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Baribeau V, Weinstein J, Wong VT, Sharkey A, Lodico DN, Matyal R, Mahmood F, Mitchell JD. Motion-Tracking Machines and Sensors: Advancing Education Technology. J Cardiothorac Vasc Anesth 2021; 36:303-308. [PMID: 34551885 DOI: 10.1053/j.jvca.2021.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/09/2021] [Accepted: 07/19/2021] [Indexed: 01/22/2023]
Abstract
Graduate medical education is predominantly based on a time-based apprenticeship model, with implied acquisition of proficiency after a pre-set amount of clinical exposure. While motion metrics have been used previously to measure skill performance indicators, these assessments have largely been performed on a summative scale to describe the performance of complete tasks or procedures. By segmenting performances of interest and assessing the essential elements individually, a more comprehensive understanding of the aspects in need of improvement for a learner can be obtained. The purpose of this review is to discuss technologies applicable to motion tracking, their benefits and limitations, approaches to data processing, and potential applications based on recent improvements in this technology. Objective analysis of motion metrics may improve educational standards of learning and efficiency by both standardizing the feedback process for trainees and reducing the volume of instructors required to facilitate practice sessions. With rigorous validation and standardization, motion metric assessment may also prove useful to demonstrate competency in technical procedures as part of a comprehensive certification process.
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Mufarrih SH, Qureshi NQ, Schaefer MS, Sharkey A, Fatima H, Chaudhary O, Krumm S, Baribeau V, Mahmood F, Schermerhorn M, Matyal R. Regional Anaesthesia for Lower Extremity Amputation is Associated with Reduced Post-operative Complications Compared with General Anaesthesia. Eur J Vasc Endovasc Surg 2021; 62:476-484. [PMID: 34303598 DOI: 10.1016/j.ejvs.2021.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/19/2021] [Accepted: 05/30/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Primary and secondary lower extremity amputation, performed for patients with lower extremity arterial disease, is associated with increased post-operative morbidity. The aim of the study was to assess the impact of regional anaesthesia vs. general anaesthesia on post-operative pulmonary complications. METHODS A retrospective analysis of 45 492 patients undergoing lower extremity amputation between 2005 and 2018 was conducted using data from the American College of Surgeons National Safety Quality Improvement Program database. Multivariable logistic regression was carried out to assess differences in primary outcome of post-operative pulmonary complications (pneumonia or respiratory failure requiring re-intubation) within 48 hours and 30 days after surgery between patients receiving regional (RA) or general anaesthesia (GA). Secondary outcomes included post-operative blood transfusion, septic shock, re-operation, and post-operative death within 30 days. RESULTS Of 45 492 patients, 40 026 (88.0%) received GA and 5 466 (12.0%) RA. Patients who received GA had higher odds of developing pulmonary complications at 48 hours (2.1% vs. 1.4%; adjusted odds ratio [aOR] 1.39, 95% confidence interval [CI] 1.09 - 1.78; p = .007) and within 30 days (6.3% vs. 5.9%; aOR 1.15, 95% CI 1.09 - 1.78; p = .039). The odds of blood transfusions (aOR 1.11, 95% CI 1.02 - 1.21; p = .017), septic shock (aOR 1.29, 95% CI 1.03 - 1.60; p = .025) and re-operation (OR 1.26, 95% CI 1.03 - 1.53; p = .023) were also higher for patients who received GA vs. patients who received RA. No difference in mortality rate was observed between patients who received GA and those who received RA (5.7% vs. 7.1%; odds ratio 0.95, 95% CI 0.84 - 1.07). CONCLUSION A statistically significant reduction in pulmonary complications was observed in patients who received RA for lower extremity amputation compared with GA.
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Montealegre-Gallegos M, Matyal R, Muñoz-Acuña R, Eichinger C, Walsh DP. A Retrocardiac Echolucency. J Cardiothorac Vasc Anesth 2021; 36:915-917. [PMID: 34362642 DOI: 10.1053/j.jvca.2021.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022]
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Mahmood F, Sharkey A, Maslow A, Mufarrih SH, Qureshi NQ, Matyal R, Khabbaz KR. Echocardiographic Assessment of the Mitral Valve for Suitability of Repair: An Intraoperative Approach From a Mitral Center. J Cardiothorac Vasc Anesth 2021; 36:2164-2176. [PMID: 34334319 DOI: 10.1053/j.jvca.2021.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/23/2021] [Accepted: 06/27/2021] [Indexed: 11/11/2022]
Abstract
Intraoperative echocardiography of the mitral valve in the precardiopulmonary bypass period is an integral part of the surgical decision-making process for assessment of suitability for repair. Although there are comprehensive reviews in the literature regarding echocardiographic examination of the mitral valve, the authors present a practical stepwise algorithmic workflow to make objective recommendations. Advances in echocardiography allow for quantitative geometric analyses of the mitral valve, along with precise assessment of the valvular apparatus with three-dimensional echocardiography. In the precardiopulmonary bypass period, echocardiographers are required to diagnose and quantify valvular dysfunction, assess suitability for repair, assist in annuloplasty ring sizing, and determine the success or failure of the surgical procedure. In this manuscript the authors outline an algorithmic approach to intraoperative echocardiography examination using two-dimensional and three-dimensional modalities to objectively analyze mitral valve function and assist in surgical decision-making.
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Fatima H, Sharkey A, Qureshi N, Mahmood F, Mufarrih SH, Baribeau V, Matyal R, Bose RR. Three-Dimensional Transesophageal Echocardiography Simulator: New Learning Tool for Advanced Imaging Techniques. J Cardiothorac Vasc Anesth 2021; 36:2090-2097. [PMID: 34275733 DOI: 10.1053/j.jvca.2021.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/20/2021] [Accepted: 05/26/2021] [Indexed: 11/11/2022]
Abstract
The use of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) has grown exponentially in recent years. Three-dimensional TEE technology has evolved to allow for real-time display of 3D images and, thus, has become the standard of care for the evaluation of cardiac anatomy and function. Its use has provided a new dimension of clinical insight when managing patients for cardiac surgery or structural heart interventions. While the intraoperative utility of 3D TEE has expanded, there has been a slower advancement in the area of training and, specifically, simulator-based training in 3D TEE. This training is essential, as the skill set involved in acquiring 3D data sets differs from that of two-dimensional (2D) TEE and requires users to be able to appreciate how 3D anatomic display differs from that of tomographic cross-sectional 2D imaging. This added skill set requires mental reconstruction and spatial reorientation to appreciate the added elevational dimension in frustum-based imaging and is best achieved in a simulation environment rather than the busy operating room. In this review article, the authors evaluate the functionality of a 3D TEE simulator and how simulators such as this can establish preclinical proficiency in novices in the expanding area of advanced 3D TEE imaging.
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Chaudhary O, Matyal R, Sharkey A. Erector Spinae Block: Questions answered, more questions raised. Ann Thorac Surg 2021; 113:1057-1058. [PMID: 34102178 DOI: 10.1016/j.athoracsur.2021.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/01/2022]
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Fatima H, Chaudhary O, Krumm S, Mufarrih SH, Mahmood F, Pannu A, Sharkey A, Baribeau V, Qureshi N, Polshin V, Bose R, Hamdan AD, Schermerhorn ML, Matyal R. Enhanced Post-Operative Recovery with Continuous Peripheral Nerve Block After Lower Extremity Amputation. Ann Vasc Surg 2021; 76:399-405. [PMID: 33895258 DOI: 10.1016/j.avsg.2021.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite progress in perioperative care standards, there has not been a significant risk reduction in morbidity and mortality rates of lower extremity amputations, an intermediate risk surgery performed on high risk patients. The single-shot peripheral nerve block has shown equivocal impact on postoperative course following lower extremity amputation. Hence, we assessed the potential of preemptive use of continuous catheter-based peripheral nerve block in lower extremity amputations for reduction in pulmonary complications, acute post-operative pain scores, and opioid use in post-operative period. METHODS A retrospective review of a quality improvement project initiated in 2018 was conducted to compare outcomes amongst general anesthesia in combination with a catheter-based peripheral nerve block (catheter group) and general anesthesia alone in patients receiving lower extremity amputation. The rate of postoperative pulmonary complications was identified as a primary endpoint. The secondary outcomes assessed were acute post-operative pain scores and opioid consumption up to 48 hours. Our analysis was adjusted for potential confounding variables inclusive of demographics, medical comorbidities, type of surgical procedure and smoking status. RESULTS Ninety-six patients were included in the study (61 in the general anesthesia group, 35 in the catheter group). After adjusting for baseline demographics, comorbidities, surgical technique and smoking status, the odds of postoperative pulmonary complications were significantly lower with catheter-based peripheral nerve block in comparison to general anesthesia alone, OR 0.11 [95% CI, 0.01- 0.88] (P = 0.048). The decrease in acute pain scores was also observed in the catheter group when compared to general anesthesia alone, OR 0.72 [95% CI, 0.56 - 0.93] (P = 0.012). Similarly, the opioid consumption was also lower in the catheter group in comparison to general anesthesia alone, OR 0.97 [95% CI, 0.95 - 0.99] (P = 0.025). CONCLUSION Preemptive use of continuous peripheral nerve block in patients undergoing lower extremity amputation reduces the incidence of pulmonary complications, acute postoperative pain scores and narcotic use in post-operative period.
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Fatima H, Amador Y, Walsh DP, Qureshi NQ, Chaudhary O, Mufarrih SH, Bose RR, Mahmood F, Matyal R. Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A Practical Echo-guided Approach Proposal. J Cardiothorac Vasc Anesth 2021; 35:2273-2282. [PMID: 34006466 DOI: 10.1053/j.jvca.2021.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 01/17/2023]
Abstract
Despite the valuable use of modern applications of perioperative ultrasound across multiple disciplines, there have been limitations to its implementation, restricting its impact on patient-based clinical outcomes. Point-of-care ultrasound evaluation of hypoxia and hypotension is an important tool to assess the underlying undifferentiated etiologies in a timely manner. However, there is a lack of consensus on the formal role of ultrasound during evaluation of perioperative hypoxia or hypotension. The previous ultrasound algorithms have adopted a complex technique that possibly ignore the pathophysiologic mechanisms underlying the conditions presenting in a similar fashion. The authors here propose a simple, sequential and focused multiorgan approach, applicable for the evaluation of perioperative hypotension and hypoxia in emergency scenarios. The authors believe this approach will enhance the care provided in the postanesthesia care unit, operating room, and intensive care unit.
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Sharkey A, Zucco L, Rubenstein L, Baribeau V, Mahmood F, Matyal R. Closed Bronchoscopy System: An Innovative Approach to Minimize Aerosolization During Bronchoscopy. A A Pract 2021; 15:e01417. [PMID: 33687348 PMCID: PMC8330621 DOI: 10.1213/xaa.0000000000001417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 01/25/2023]
Abstract
Health care workers performing aerosolizing procedures on patients with transmissible infections such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are at high-risk for disease acquisition. Current guidelines designed to protect health care workers during aerosolizing procedures prioritize personal protective equipment and enhanced infection control techniques, in particular during procedures such as intubation. To date, little emphasis has been placed on risk mitigation in the setting of bronchoscopy, a procedure that has significant aerosolization potential. Herein, we present an innovative closed bronchoscopy system designed to reduce aerosolization during bronchoscopy.
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Mahmood E, Sharkey A, Matyal R, Mahmood F, Chaudhary O, Khabbaz K. Response by Mahmood et al to Letter Regarding Article, "Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery". Circulation 2020; 142:e504-e505. [PMID: 33347330 DOI: 10.1161/circulationaha.120.051365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fatima H, Chaudhary O, Krumm S, Mufarrih SH, Qureshi NQ, Oren-Grinberg A, Bose RR, Huang L, Mahmood F, Matyal R. Workflow of Ultrasound-Guided Arterial Access. J Cardiothorac Vasc Anesth 2020; 35:1611-1617. [PMID: 33446403 DOI: 10.1053/j.jvca.2020.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/02/2020] [Accepted: 12/11/2020] [Indexed: 11/11/2022]
Abstract
Arterial line cannulations frequently are performed in various clinical settings to facilitate hemodynamic monitoring and metabolic assessments. Palpation-guided technique generally is performed due to the superficial nature of the peripheral arteries; however, this approach may be challenging in patients with obesity, edema, and hypotension. Difficult line placements are a significant contributor of reduced operating room efficiency due to time delays seen in procedural workflow. Real-time ultrasound guidance is shown to improve success rates of arterial cannulation and reduction in multiple attempts, leading to time efficiency and less likelihood of arterial spasms or hematoma formation. In this report, the authors demonstrate the workflow of ultrasound-guided arterial line cannulation, outline the features of their institutional multi-modal training project for quality improvement, and evaluate the possible effect of the initiative on surgical delays seen with difficult line placements.
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Weinstein JL, El-Gabalawy F, Sarwar A, DeBacker SS, Faintuch S, Berkowitz SJ, Bulman JC, Palmer MR, Matyal R, Mahmood F, Ahmed M. Analysis of Kinematic Differences in Hand Motion between Novice and Experienced Operators in IR: A Pilot Study. J Vasc Interv Radiol 2020; 32:226-234. [PMID: 33339678 DOI: 10.1016/j.jvir.2020.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/18/2020] [Accepted: 10/12/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To prospectively validate electromagnetic hand motion tracking in interventional radiology to detect differences in operator experience using simulation. METHODS Sheath task: Six attending interventional radiologists (experts) and 6 radiology trainees (trainees) placed a wire through a sheath and performed a "pin-pull" maneuver, while an electromagnetic motion detection system recorded the hand motion. Radial task: Eight experts and 12 trainees performed palpatory radial artery access task on a radial access simulator. The trainees repeated the task with the nondominant hand. The experts were classified by their most frequent radial artery access technique as having either palpatory, ultrasound, or overall limited experience. The time, path length, and number of movements were calculated. Mann-Whitney U tests were used to compare the groups, and P < .05 was considered significant. RESULTS Sheath task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (11.7 seconds ± 3.3 vs 19.7 seconds ± 6.5, P < .01; 1.1 m ± 0.3 vs 1.4 m ± 0.4, P < .01; and 19.5 movements ± 8.5 vs 31.0 movements ± 8.0, P < .01, respectively). Radial task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (24.2 seconds ± 10.6 vs 33.1 seconds ± 16.9, P < .01; 2.0 m ± 0.5 vs 3.0 m ± 1.9, P < .001; and 36.5 movements ± 15.0 vs 54.5 movements ± 28.0, P < .001, respectively). The trainees had a shorter path length for their dominant hand than their nondominant hand (3.0 m ± 1.9 vs 3.5 m ± 1.9, P < .05). The expert palpatory group had a shorter path length than the ultrasound and limited experience groups (1.8 m ± 0.4 vs 2.0 m ± 0.4 and 2.3 m ± 1.2, respectively, P < .05). CONCLUSIONS Electromagnetic hand motion tracking can differentiate between the expert and trainee operators for simulated interventional tasks.
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Liu S, Bose R, Ahmed A, Maslow A, Feng Y, Sharkey A, Baribeau Y, Mahmood F, Matyal R, Khabbaz K. Artificial Intelligence-Based Assessment of Indices of Right Ventricular Function. J Cardiothorac Vasc Anesth 2020; 34:2698-2702. [DOI: 10.1053/j.jvca.2020.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/10/2020] [Accepted: 01/14/2020] [Indexed: 12/13/2022]
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Chaudhary O, Baribeau Y, Urits I, Sharkey A, Rashid R, Hess P, Krumm S, Fatima H, Zhang Q, Gangadharan S, Mahmood F, Matyal R. Use of Erector Spinae Plane Block in Thoracic Surgery Leads to Rapid Recovery From Anesthesia. Ann Thorac Surg 2020; 110:1153-1159. [DOI: 10.1016/j.athoracsur.2020.03.117] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/05/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022]
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Fatima H, Mahmood F, Sehgal S, Belani K, Sharkey A, Chaudhary O, Baribeau Y, Matyal R, Khabbaz KR. Artificial Intelligence for Dynamic Echocardiographic Tricuspid Valve Analysis: A New Tool in Echocardiography. J Cardiothorac Vasc Anesth 2020; 34:2703-2706. [DOI: 10.1053/j.jvca.2020.04.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 11/11/2022]
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Zhang Q, Feng R, Chaudhary O, Mahmood E, Baribeau Y, Rashid R, Khabbaz KR, Chu LM, Liu DC, Senthilnathan V, Cassavaugh J, Mahmood F, Robson SC, Matyal R. Cardiopulmonary Bypass Suppresses Forkhead Box O3 and Downstream Autophagy in the Diabetic Human Heart. Ann Thorac Surg 2020; 111:937-944. [PMID: 32712101 DOI: 10.1016/j.athoracsur.2020.05.142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 05/07/2020] [Accepted: 05/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Autophagy is an integral component of cellular homeostasis and metabolism. The exact mechanism of impaired autophagy in diabetes mellitus is unknown. Forkhead Box O3 (FOXO3α) is a key regulator of oxidative stress-related responses. We hypothesize FOXO3α is a direct upstream regulator of the autophagy pathway, and its upregulation is compromised in diabetic patients during stress of cardiopulmonary bypass (CPB). METHODS The study enrolled 32 diabetic and 33 nondiabetic patients undergoing a cardiac surgical procedure on CPB. Right atrial tissue and serum samples were collected before and after CPB per protocol. A set of key components were quantitatively assessed and compared by microarray, immunoblotting, and immunohistochemistry studies. Data were analyzed using paired or unpaired student test. A P of <.05 or less was considered significant. RESULTS Serum microarray showed FOXO3α was upregulated in the diabetic vs nondiabetic group after CPB (P = .033), autophagy-related 4B gene and Beclin 1 gene were greatly upregulated in the nondiabetic group (P = .028 and P = .002, respectively). On immunoblotting, there was upregulation of FOXO3α in the nondiabetic patients after CPB (P = .003). There were increased levels of Beclin-1, Bcl-2, and light chain 3B after CPB in the nondiabetic group only (P = .016, P = .005, P = .002, respectively). Sirtuin 1, Unc-51-like autophagy activating kinase 1 (ULK1), peroxisome proliferator-activated receptor gamma coactivator 1α (PGC1α), and mammalian target of rapamycin (mTOR) were not significantly changed in the nondiabetic group after CPB. CONCLUSIONS Compared with nondiabetic patients, there was no significant upregulation of FOXO3α in diabetic patients, which could possibly explain the lack of upregulation of the autophagy process after CPB. FOXO3α could potentially serve as a therapeutic target to improve cellular homeostasis.
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Baribeau Y, Sharkey A, Chaudhary O, Krumm S, Fatima H, Mahmood F, Matyal R. Handheld Point-of-Care Ultrasound Probes: The New Generation of POCUS. J Cardiothorac Vasc Anesth 2020; 34:3139-3145. [PMID: 32736998 PMCID: PMC7340048 DOI: 10.1053/j.jvca.2020.07.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 12/20/2022]
Abstract
Recent advances in ultrasound technology have made ultrasound equipment more versatile, portable, and accessible than ever. Modern handheld, ultra-portable ultrasound devices have been developed by multiple companies and are contributing to make bedside ultrasound evaluation a practice available to all physicians. The significance of making point-of-care ultrasound (POCUS) a common practice that all physicians eventually can use in the evaluation of their patients is changing the way medicine is practiced, allowing physicians to quickly obtain valuable information to complement the traditional physical examination. Despite the proven benefits of using bedside ultrasound imaging as a part of the patient evaluation and for procedure guidance, adoption of this technology still is not widespread among anesthesiology clinicians nor is there uniform teaching of ultrasound skills to anesthesia residents and faculty. Among obstacles that have been identified as precluding achievement of the goal of widespread utilization of POCUS among anesthesia professionals and trainees, are the availability of equipment for all physicians when it is needed and lack of instructor supervision for trainees who desire to use ultrasound but do not always have an instructor knowledgeable in POCUS with them when an ultrasound examination is warranted. Herein, the characteristics, advantages, and limitations of available ultra-portable, handheld ultrasound devices are analyzed, with a focus on the Butterfly iQ (Butterfly Network, Inc, Guilford, CT) pocket probe, which is available at the authors’ institution, and how some of its features, such as the capacity to emulate multiple transducers and its cloud-sharing and teleguidance technology, may contribute to increase the availability and use of POCUS by anesthesia clinicians.
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Neves SE, Fatima H, Walsh DP, Mahmood F, Chaudhary O, Matyal R. Role of Ultrasound-Guided Evaluation of Dyspnea in the Coronavirus Disease 2019 Pandemic. J Cardiothorac Vasc Anesth 2020; 34:3197-3202. [PMID: 32737001 PMCID: PMC7340068 DOI: 10.1053/j.jvca.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
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Mahmood E, Matyal R, Mahmood F, Xu X, Sharkey A, Chaudhary O, Karani S, Khabbaz K. Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery. Circulation 2020; 142:20-28. [PMID: 32489114 DOI: 10.1161/circulationaha.119.044642] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the impact of left atrial appendage (LAA) exclusion on short-term outcomes in patients with atrial fibrillation undergoing isolated coronary artery bypass graft surgery. METHODS We queried the 2010 to 2014 National Readmissions Database for patients who underwent coronary artery bypass graft repair with and without LAA ligation by using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification: 36.1xx). Only patients with a history of atrial fibrillation were included in our analysis. The primary outcome of our study was 30-day readmissions following discharge. Secondary outcomes were in-hospital mortality and stroke. To assess the postoperative outcomes, we used multivariate logistic regression models to adjust for clinical and demographic covariates. RESULTS In total, we analyzed 253 287 patients undergoing coronary artery bypass graft surgery, 7.0% of whom received LAA closure. LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P<0.0001) and acute kidney injury (21.8% versus 18.5%, P<0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with a nonsignificant reduction in stroke (7.9% versus 8.6%, P=0.12), no difference in in-hospital mortality (2.2% versus 2.2% P=0.99), and a greater risk of 30-day readmission (16.0% versus 9.6%, P<0.0001). After covariate adjustment, LAA ligation remained a significant predictor of 30-day readmission (odds ratio, 1.640 [95% CI, 1.603-1.677], P<0.0001). CONCLUSIONS LAA exclusion during isolated coronary artery bypass graft surgery in patients with atrial fibrillation is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.
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Fatima H, Matyal R, Mahmood F, Baribeau Y, Khabbaz KR. Ischemic Mitral Regurgitation: To Fix or Not to Fix. J Cardiothorac Vasc Anesth 2020; 34:2532-2535. [PMID: 32540246 DOI: 10.1053/j.jvca.2020.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/10/2020] [Accepted: 04/20/2020] [Indexed: 11/11/2022]
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Baribeau Y, Mahmood F, Sharkey A, Bortman J, Matyal R, Laham R, Mahmood F. Real-Time 3-Dimensional Transesophageal Echocardiography Imaging-Guided Percutaneous Closure of Left Ventricular to Left Atrial Fistula. A A Pract 2020; 13:473-476. [PMID: 31651413 DOI: 10.1213/xaa.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Walsh DP, Murugappan KR, Oren-Grinberg A, Wong VT, Mitchell JD, Matyal R. Tool to improve qualitative assessment of left ventricular systolic function. Echo Res Pract 2020; 7:1-8. [PMID: 32190341 PMCID: PMC7077518 DOI: 10.1530/erp-19-0053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/17/2020] [Indexed: 02/01/2023] Open
Abstract
Interactive online learning tools have revolutionized graduate medical education and can impart echocardiographic image interpretive skills. We created self-paced, interactive online training modules using a repository of echocardiography videos of normal and various degrees of abnormal left ventricles. In this study, we tested the feasibility of this learning tool. Thirteen anesthesia interns took a pre-test and then had 3 weeks to complete the training modules on their own time before taking a post-test. The average score on the post-test (74.6% ± 11.08%) was higher than the average score on the pre-test (57.7% ± 9.27%) (P < 0.001). Scores did not differ between extreme function (severe dysfunction or hyperdynamic function) and non-extreme function (normal function or mild or moderate dysfunction) questions on both the pre-test (P = 0.278) and post-test (P = 0.093). The interns scored higher on the post-test than the pre-test on both extreme (P = 0.0062) and non-extreme (P = 0.0083) questions. After using an online educational tool that allowed learning on their own time and pace, trainees improved their ability to correctly categorize left ventricular systolic function. Left ventricular systolic function is often a key echocardiographic question that can be difficult to master. The promising performance of this educational resource may lead to more time- and cost-effective methods for improving diagnostic accuracy among learners.
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Baribeau Y, Bortman J, Khamooshian A, Laham R, Mahmood F, Mahmood F, Sharkey A, Steely A, Matyal R. A 3-Dimensionally Printed, High-Fidelity Ultrasound-Guided Pericardiocentesis Training Model. J Cardiothorac Vasc Anesth 2020; 34:245-247. [DOI: 10.1053/j.jvca.2019.08.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 08/29/2019] [Indexed: 11/11/2022]
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Baribeau Y, Sharkey A, Mahmood E, Feng R, Chaudhary O, Baribeau V, Mahmood F, Matyal R, Khabbaz K. Three-Dimensional Printing and Transesophageal Echocardiographic Imaging of Patient-Specific Mitral Valve Models in a Pulsatile Phantom Model. J Cardiothorac Vasc Anesth 2019; 33:3469-3475. [DOI: 10.1053/j.jvca.2019.07.141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 11/11/2022]
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