BackgroundPatients with severe aortic stenosis (AS) at high risk for aortic valve replacement are a unique population with multiple treatment options, including medical therapy, surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR). Traditionally, in elderly populations, goals of treatment may favour quality of life over survival. Professional guidelines recommend that clinicians engage patients in shared decision making, a process that may lead to decisions more aligned with patient‐defined goals of care. Goals of care for high‐risk patients with AS are not well defined in the literature, and patient‐reported barriers to shared decision making highlight the need for explicit encouragement from clinicians for patient involvement.ObjectiveThe purpose of this study was to elicit and report patient‐defined goals from elderly patients facing treatment decisions for severe AS.MethodsThis analysis was conducted at Dartmouth‐Hitchcock Medical Center, an academic medical institution. In a retrospective manner, we qualitatively analysed goal statements reported by high‐risk, elderly patients with severe AS evaluated for TAVR between June 2012 and August 2014.ResultsForty‐six patients provided treatment goals during consideration of TAVR and defined preferred outcomes as maintaining independence, staying alive, reducing symptoms or, most commonly, increasing their ability to do a specific activity or hobby.ConclusionsIn the high‐risk patient population considering TAVR, patient‐reported goals may be obtained with a simple question delivered during the clinical encounter. Encouraging patients to define their goals may lead to a greater degree of shared decision making, as advocated in current professional guidelines.

Based on high quality evidence, prophylactic propofol appears to be effective for reducing the incidence and severity of EA in children emerging from general anesthesia.

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IMPORTANCE Shared decision-making (SDM) is widely advocated for patients with valvular heart disease yet is not integrated into the heart team model for patients with symptomatic aortic stenosis. Decision aids (DAs) have been shown to improve patient-centered outcomes and may facilitate SDM.OBJECTIVE To determine whether the repeated use of a DA by heart teams is associated with greater SDM, along with improved patient-centered outcomes and clinician attitudes about DAs. DESIGN, SETTING, AND PARTICIPANTSThis mixed-methods study included a nonrandomized pre-post intervention and clinician interviews. It was conducted between April 30, 2015, and December 7, 2017, with quantitative analysis performed between January 12, 2017, and May 26, 2017, within 2 academic medical centers in northern New England among 35 patients with symptomatic aortic stenosis who were at high to prohibitive risk for surgery. The qualitative analysis was performed between August 6, 2018, and May 7, 2019. The Severe Aortic Stenosis Decision Aid was delivered by 6 clinicians, with patients choosing between transcatheter aortic valve replacement and medical management.MAIN OUTCOMES AND MEASURES Clinician SDM performance was measured using the Observer OPTION 5 scale with dual-independent coding of audiotaped clinic visits. Previsit and postvisit surveys measured the patient's knowledge, satisfaction, and decisional conflict. Audiotaped clinician interviews were coded, and qualitative thematic analysis was performed.RESULTS Six male clinicians and 35 patients (19 of 34 women [55.9%; 1 survey was missing]; mean [SD] age, 85.8 [7.8] years) participated in the study. Shared decision-making increased stepwise with repeated use of the DA (mean [SD] Observer OPTION 5 scores: usual care, 17.9 [7.6]; first use of a DA, 60.5 [30.9]; fifth use of a DA, 79.0 [8.4]; P < .001 for comparison between usual care and fifth use of DA). Multiple uses of the DA were associated with increased patient knowledge (mean difference, 18.0%; 95% CI, 1.2%-34.8%; P = .04) and satisfaction (mean difference, 6.7%; 95% CI, 2.5%-10.8%; P = .01) but not decisional conflict (mean [SD]: usual care, 96.0% [9.4%]; first use of DA, 93.8% [12.5%]; fifth use of DA, 95.0% [11.2%]; P = .60). Qualitative analysis of clinicians' interviews revealed that clinicians perceived that they used an SDM approach without DAs and that the DA was not well understood by elderly patients. There was infrequent values clarification or discussion of stroke risk. CONCLUSION AND RELEVANCEIn a mixed-methods pilot study, use of a DA for severe aortic stenosis by heart team clinicians was associated with improved SDM and patient-centered outcomes. However, in qualitative interviews, heart team clinicians did not perceive a significant benefit of the DA, and therefore sustained implementation is unlikely. This pilot study of SDM clarifies new research directions for heart teams.

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Many patients with severe mitral regurgitation cannot undergo conventional mitral valve surgery due to prohibitive surgical risk and are candidates for transcatheter repair with an edge-to-edge technique. Prior reports suggest efficacy with this approach for mitral regurgitation due to hypertrophic cardiomyopathy with left ventricular outflow obstruction. We present a case report of transcatheter mitral valve repair for posterior leaflet prolapse with concomitant left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve in the absence of hypertrophic cardiomyopathy.

Tailoring of lectures for non-physician audiences may be beneficial given differences in baseline knowledge. More emphasis is needed on statin use for all providers and on smoking cessation and treatment of hypertension for nurses, students, and other healthcare professionals.

Volume 149, Number 4 • Viewpoints 837e Medicaid Services, relative value units dictate the exact dollar amount reimbursed to providers for any given medical service or procedure. We sought to identify and describe trends in Medicare reimbursement for microsurgery procedures from 2007 to 2020 in comparison to inflation. This study conformed to the Declaration of Helsinki's ethical principles for medical research.We identified Current Procedural Terminology (CPT) codes pertaining to procedures that utilize commonly performed microsurgical techniques (Table 1). Using the Physician Fee Schedule Look-Up Tool, available through the Centers for Medicare and Medicaid Services, we gathered relevant data around the relative value units for work, practice expense, and professional liability insurance as well as the conversion factors for each microsurgical CPT code from 2007 to 2020. Inflation data, as well as the general consumer price index, were obtained through the U.S. Department of Labor; these data are freely accessible through the Bureau of Labor Statistics. We utilized descriptive statistics as described in our previous publication. 2 We found that Medicare reimbursement for the 34 included codes increased, on average, by 2.28 percent from 2007 to 2020. The range of unadjusted difference in reimbursement was wide (−22 percent to +24 percent). The consumer price index changed by 27 percent from 2007 to 2020, according to the U.S. Department of Labor. After adjusting for changes in inflation rate, we found that Medicare reimbursement decreased by 1.74 percent annually, on average. Relative differences in overall reimbursement decreased for the included CPT codes from 2007 to 2020 by 19.97 percent, on average, when we adjusted for inflation (Table 2). In the included years, physician work, practice expense, and professional liability insurance relative value units increased (work, 0.59 percent; facility, 11.00 percent; malpractice, 96.13 percent). The change in conversion factor was −4.78 percent across the study period.Our results demonstrate that Medicare reimbursement rates for microsurgery are lagging behind consumer price index inflation. A recent study showed that microsurgical procedures are profitable for hospitals while reimbursement rates remain low for physicians by looking at projected Medicare payments to the surgeon and hospital for head and neck reconstructive microsurgery procedures 3 ; similar trends for low reimbursement for breast reconstruction have also been demonstrated. 4 The effects of inflation on Medicare reimbursement may also particularly affect microsurgical procedures, which have an added layer of complexity due to coding rules and bundling of the reimbursements for both the procedure and the use of the operating microscope. It is crucial for these data to be readily available to physicians given that Medicare may now include certain patients under age 65. Microsurgical procedures are performed on patients of all ages, so understanding these trends is particularly important in this con...