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Vriz O, Mushtaq A, Shaik A, El-Shaer A, Feras K, Eltayeb A, Alsergnai H, Kholaif N, Al Hussein M, Albert-Brotons D, Simon AR, Tsai FW. Reciprocal interferences of the left ventricular assist device and the aortic valve competence. Front Cardiovasc Med 2023; 9:1094796. [PMID: 36698950 PMCID: PMC9870593 DOI: 10.3389/fcvm.2022.1094796] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
Patients suffering from end-stage heart failure tend to have high mortality rates. With growing numbers of patients progressing into severe heart failure, the shortage of available donors is a growing concern, with less than 10% of patients undergoing cardiac transplantation (CTx). Fortunately, the use of left ventricular assist devices (LVADs), a variant of mechanical circulatory support has been on the rise in recent years. The expansion of LVADs has led them to be incorporated into a variety of clinical settings, based on the goals of therapy for patients ailing from heart failure. However, with an increase in the use of LVADs, there are a host of complications that arise with it. One such complication is the development and progression of aortic regurgitation (AR) which is noted to adversely influence patient outcomes and compromise pump benefits leading to increased morbidity and mortality. The underlying mechanisms are likely multifactorial and involve the aortic root-aortic valve (AV) complex, as well as the LVAD device, patient, and other factors, all of them alter the physiological mechanics of the heart resulting in AV dysfunction. Thus, it is imperative to screen patients before LVAD implantation for AR, as moderate or greater AR requires a concurrent intervention at the time of LVADs implantation. No current strict guidelines were identified in the literature search on how to actively manage and limit the development and/or progression of AR, due to the limited information. However, some recommendations include medical management by targeting fluid overload and arterial blood pressure, along with adjusting the settings of the LVADs device itself. Surgical interventions are to be considered depending on patient factors, goals of care, and the underlying pathology. These interventions include the closure of the AV, replacement of the valve, and percutaneous approach via percutaneous occluding device or transcatheter aortic valve implantation. In the present review, we describe the interaction between AV and LVAD placement, in terms of patient management and prognosis. Also it is provided a comprehensive echocardiographic strategy for the precise assessment of AV regurgitation severity.
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Affiliation(s)
- Olga Vriz
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia,*Correspondence: Olga Vriz,
| | - Ali Mushtaq
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdullah Shaik
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ahmed El-Shaer
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Khalid Feras
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdalla Eltayeb
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hani Alsergnai
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Naji Kholaif
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mosaad Al Hussein
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dimpna Albert-Brotons
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Andre Rudiger Simon
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Felix Wang Tsai
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Katapadi A, Umland M, Khandheria BK. Update on the Practical Role of Echocardiography in Selection, Implantation, and Management of Patients Requiring Left Ventricular Assist Device Therapy. Curr Cardiol Rep 2022; 24:1587-1597. [PMID: 35984555 DOI: 10.1007/s11886-022-01771-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Echocardiography is a valuable tool for management of patients with a left ventricular assist device (LVAD). We present an updated review on the practical applications of the role of echocardiography for pre- and postoperative evaluation of patients selected. RECENT FINDINGS The LVAD is a temporary or permanent option for patients with advanced heart failure who are unresponsive to other therapy. Use of the device has its own risks, and implantation remains a complex procedure. Transthoracic and transesophageal echocardiography are useful tools for patient evaluation and monitoring both peri- and postoperatively, as we previously presented. Assessment of left and right ventricular function, complications such as thrombus formation or intracardiac shunting, and valvular disease are all important in this assessment. This also aids in predicting postoperative complications. Placement of the device is confirmed intraoperatively, and subsequent ramp studies are used to determine optimal device settings. Right ventricular (RV) failure is the most common postoperative complication and preoperative evaluation of its function is crucial. Studies suggest that tricuspid annular plane systolic excursion, RV fractional area change, and RV global longitudinal strain are strong predictors of RV failure; LV ejection fraction, size, and end-diastolic diameter are also important markers. Aortic regurgitation and mitral stenosis must always be corrected prior to LVAD placement. However, direct visualization before and after implantation, especially to rule out potential contraindications such as thrombi, cannot be overemphasized. Ramp studies remain an integral part of device optimization and may result in greater myocardial recovery than previously realized.
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Affiliation(s)
- Aashish Katapadi
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA
| | - Matt Umland
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA
| | - Bijoy K Khandheria
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA.
- School of Medicine and Public Health, University of Wisconsin, Milwaukee, WI, 53215, USA.
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Menon P, Kapoor PM, Choudhury M. Echocardiography for Left Ventricular Assist Device Patients. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1757363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
AbstractHeart transplantation is the only cure for patients with end-stage heart failure; the shortage of donors has led to a high mortality rate among these patients. A left ventricular assist device (LVAD) is a device to provide mechanical circulatory support for patients unresponsive to heart failure therapy. Echocardiography should be considered an indispensable tool in the evaluation of patients with an LVAD. In fact, as outlined in this review, it provides useful and readily available information that could be crucial for the patient's survival. In the preoperative assessment, it is important to detect through echocardiography conditions and parameters that could hint the development of a postoperative complication, in order to treat them before LVAD implant or to consider the patient ineligible to this advanced treatment.
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Affiliation(s)
- Priya Menon
- Cardiac Anaesthesia and Critical Care, CTC, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Poonam Malhotra Kapoor
- Cardiac Anaesthesia and Critical Care, CTC, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Minati Choudhury
- Cardiac Anaesthesia and Critical Care, CTC, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Echocardiography for left ventricular assist device implantation and evaluation: an indispensable tool. Heart Fail Rev 2021; 27:891-902. [PMID: 33428013 DOI: 10.1007/s10741-021-10073-1] [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] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
Echocardiography is an indispensable tool in the evaluation, placement, management and follow-up of patients with left ventricular assist devices (LVAD). While transoesophageal echocardiography is the ideal tool in guiding the implantation procedure, transthoracic echocardiography is essential during the initial evaluation, patient selection and in the post-operative follow-up. This review attempts to summarize which parameters the echocardiographic assessment should focused on during each step. In particular, during the pre-operative assessment, it is of paramount importance to assess the presence of aortic regurgitation and most importantly to evaluate right ventricular function, since it is one of the strongest predictor of post-implant right ventricular failure. During the procedure, through transoesophageal echocardiography, it is possible to confirm the correct placement of the inflow cannula, to assess right ventricular function and to guide the choice of the right pump speed. Transthoracic echocardiographic is an essential part in the patient's follow-up once the LVAD has been implanted, in order to attest the onset of possible complications.
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Turner KR. Right Ventricular Failure After Left Ventricular Assist Device Placement—The Beginning of the End or Just Another Challenge? J Cardiothorac Vasc Anesth 2019; 33:1105-1121. [DOI: 10.1053/j.jvca.2018.07.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Indexed: 12/19/2022]
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Birati EY, Hanff TC, Maldonado D, Grandin EW, Kennel PJ, Mazurek JA, Vorovich E, Seigerman M, Howard JLL, Acker MA, Naka Y, Wald J, Goldberg LR, Jessup M, Atluri P, Margulies KB, Schulze PC, Rame JE. Predicting Long Term Outcome in Patients Treated With Continuous Flow Left Ventricular Assist Device: The Penn-Columbia Risk Score. J Am Heart Assoc 2018. [PMID: 29514805 PMCID: PMC5907534 DOI: 10.1161/jaha.117.006408] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Predicting which patients are unlikely to benefit from continuous flow left ventricular assist device (LVAD) treatment is crucial for the identification of appropriate patients. Previously developed scoring systems are limited to past eras of device or restricted to specific devices. Our objective was to create a risk model for patients treated with continuous flow LVAD based on the preimplant variables. Methods and Results We performed a retrospective analysis of all patients implanted with a continuous flow LVAD between 2006 and 2014 at the University of Pennsylvania and included a total of 210 patients (male 78%; mean age, 56±15; mean follow‐up, 465±486 days). From all plausible preoperative covariates, we performed univariate Cox regression analysis for covariates affecting the odds of 1‐year survival following implantation (P<0.2). These variables were included in a multivariable model and dropped if significance rose above P=0.2. From this base model, we performed step‐wise forward and backward selection for other covariates that improved power by minimizing Akaike Information Criteria while maximizing the Harrell Concordance Index. We then used Kaplan–Meier curves, the log‐rank test, and Cox proportional hazard models to assess internal validity of the scoring system and its ability to stratify survival. A final optimized model was identified based on clinical and echocardiographic parameters preceding LVAD implantation. One‐year mortality was significantly higher in patients with higher risk scores (hazard ratio, 1.38; P=0.004). This hazard ratio represents the multiplied risk of death for every increase of 1 point in the risk score. The risk score was validated in a separate patient cohort of 260 patients at Columbia University, which confirmed the prognostic utility of this risk score (P=0.0237). Conclusion We present a novel risk score and its validation for prediction of long‐term survival in patients with current types of continuous flow LVAD support.
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Affiliation(s)
- Edo Y Birati
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Thomas C Hanff
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dawn Maldonado
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - E Wilson Grandin
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Peter J Kennel
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Jeremy A Mazurek
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Esther Vorovich
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew Seigerman
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jessica L L Howard
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yoshifumi Naka
- Division of Cardiovascular Surgery, Columbia University Medical Center, New York, NY
| | - Joyce Wald
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee R Goldberg
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mariell Jessup
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kenneth B Margulies
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - P Christian Schulze
- Division of Cardiology, Columbia University Medical Center, New York, NY.,Division of Cardiology, Department of Internal Medicine I, Friedrich Schiller University, Jena, Germany
| | - J Eduardo Rame
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Role of Echocardiography in the Evaluation of Left Ventricular Assist Devices: the Importance of Emerging Technologies. Curr Cardiol Rep 2017; 18:62. [PMID: 27216842 DOI: 10.1007/s11886-016-0739-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The role of left ventricular assist devices (LVAD) in patients with end-stage heart failure is well known, both as a temporary treatment before transplantation and as destination therapy, in a scenario of a relative shortage of donors to satisfy the increasing requests for transplantation. The increased population of LVAD patients needs careful imaging assessment before, during, and after LVAD implantation; echocardiography is the best tool for their evaluation and is considered the diagnostic technique of choice for the assessment before, during, and after device implantation. Although the conventional echocardiographic assessment is quite effective in evaluating the main critical issues, the role of new technologies like three-dimensional echocardiography and myocardial deformation measurements is still not properly clarified. In this review, we aim to provide an overview of the main elements that should be considered in the assessment of these patients, underlining the role that could be played by new techniques to improve the diagnostic and prognostic effectiveness of echocardiography in this setting.
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Matzke-Ogi A, Jannasch K, Shatirishvili M, Fuchs B, Chiblak S, Morton J, Tawk B, Lindner T, Sansom O, Alves F, Warth A, Schwager C, Mier W, Kleeff J, Ponta H, Abdollahi A, Orian-Rousseau V. Inhibition of Tumor Growth and Metastasis in Pancreatic Cancer Models by Interference With CD44v6 Signaling. Gastroenterology 2016; 150:513-25.e10. [PMID: 26597578 DOI: 10.1053/j.gastro.2015.10.020] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 10/12/2015] [Accepted: 10/13/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Cancer cells with high metastatic potential and stem cell-like characteristics express the cell surface marker CD44. CD44 isoforms that include the v6 exon are co-receptors for the receptor tyrosine kinases MET and Vascular Endothelial Growth factor Receptor-2 (VEGFR-2). We studied CD44v6 signaling in several pancreatic cancer cell lines, and its role in tumor growth and metastasis in several models of pancreatic cancer. METHODS We analyzed the effects of v6 peptides that interfere with the co-receptor functions of CD44v6 for MET and VEGFR-2 in tumors and metastases grown from cells that express different CD44 isoforms, including CD44v6. The peptides were injected into rats with syngeneic tumors and mice with orthotopic or xenograft tumors. We also tested the effects of the peptides in mice with xenograft tumors grown from patient tumor samples and mice that express an oncogenic form of RAS and develop spontaneous pancreatic cancer (KPC mice). We measured levels of CD44v6 messenger RNA (mRNA) in pancreatic cancer tissues from 136 patients. RESULTS Xenograft tumors grown from human cancer cells injected with v6 peptides were smaller and formed fewer metastases in mice. The v6 peptide was more efficient than the MET inhibitor crizotinib and/or the VEGFR-2 inhibitor pazopanib in reducing xenograft tumor growth and metastasis. Injection of KPC mice with the v6 peptide increased their survival time. Injection of mice and rats bearing metastases with the v6 peptide induced regression of metastases. Higher levels of CD44v6 mRNA in human pancreatic tumor tissues were associated with increased expression of MET, tumor metastasis, and shorter patient survival times. CONCLUSIONS Peptide inhibitors of CD44v6 isoforms block tumor growth and metastasis in several independent models of pancreatic cancer. The v6 peptides induced regression of metastases. Levels of CD44v6 mRNA are increased, along with those of MET mRNA, in patients with metastatic pancreatic tumors, compared with nonmetastatic tumors; the increased levels correlated with shorter patient survival time.
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Affiliation(s)
- Alexandra Matzke-Ogi
- Karlsruhe Institute of Technology, Institute of Toxicology and Genetics, Eggenstein-Leopoldshafen, Germany; Amcure GmbH, Eggenstein-Leopoldshafen, Germany
| | - Katharina Jannasch
- Department of Hematology and Oncology, University Medicine Göttingen, Göttingen, Germany
| | - Marine Shatirishvili
- Karlsruhe Institute of Technology, Institute of Toxicology and Genetics, Eggenstein-Leopoldshafen, Germany
| | - Beatrix Fuchs
- Karlsruhe Institute of Technology, Institute of Toxicology and Genetics, Eggenstein-Leopoldshafen, Germany
| | - Sara Chiblak
- Molecular and Translational Radiation Oncology, Heidelberg Institute of Radiation Oncology, University of Heidelberg Medical School and German Cancer Research Center, Heidelberg, Germany; The German Cancer Consortium, Heidelberg, Germany
| | - Jennifer Morton
- Cancer Research UK Beatson Institute, Glasgow, United Kingdom
| | - Bouchra Tawk
- Molecular and Translational Radiation Oncology, Heidelberg Institute of Radiation Oncology, University of Heidelberg Medical School and German Cancer Research Center, Heidelberg, Germany; The German Cancer Consortium, Heidelberg, Germany
| | - Thomas Lindner
- Department of Nuclear Medicine, University of Heidelberg, Heidelberg, Germany
| | - Owen Sansom
- Cancer Research UK Beatson Institute, Glasgow, United Kingdom
| | - Frauke Alves
- Department of Hematology and Oncology, University Medicine Göttingen, Göttingen, Germany
| | - Arne Warth
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Schwager
- Molecular and Translational Radiation Oncology, Heidelberg Institute of Radiation Oncology, University of Heidelberg Medical School and German Cancer Research Center, Heidelberg, Germany; The German Cancer Consortium, Heidelberg, Germany
| | - Walter Mier
- Department of Nuclear Medicine, University of Heidelberg, Heidelberg, Germany
| | - Jörg Kleeff
- Department of Surgery, Technische Universität München, Munich, Germany
| | | | - Amir Abdollahi
- Molecular and Translational Radiation Oncology, Heidelberg Institute of Radiation Oncology, University of Heidelberg Medical School and German Cancer Research Center, Heidelberg, Germany; The German Cancer Consortium, Heidelberg, Germany
| | - Véronique Orian-Rousseau
- Karlsruhe Institute of Technology, Institute of Toxicology and Genetics, Eggenstein-Leopoldshafen, Germany.
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Flores AS, Essandoh M, Yerington GC, Bhatt AM, Iyer MH, Perez W, Davila VR, Tripathi RS, Turner K, Dimitrova G, Andritsos MJ. Echocardiographic assessment for ventricular assist device placement. J Thorac Dis 2016; 7:2139-50. [PMID: 26793334 DOI: 10.3978/j.issn.2072-1439.2015.10.69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
While many factors depend on successful implantation and outcome of left ventricular assist devices (LVAD), echocardiography remains an integral part and is vital to the success of this process. Transesophageal echocardiography (TEE) allows interrogation of all the cardiac structures and great vessels. The pre-implantation TEE exam establishes a baseline and may identify potential problems that need palliation. Among these, most significant are aortic insufficiency (AI), intracardiac thrombi, poor right ventricular (RV) function, and intracardiac shunts. The post-implantation exam allows for adequate de-airing of the heart and successful LVAD initiation. The position and flow profiles of the inflow and outflow cannulas of the LVAD may be assessed. Finally, it assists in the astute management and vigilant identification and correction of a number of complications in the immediate post-implantation period. TEE will continue to remain vital to the successful outcomes LVAD patients.
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Affiliation(s)
- Antolin S Flores
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Michael Essandoh
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Gregory C Yerington
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Amar M Bhatt
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Manoj H Iyer
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - William Perez
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Victor R Davila
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Ravi S Tripathi
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Katja Turner
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Galina Dimitrova
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Michael J Andritsos
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
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