Intracardiac Echocardiography in Structural Heart Disease Interventions

Intracardiac echocardiography has historically been used to guide a limited number of transcatheter cardiac interventions. However, the tremendous advances in structural heart disease interventions in the last decade led to a growing interest in intracardiac echocardiography as a potential alternative to transesophageal echocardiography that mitigates the need for endotracheal intubation. Nonetheless, the scarcity of data, the imperfection of the current probes, and the limited experience among operators prevented a wider adoption of this technology. This review summarizes the contemporary relevant evidence and provides the structural interventionalist with an illustrative guide on the use of intracardiac echocardiography to guide various structural heart interventions.     

Bispectral Index Monitoring for Nurse-Administered Propofol Sedation During Upper Endoscopic Ultrasound: A Prospective,Randomized Controlled Trial

Bispectral index monitoring (BIS) is a quantitative assessment of brain cortical activity. The aim of this study was to determine if BIS-guided nurse-administered propofol sedation would decrease by >/=20% both recovery time and propofol dose compared to standard propofol sedation for endoscopic ultrasound (EUS). Prospectively, eligible outpatients were randomized to BIS-guided or standard propofol sedation during EUS. Propofol was given by nurses in intermittent boluses with sedation targeted at a BIS score of <65-75. For the control group, the nurse was blinded to BIS scores and sedation was titrated to a modified observer's assessment of alertness/sedation scale (MOAA/S) score 相似文献   

Sedation and monitoring for gastrointestinal endoscopy

The safe sedation of patients for diagnostic or therapeutic procedures requires a combination of properly trained physicians and suitable facilities.Additionally,appropriate selection and preparation of patients,suitable sedative technique,application of drugs,adequate monitoring,and proper recovery of patients is essential.The goal of procedural sedation is the safe and effective control of pain and anxiety as well as to provide an appropriate degree of memory loss or decreased awareness.Sedation practices for gastrointestinal endoscopy(GIE) vary widely.The majority of GIE patients are ambulatory cases.Most of this procedure requires a short time.So,short acting,rapid onset drugs with little adverse effects and improved safety profiles are commonly used.The present review focuses on commonly used regimens and monitoring practices in GIE sedation.This article is to discuss the decision making process used to determine appropriate pre-sedation assessment,monitoring,drug selection,dose of sedative agents,sedation endpoint and post-sedation care.It also reviews the current status of sedation and monitoring for GIE procedures in Thailand.     

Artificial Intelligence and Transcatheter Interventions for Structural Heart Disease: A glance at the (near) future

With innovations in therapeutic technologies and changes in population demographics, transcatheter interventions for structural heart disease have become the preferred treatment and will keep growing. Yet, a thorough clinical selection and efficient pathway from diagnosis to treatment and follow-up are mandatory. In this review we reflect on how artificial intelligence may help to improve patient selection, pre-procedural planning, procedure execution and follow-up so to establish efficient and high quality health care in an increasing number of patients.     

Fluoroscopic Anatomy of Right-Sided Heart Structures for Transcatheter Interventions

Performing transcatheter tricuspid valve interventions requires a thorough knowledge of right-heart imaging. Integration of chamber views across the spectrum of imaging modalities (i.e., multislice computed tomography, fluoroscopy, and echocardiography) can facilitate transcatheter interventions on the right heart. Optimal fluoroscopic viewing angles for guiding interventional procedures can be obtained using pre-procedural multislice computed tomography scans. The present paper describes fluoroscopic viewing angles necessary to appreciate right-heart chamber anatomy and their relationship to echocardiography using multislice computed tomography.     

Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: A large single-center retrospective review

BACKGROUNDForeign object ingestion (FOI) and food bolus impaction (FBI) are common causes of emergent endoscopic intervention. The choice of sedation used is often dictated by physician experience. Many endoscopists frequently prefer to use monitored anesthesia care (MAC) and general anesthesia (GA) as opposed to conscious sedation (CS) due to the concern for inadequate airway protection. However, there is insufficient data examining the safety of different sedation modalities in emergent endoscopic management of FOI and FBI.AIMTo investigate the complication rates of emergent endoscopic extraction performed under different sedation modalities.METHODSWe conducted a retrospective chart review of patients presenting with acute FBI and FOI between 2010 and 2018 in two hospitals. A standardized questionnaire was utilized to collect data on demographics, endoscopic details, sedation practices, hospital stay and adverse events. Complications recognized during and within 24 h of the procedure were considered early, whereas patients presenting with a procedure-related adverse event within two weeks of the index event were considered delayed complications. Complication rates of patients who underwent emergent endoscopic retrieval were compared based on sedation types, namely CS, MAC and GA. Chi-square analysis and multiple logistic regression were used to compare complication rate based on sedation type.RESULTSAmong the 929 procedures analyzed, 353 procedures (38.0%) were performed under CS, 278 procedures (29.9%) under MAC and the rest (32.1%) under GA. The median age of the subjects was 52 years old, with 57.4% being male. The majority of the procedures (64.3%) were FBI with the rest being FOI (35.7%). A total of 132 subjects (14.2%) had chronic comorbidities while 29.0% had psychiatric disorders. The most commonly observed early complications were mucosal laceration (3.8%) and bleeding (2.6%). The most common delayed complication was aspiration pneumonia (1.8%). A total of 20 patients (5.6%) could not adequately be sedated with CS and had to be converted to MAC or GA. Patient sedated with MAC and GA were more likely to require hospitalization, P < 0.0001. Analysis revealed no statistically significant difference in the complication rate between patients sedated under CS (14.7%), MAC (14.7%) and GA (19.5%), P = 0.19.CONCLUSIONFor patients who present with FOI or FBI and undergo emergent endoscopic treatment, there is no significant difference in adverse event rates between CS, MAC and GA.     

Implementation of Real Time Three-Dimensional Transesophageal Echocardiography in Percutaneous Mitral Balloon Valvuloplasty and Structural Heart Disease Interventions

Percutaneous interventions for structural heart disease are performed in a dynamic and complex environment that necessitates multiple imaging modalities to achieve procedural success. Structural interventions are routinely guided by two-dimensional (2D) modalities such as x-ray fluoroscopy, transesophageal echocardiography (TEE), and intracardiac echocardiography. Real time imaging with three-dimensional (3D) echocardiography is a novel method of guidance to facilitate complex structural interventions with the promise of greater safety and efficacy. Real time 3D TEE (RT3D-TEE) affords the capability of imaging catheters and devices, the interventional objective, and adjacent structures simultaneously. We present an overview of RT3D-TEE and explore its functionality in structural heart interventions by using percutaneous mitral balloon valvuloplasty as a model.     

Semilunar Valve Interventions for Congenital Heart Disease: JACC State-of-the-Art Review

Transcatheter balloon valvuloplasty for the treatment of aortic and pulmonary valve stenosis was first described nearly 40 years ago. Since that time, the technique has been refined in an effort to optimize acute outcomes while reducing the long-term need for reintervention and valve replacement. Balloon pulmonary valvuloplasty is considered first-line therapy for pulmonary valve stenosis and generally results in successful relief of valvar obstruction. Larger balloon to annulus (BAR) diameter ratios can increase the risk for significant valvar regurgitation. However, the development of regurgitation resulting in right ventricular dilation and dysfunction necessitating pulmonary valve replacement is uncommon in long-term follow-up. Balloon aortic valvuloplasty has generally been the first-line therapy for aortic valve stenosis, although some contemporary studies have documented improved outcomes following surgical valvuloplasty in a subset of patients who achieve tri-leaflet valve morphology following surgical repair. Over time, progressive aortic regurgitation is common and frequently results in the need for aortic valve replacement. Neonates with critical aortic valve stenosis remain a particularly high-risk group. More contemporary data suggest that acutely achieving an aortic valve gradient <35 mm Hg with mild aortic regurgitation may improve long-term valve performance and reduce the need for valve replacement. Continued study will help to further improve outcomes and reduce the need for future reinterventions.     

Coronary and Structural Heart Disease Interventions During COVID-19 Pandemic: A Road Map for Clinicians and Health Care Delivery Systems

BackgroundBecause of the COVID-19 pandemic, cath labs have had to modify their workflow for elective and urgent patients.MethodsWe surveyed 16 physicians across 3 hospitals in our healthcare system to address COVID-19 related concerns in the management of interventional and structural heart disease patients, and to formulate system wide criteria for deferring cases till after the pandemic.ResultsOur survey yielded common concerns centered on the need to protect patients, cath lab staff and physicians from unnecessary exposure to COVID-19; for COVID-19 testing prior to arrival to the cath lab; for clear communication between the referring physician and the interventionalist; but there was initial uncertainty among physicians regarding the optimal management of ST elevation myocardial infarction (STEMI; percutaneous coronary intervention versus thrombolytics). Patients with stable angina and hemodynamically stable acute coronary syndromes were deemed suitable for initial medical management, except when they had large ischemic burden. Most transcatheter aortic valve implantations (TAVI) were felt appropriate for postponement except in symptomatic patients with aortic valve area <0.5 cm² or recent hospitalization for heart failure (HF). Most percutaneous mitral valve repair (pMVR) procedures were felt appropriate for postponement except in patients with HF. All left atrial appendage closure (LAAC) and patent foramen ovale (PFO)/atrial septal defect (ASD) closure procedures were felt appropriate for postponement.ConclusionOur survey of an experienced team of clinicians yielded concise guidelines to direct the management of CAD and structural heart disease patients during the initial phases of the COVID-19 pandemic.     

Stepwise sedation for elderly patients with mild/moderate COPD during upper gastrointestinal endoscopy

AIM: To investigate stepwise sedation for elderly patients with mild/moderate chronic obstructive pulmonary disease (COPD) during upper gastrointestinal (GI) endoscopy. METHODS: Eighty-six elderly patients with mild/moderate COPD and 82 elderly patients without COPD scheduled for upper GI endoscopy were randomly assigned to receive one of the following two sedation methods: stepwise sedation involving three-stage administration of propofol combined with midazolam [COPD with stepwise sedation (group Cs), and nonCOPD with stepwise sedation (group Ns)] or continuous sedation involving continuous administration of propofol combined with midazolam [COPD with continuous sedation (group Cc), and non-COPD with continuous sedation (group Nc)]. Saturation of peripheral oxygen (SpO 2 ), blood pressure, and pulse rate were monitored, and patient discomfort, adverse events, drugs dosage, and recovery time were recorded. RESULTS: All endoscopies were completed successfully. The occurrences of hypoxemia in groups Cs, Cc, Ns, and Nc were 4 (9.3%), 12 (27.9%), 3 (7.3%), and 5 (12.2%), respectively. The occurrence of hypoxemia in group Cs was significantly lower than that in group Cc (P < 0.05). The average decreases in value of SpO 2 , systolic blood pressure, and diastolic blood pressure in group Cs were significantly lower than those in group Cc. Additionally, propofol dosage and overall rate of adverse events in group Cs were lower than those in group Cc. Finally, the recovery time in group Cs was significantly shorter than that in group Cc, and that in group Ns was significantly shorter than that in group Nc (P < 0.001). CONCLUSION: The stepwise sedation method is effective and safer than the continuous sedation method for elderly patients with mild/moderate COPD during upper GI endoscopy.     

Home Videoconferencing for Patients with Severe Congential Heart Disease Following Discharge

Background. Centralization of pediatric cardiology services into a small number of tertiary centers and the particular stress that accompanies diagnosis and surgical management of severe congenital heart disease (CHD) renders psychological support for families and clinical monitoring of patients following discharge increasingly important. Telemedicine has an increasing role in clinical and academic medicine. Improvements in quality and reliability of videoconferencing systems have allowed this to become a useful diagnostic tool. Objective. This study aimed to assess the benefits of home monitoring by videoconferencing compared with contacting by telephone only, in terms of decreasing anxiety levels and clinical monitoring in the postdischarge period. Methods. We performed a prospective, controlled study of children with a recent diagnosis of severe CHD and those recovering from palliative or corrective surgery for severe CHD. We used standardized anxiety scores to assess anxiety after discharge in families followed up by home videoconferencing or telephone calls and assessed the clinical information available through videoconferencing or telephone calls by structured questionnaires. Results. Videoconferencing decreased anxiety levels compared with telephone calls (P < .05). Improved clinical information was available in the videoconferencing group, resulting in more appropriate and timely hospital attendance. Conclusion. Videoconferencing is acceptable to parents and physicians and provides a more effective form of follow‐up in terms of clinical observation and parental anxiety levels.