Search Results (100)

Background: In recent years, multiple transcatheter devices have been developed for tricuspid valve intervention. The aim of this study was to evaluate acute tricuspid annular remodeling following percutaneous leaflet repair using a leaflet approximation device for the reduction of tricuspid regurgitation (TR). Methods: This retrospective cohort study included 26 consecutive patients treated at two centers. Tricuspid annular geometry was assessed using three-dimensional transesophageal echocardiography during the procedure. Results: The mean age of the cohort was 79.3 years, and 88.5% were female. All patients had severe or greater TR pre-procedure, mostly due to annular dilation. The procedure was successful in all cases, with at least a one-grade reduction in TR observed prior to hospital discharge. Significant reductions were observed in the mean septal-lateral diameter (4.09 ± 0.44 cm vs. 3.54 ± 0.53 cm, p < 0.0001), mean major diameter (4.65 ± 0.63 cm vs. 4.28 ± 0.65 cm, p = 0.0002), planimetric area (14.00 ± 2.91 cm² vs. 11.25 ± 2.91 cm², p < 0.0001), and perimeter (13.62 ± 1.43 cm vs. 12.42 ± 1.62 cm, p < 0.0001) of the tricuspid annulus. Conclusions: In this small real-world cohort, transcatheter edge-to-edge repair was found to be both effective and safe. The use of a leaflet approximation device not only reduced TR severity but also led to significant reductions in annular dimensions. To our knowledge, this study provides additional evidence of acute tricuspid annulus remodeling following edge-to-edge repair, which may have significant therapeutic implications. Full article

The increasing interest in tricuspid regurgitation (TR) is due to the deep link between mortality and the severity of TR, as well as the limited application of surgical solutions in a setting marked by high in-hospital mortality, attributed to the late presentation of the disease. This delay in intervention is likely associated with a limited understanding of valvular and ventricular anatomy as well as the pathophysiology of the disease, leading to an underestimation of TR severity. With the rapid development of transcatheter solutions showing early safety and efficacy, there is a growing necessity to accurately understand and diagnose the valvular disease process to determine suitable management strategies. This review will outline the normal and pathological anatomy of the tricuspid valve, classify the anatomical substrates of TR, and present new risk stratification methods to determine the appropriate timing for both medical and surgical treatment. Full article

Aims: The global prevalence of pulmonary hypertension (PHT) among the elderly population aged 65 years and above is estimated to be 10%. While it is known to be associated with poor prognoses in patients with cardiovascular or pulmonary diseases, the significance of PHT as an incidental finding among individuals without these conditions remains unclear. The aim of this study was to investigate the relationship between incidental PHT detected by echocardiography and long-term all-cause mortality in patients without known cardiovascular or pulmonary diseases. Methods and Results: This retrospective, single-center cohort study included 8283 patients who underwent two consecutive echocardiographic examinations evaluating pulmonary pressure by assessing the maximal velocity of the tricuspid regurgitation jet. In total, 1705 (20.6%) patients were found to have PHT during the first echocardiography. Using a Cox proportional hazard model for all-cause mortality, PHT was found to be a significant and independent risk factor for all-cause mortality, increasing the risk by 34% (Adj. HR—1.34, 95% CI 1.21–1.47, p < 0.001). There was a direct relationship between PHT severity and long-term all-cause mortality, with patients with severe PHT having a two-fold higher risk compared to those with normal pulmonary blood pressure (Adj. HR—2, 95% CI: 1.58–2.54, p < 0.001). A “cutoff point” of sPAP > 40 mmHg was established, where pulmonary pressure values remained high and even worsened over time (p < 0.001). Conclusions: The incidental diagnosis of PHT by echocardiography in patients without known cardiovascular or pulmonary diseases is an independent risk factor for long-term all-cause mortality. Patients with sPAP ≥ 40 mmHg warrant a comprehensive clinical assessment. Full article

Over the last ten years, transcatheter tricuspid valve interventions (TTVIs) have emerged as effective options for symptomatic patients with moderate-to-severe tricuspid regurgitation (TR) who are at prohibitive surgical risk. Successful application of these therapies depends on a patient-tailored, multimodal imaging workflow. Transthoracic and transesophageal echocardiography remain the first-line diagnostic tools, rapidly stratifying TR severity, mechanism, and right ventricular function, and identifying cases requiring further evaluation. Cardiac computed tomography (CT) then provides anatomical detail—quantifying tricuspid annular dimension, leaflet tethering, coronary artery course, and venous access anatomy—to refine candidacy and simulate optimal device sizing and implantation angles. In patients with suboptimal echocardiographic windows or equivocal functional data, cardiovascular magnetic resonance (CMR) offers gold-standard quantification of RV volumes, ejection fraction, regurgitant volume, and tissue characterization to detect fibrosis. Integration of echo-derived parameters, CT anatomical notes, and CMR functional assessment enables the heart team to better select patients, plan procedures, and determine the optimal timing, thereby maximizing procedural success and minimizing complications. This review describes the current strengths, limitations, and future directions of multimodality imaging in comprehensive evaluations of TTVI candidates. Full article

Background: Coronary heart disease (CHD) remains the most prevalent pathology within the circulatory system. Among its chronic complications, ischemic mitral valve regurgitation (IMR) is observed in approximately 15% of patients with sustained myocardial ischemia. The presence of this complex valvular defect significantly increases both overall mortality and the incidence of adverse cardiovascular events. Notably, the presence of moderate to severe mitral regurgitation in patients undergoing surgical revascularization has been shown to double the risk of death. Despite the well-established etiology of IMR, data regarding the efficacy of surgical interventions and the determinants of postoperative outcomes remain inconclusive. Methods: The objective of the present study was to evaluate both early and long-term outcomes of surgical treatment of mitral regurgitation in patients undergoing coronary artery bypass grafting (CABG) due to ischemic heart disease. Particular attention was given to the influence of the severity of regurgitation, left ventricular ejection fraction (LVEF), and the dimensions of the left atrium (LA) and left ventricle (LV) on the postoperative prognosis. An additional aim was to identify preoperative risk factors associated with increased postoperative mortality and morbidity. A retrospective analysis was conducted on 421 patients diagnosed with ischemic mitral regurgitation who underwent concomitant mitral valve surgery and CABG. Exclusion criteria included emergent and urgent procedures as well as non-ischemic etiologies of mitral valve dysfunction. Results: The study cohort comprised 34.9% women and 65.1% men, with the mean age of 65.7 years (±7.57). A substantial proportion (76.7%) of patients were aged over 60 years. More than half (51.5%) presented with severe heart failure symptoms, classified as NYHA class III or IV, while over 70% were categorized as CCS class II or III. Among the surgical procedures performed, 344 patients underwent mitral valve repair, and 77 patients required mitral valve replacement. Additionally, 119 individuals underwent concomitant tricuspid valve repair. Short-term survival was significantly affected by the presence of hypertension, prior cerebrovascular events, and chronic kidney disease. In contrast, hypertension and chronic obstructive pulmonary disease were identified as significant predictors of adverse late-term outcomes. Conclusions: Interestingly, neither the preoperative severity of mitral regurgitation nor the echocardiographic measurements of LA and LV dimensions were found to significantly influence surgical outcomes. The perioperative risk, as assessed by the EuroSCORE II (average score: 10.0%), corresponded closely with observed mortality rates following mitral valve repair (9.9%) and replacement (10.4%). Notably, the need for concomitant tricuspid valve surgery was associated with an elevated mortality rate (12.4%). Furthermore, the preoperative echocardiographic evaluation of LA regurgitation severity, as well as LA and LV dimensions, did not exhibit a statistically significant impact on either early or long-term surgical outcomes. However, a reduced LVEF was correlated with increased long-term mortality. The presence of advanced clinical symptoms and the necessity for tricuspid valve repair were independently associated with a poorer late-term prognosis. Importantly, the annual mortality rate observed in the late-term follow-up of patients who underwent surgical treatment of ischemic mitral regurgitation was lower than rates reported in the literature for patients managed conservatively. The EuroSCORE II scale proved to be a reliable and precise tool in predicting surgical risk and outcomes in this patient population. Full article

Background: Atrial fibrillation (AF) frequently occurs in individuals with hypercapnic type 2 respiratory failure and has the potential to adversely affect patient outcomes. This study sought to investigate the clinical features and prognostic significance of atrial fibrillation in patients admitted to the intensive care unit with hypercapnic type 2 respiratory failure. Methods: This retrospective, single-center study included 200 adult patients diagnosed with hypercapnic type 2 respiratory failure between May 2022 and May 2023. Patients were grouped according to whether atrial fibrillation was present or not. Demographic, laboratory, and echocardiographic findings, comorbidities, and outcomes were compared. Kaplan–Meier survival analysis and Cox regression were used to identify mortality predictors. Results: AF was present in 50.5% of patients. Those with AF were older, had higher Charlson Comorbidity Index scores, and a greater prevalence of heart failure (p < 0.001). No significant differences were found in arterial blood gas values. AF patients had higher urea, creatinine, and BNP levels, and lower hemoglobin, lymphocyte, eosinophil, and monocyte counts (p < 0.05). Echocardiography showed more severe tricuspid and mitral regurgitation, lower ejection fractions, and higher systolic pulmonary pressures in the AF group. About 20% of AF patients were not receiving anticoagulants at ICU admission. AF was associated with shorter survival (49.6 ± 4.07 vs. 61.4 ± 3.8 days, p = 0.031) and 1.6-fold higher mortality risk (HR: 1.60, 95% CI: 1.04–2.47). Advanced age and low hemoglobin were independent predictors of mortality. Conclusions: AF is frequent among patients with type 2 respiratory failure and is linked to increased mortality. Despite known complications, treatment remains underutilized. AF should be actively screened during ICU admissions for respiratory failure. Full article

The present study aimed to compare pulmonary vein (PV) diameters between Cavalier King Charles Spaniels (CKCSs) with myxomatous mitral valve disease (MMVD) and healthy CKCSs, assess correlations between PV diameters and echocardiographic parameters, and identify the optimal PV diameter cut-off value that distinguishes stage C from stage B2. CKCSs were recruited both retrospectively and prospectively and classified according to the ACVIM guidelines (stages A, B1, B2, and C). From a left apical view, the diameters of three PVs (PV1, PV2, and PV3) were measured with high reproducibility. In healthy dogs, the PV2 diameter showed no correlation with body weight. The PV2 diameter was significantly higher in stage B2 compared to B1 and in stage C compared to B2, while no difference was found between stages A and B1. The median (IQR) PV2 diameters were 4.9 mm (3.9–5.2) in stage A, 5.1 mm (4.0–6.0) in stage B1, 9.3 mm (7.3–11.1) in stage B2, and 13.7 mm (9.9–15.1) in stage C. Positive correlations were observed between the PV2 diameter and the left ventricular internal diameter normalized for body weight, the left atrium-to-aorta ratio, mitral E wave peak velocity, tricuspid regurgitation pressure gradient, and regurgitant fraction. A PV2 diameter cut-off value of 12.8 mm discriminated stage C from stage B2 with 57% sensitivity and 93% specificity. The PV2 diameter is a reproducible echocardiographic measure that increases with MMVD severity and could assist in the early detection of congestive heart failure. However, the modest sensitivity observed reflects the overlap of PV2 measurements between stages B2 and C. Therefore, PV2 should be interpreted with caution and considered a supportive, rather than exclusive, tool in disease staging and therapeutic decision-making. Full article

Background: The outcome of patients undergoing transcatheter aortic valve replacement (TAVR) can be affected by coexisting tricuspid regurgitation (TR). The aim of the study is to investigate the clinical results of patients undergoing TAVR with or without concomitant significant TR. Methods: Patients undergoing TAVR were divided into two groups according to TR severity: none/mild TR (low-grade) and moderate/severe TR (significant). Data were analysed and compared. Primary endpoint was the mortality 1-year. Secondary endpoints were re-hospitalization and the degree of postoperative and 1-year TR. Results: TAVR procedures were performed in 345 patients between September 2011 and February 2020. Median STS score was 4.3% (IQR: 2.6–7.2), median LVEF was 59.0% (IQR: 45.0–62.0), median aortic area was 0.70cm² (IQR: 0.60–0.86), median mean gradient was 43.0mmHg (IQR: 36.0–53.0). Before TAVR, 297 patients (86.1%) had low-grade TR and 48 (13.9%) significant TR. Mean age was 82.4 ± 5.7 and 83.8 ± 6.2 years in low-grade and significant TR group, respectively (p = 0.109), with 47.5% (low-grade TR) and 56.3% (significant TR) of female patients (p = 0.279). Patients showed differences in EuroSCORE-II (3.2% (IQR: 1.9–5.7) in low-grade TR vs. 5.6% (IQR: 3.7–8.1) in significant TR; p < 0.001), impaired right ventricular function (3.0% vs. 20.8%; p < 0.001) and pulmonary hypertension (9.1% vs. 39.6%; p < 0.001). Mean valve size was 27.7 ± 2.9 mm. Hospital mortality was 2.0% in low-grade TR and 4.2% in significantTR patients (p = 0.308). Among discharged patients (n = 337), seven patients died within 30 days (2.0% low-grade TR; 2.1% significant TR; logrank test p = 0.154) and 40 were re-hospitalized for heart failure (11.1% low-grade TR; 14.6% significant TR; p = 0.470). After one year, 26 patients died, corresponding to a mortality of 7.9 deaths per 100-person year (95% CI 5.2–12.0) in low-grade TR group and 9.1 deaths per 100-person year (95% CI 3.4–24.3) in significant TR group (logrank test p = 0.815), with HR (low grade vs. significant TR) of 0.87, 95% CI 0.26–2.89. Re-hospitalization for heart failure was 16.5% and 19.6% for low-grade and significant TR, respectively (p = 0.713). Echocardiographic and functional changes over time showed no significant interaction between TR and time. Conclusions: In our experience, patients undergoing TAVR showed similar 30-day and 1-year outcome and re-hospitalization rate, regardless of the degree of concomitant tricuspid regurgitation. Full article

Background: Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis (AS), particularly in high-risk patients. However, comorbidities such as pulmonary hypertension (PH) and secondary tricuspid regurgitation (TR) contribute to adverse outcomes. Tricuspid annulus (TA) dilatation (TAD), a key marker of right ventricular dysfunction, has been associated with PH and TR progression. While echocardiographic assessment of TA has limitations, cardiac computed tomography (CT), routinely performed before TAVI, enables precise TA measurement. This study aimed to determine clinically relevant TA and TA indexed to body surface area (TA/BSA) cut-offs and assess their prognostic significance for long-term mortality. Methods: This retrospective, single-center study included 522 patients who underwent transfemoral TAVI between 2016 and 2022. Pre-procedural CT-derived TA measurements were analyzed to establish cut-off values predictive of right ventricular dysfunction in TAVI. Receiver operating characteristic (ROC) analysis was performed, and Kaplan–Meier survival curves, log-rank tests, and Cox regression were used to assess the impact of TA dimensions on long-term survival. Results: TAD correlated moderately with right ventricular dysfunction, with optimal cut-offs identified as TA ≥ 44.50 mm and TA/BSA ≥ 23.00 mm/m². However, Kaplan–Meier and Cox regression analyses demonstrated no significant association between TA or TA/BSA and long-term survival, with area under the curve (AUC) values close to 0.50, indicating poor prognostic value. Conclusions: Despite its relevance regarding right ventricular dysfunction in TAVI patients, TAD does not independently predict long-term mortality following TAVI. These findings challenge prior assumptions and suggest that TA dimensions alone should not guide risk stratification in TAVI patients. Further research is needed to refine prognostic models integrating multiple clinical and imaging parameters. Full article

Background and Objectives: Associated mitral regurgitation (MR) is frequently observed during transcatheter aortic valve implantation (TAVI). The progression of moderate MR remains undetermined, given uncertain clinical significance and natural history. This study aims to assess the evolution of moderate MR following TAVI. Materials and Methods: Between 2018 and 2023, 1476 patients underwent TAVI. We excluded those with previous aortic or mitral valve interventions, endocarditis, concomitant percutaneous coronary intervention, or emergent procedures. Patients with severe aortic or tricuspid regurgitation or significant mitral stenosis were excluded. Ultimately, only patients with moderate MR were included, resulting in a final population of 154 patients. Results: Mean age was 81.4 ± 7.8 years, 48.1% (74/154) were female, and 48.1% (74/154) were functional MR. There was one surgical conversion due to annular rupture. Thirty-day mortality was 1.9% (3/154). Postoperative echocardiography showed 38 (24.7%) patients with none/trace MR, 91 (59.1%) with mild MR, 22 (14.3%) with moderate MR, and 3 (1.9%) with severe MR. Finally, according to the echocardiographic follow-up [median follow-up 1.0 (IQR: 0.1–1.2) years], 20.1% (31/154) had no/trace MR, 39.6% (61/154) had mild MR, 35.7% (55/154) had moderate MR, and 4.5% (7/154) had severe MR. Overall, 67 (43.5%) patients had any MR grade progression, 62 (40.3%) had stable disease, and 25 (16.2%) had any MR grade reduction at the last follow-up from the operation. No difference in MR evolution was seen between functional and primary MR. Conclusions: Concomitant moderate MR during TAVI has a variable evolution over time. A more detailed characterization of patients with preoperative moderate MR undergoing TAVI is necessary to identify those with a disease progression risk. Full article

Impacting more than 70 million people worldwide, tricuspid regurgitation (TR) refers to the retrograde flow of blood from the right ventricle to the right atrium due to the improper closure of the tricuspid valve. Depending on the severity of TR, signs and symptoms can range from asymptomatic to features of right heart failure, including dyspnea, exercise intolerance, peripheral edema, and ascites. Severe features such as these necessitate treatment. In recent years, advancements in management, including surgical and transcatheter interventions, have taken prominence, leading to improved short-term outcomes in this patient population. However, there is still a dearth of evidence regarding the long-term outcomes of surgical and transcatheter interventions for TR. This comprehensive review aims to present clinicians with recent findings from pivotal clinical studies on interventional clinical outcomes in an effort to help guide their judgment when it comes to deciding the best course of treatment for their patients. Full article

Background: Atrial fibrillation (AF) has been identified as a risk factor for functional tricuspid regurgitation (FTR) in the absence of other known etiologies, although limited interventional options are available. K-Clip™, a novel transcatheter tricuspid annuloplasty device, is a clip-based annular plication approach for FTR. To date, no studies have investigated the short-term outcomes of K-Clip™ for patients with severe FTR associated with AF. Therefore, the aim of this study was to explore the feasibility and effectiveness of transcatheter annular repair with K-Clip™ for FTR in patients with persistent AF. Methods: Patients with FTR and persistent AF who underwent transcatheter annular repair with K-Clip™ at nine centers in China during the inclusion period were included (This study derived from Confirmatory Clinical Study of Treating Tricuspid Regurgitation With K-Clip™ Transcatheter Annuloplasty System [TriStar study}). Baseline data, imaging results, and follow-up data were collected. Results: All 52 patients (23 men, 74.02 ± 7.03 years) received successful intervention, and the mean operation time and radian exposure were 2.64 ± 1.09 h and 133.33 ± 743.06 mGy, respectively. No death cases and a low major adverse event occurrence rate were reported in 30 days. A significant decrease in FTR was documented, and TR remained severe in only two patients (3.8%). The regurgitation volume decreased significantly, accompanied by a notable reduction in the effective regurgitation orifice area and tricuspid annulus diameter, which subsequently led to the reversal of right heart remodeling. Furthermore, a decrease in pulmonary artery systolic pressure and an increase in cardiac output were documented. Conclusions: Transcatheter annular repair with K-Clip™ showed favorable short-term prognosis and significant improvement in FTR in patients with severe FTR associated with persistent AF. K-Clip™ could be a novel option for that group of patients. Full article

Background: Transcatheter tricuspid edge-to-edge repair (T-TEER) is widely used to treat atrial (AFTR) and ventricular (VFTR) functional tricuspid regurgitation (FTR). Methods: The outcome of 136 patients treated with T-TEER for severe AFTR or VFTR was analyzed using a composite endpoint of all-cause death and rehospitalization for decompensated heart failure. AFTR was defined as TR in the context of left ventricular ejection fraction ≥50%, right ventricular fractional area change (RVFAC) ≥ 35% and sPAP ≤ 50 mmHg. Results: Patients with VFTR (N = 109) and AFTR (N = 27, 19.9%) were both elderly (82.0 {IQR: 74.5–84.5} vs. 82.0 {IQR: 75.0–84.0} years, p = 0.98) and had similar interventional risk according to the EuroScore II (6.1 {4.0–9.8} vs. 4.7 {3.6–9.6} %, p = 0.3). Atrial fibrillation was equally frequent in both groups (89.9 vs. 88.9%, p = 0.88). AFTR patients were significantly more often female (56.0 vs. 77.8%, p = 0.04) and had lower NT-proBNP (3600.0 {1706.0–6302.0} vs. 1988.0 {1034.8–3723.3} pg/mL, p < 0.01). While RVFAC (29.5 ± 8.6 vs. 42.1 ± 4.3%, p < 0.01) and LVEF (48.5 ± 12.3 vs. 58.6 ± 8.0%, p < 0.01) were expectedly lower in patients with VFTR, right atrial dilation (RA volume: 126.7 ± 56.5 vs. 127.6 ± 74.2 mL, p = 0.99) was similar. Successful T-TEER with TR reduction ≥ 2 degrees (96.3 vs. 92.6%, p = 0.34) was observed in both groups, and residual TR ≤ II was equally frequent (94.5 vs. 96.3%, p = 1.0). The incidence of the 1-year composite endpoint was significantly higher (34.3 vs. 12.0%) in patients with VFTR (log-rank p = 0.02). AFTR was inversely associated with the composite endpoint (HR: 0.21, 95% CI: 0.06–0.7, p < 0.01) in multivariate Cox regression. Conclusions: Despite equally effective TR reduction through T-TEER, a better outcome was observed in patients with AFTR. Full article

Background. Stroke volume index (SVI) is an important prognostic parameter in pulmonary arterial hypertension (PAH). The direct Fick (DF) method represents the gold standard for measuring it. Indirect Fick (IF) and thermodilution (TD) are simpler and widely used alternatives. However, data on the accuracy of these methods in estimating SVI in PAH are scant. We aimed to compare these different invasive methods, and in a subgroup of patients, to a non-invasive method using MRI. Methods. We enrolled 103 PAH patients undergoing a diagnostic or follow-up right heart catheterization at our centre (mean age 56 years, 56% female). The Bland–Altman analysis was used to assess agreement between methods. Potential demographic, clinical, and hemodynamic biases were explored. The accuracy of cardiac magnetic resonance (CMR)-derived SVI was assessed in a subset of patients. Results. The mean bias for IF-SVI vs. DF-SVI was −5.53 mL/min/m² with a median percentage error (PE) of 15%. The mean bias was lower, 0.09 mL/min/m², for TD-SVI vs. DF-SVI with a median PE of 10%. Low cardiac index and severe tricuspid regurgitation (TR) were associated with a greater bias between TD and DF. CMR-SVI showed good accuracy and precision even in patients with severe TR, compared to DF. Conclusions. The indirect Fick is the less reliable method to assess SVI also in PAH patients. Thermodilution is a valid alternative to direct Fick, but it should be used with caution in patients with severe TR or low cardiac index. SVI measured by cardiac MRI is a promising non-invasive alternative, especially in patients with severe TR. Our observation needs to be confirmed by other series and larger studies. Full article

Noncardiogenic pulmonary edema after cardiac surgery is a rare but severe complication. The etiology remains poorly understood; however, the issue may arise from multiple sources. Possible causes include a significant inflammatory response or an autoimmune process. Pulmonary edema resulting from noncardiac etiologies can necessitate extracorporeal membrane oxygenation (ECMO) because most of the cases present a substantial volume of fluid expelled from the lungs and the medical team must manage the inability to achieve effective ventilation. A 64-year-old patient with known heart disease was admitted to our clinic with acute pulmonary edema. His medical history included Barlow’s disease, severe mitral regurgitation (IIP2), moderate–severe tricuspid regurgitation, and moderate pulmonary hypertension. The patient had a coronary angiography performed in a prior hospitalization before the surgical intervention which indicated the absence of coronary lesions. Preoperative screening (nasal, pharyngeal exudate, inguinal pouch culture, and urine culture) was negative, with no active dental infections. The patient was stabilized, and 14 days post-admission, mitral and tricuspid valve repair was performed via a thoracoscopic approach. After being admitted to intensive care post-surgery, the patient quickly developed pulmonary edema, producing a large volume (4.5 L) of yellow secretions through the intubation tube followed by hemodynamic instability necessitating high doses of medications to support circulation but no cardiorespiratory arrest. Due to his worsening condition, the patient was urgently taken back to the operating room, where veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated to support oxygenation and stabilize the patient. Full article