Shawwaf, Kenan A.

Mitral regurgitation (MR) in lung transplant (LTx) recipients is a rare but complex cardiopulmonary phenomenon. The overlap between symptoms of MR and post-LTx complications, such as primary graft dysfunction, complicates its diagnosis and management. This systematic review aims to characterize the incidence, pathophysiology, presentation, and management of MR in LTx patients. We conducted a literature search in PubMed, Web of Science, Scopus, and Embase. The search yielded 133 studies, of which 11 were included. Data regarding MR development, clinical presentation, echocardiographic findings, and management strategies were extracted and analyzed. Perioperative MR, occurring during or immediately post-LTx, was frequently attributed to the systolic anterior motion of the mitral valve (MV) occurring in the setting of hypovolemia and/or inotrope usage. Later postoperative MR, on the other hand, was associated with reverse ventricular remodeling and mitral annular dilation, although some variability in the literature was present. Preexisting MR or ventricular dysfunction, elongated MV leaflets, and bilateral LTx procedure appeared to be risk factors for MR development. Management was dependent on the timing of MR and its pathophysiology, where systolic anterior motion–related MR was treated with medical therapy, whereas postoperative MR often required MV interventions. In conclusion, the diagnosis of MR in LTx patients is complicated by its symptomatic overlap with other post-LTx complications. Echocardiographic monitoring in patients with preexisting MR, regardless of severity, is essential for early identification and management. Further research is needed to better understand the underlying mechanisms and refine management strategies for MR in this population.

BACKGROUND: Within the US, there has been an overall increase in cost of malpractice insurance for surgeons and decrease in federal reimbursement for surgical work. This study aimed to analyze state-to-state variability to understand differences in costs relative to reimbursement for surgeons and temporal trends. STUDY DESIGN: This study uses publicly available data to conduct a cross-sectional evaluation of surgeon medical malpractice premium rates and surgical reimbursement between 2013 and 2023. Surgeon reimbursement was represented in terms of the unit reimbursement rate for laparoscopic cholecystectomy (LC). The ratio of surgeon reimbursement to malpractice cost was calculated and considered as the number of LCs required in each state to cover the cost of malpractice insurance. RESULTS: Inflation-adjusted reimbursement for LC decreased in all states with a mean decrease of 24%. Although there was an overall decrease in inflation-adjusted medical malpractice premium cost, some states experienced an increase of up to 22% (Rhode Island), whereas other states experienced a decrease in cost of 62% (Oregon). For the year 2023, there was significant variability in the number of LCs needed to afford malpractice insurance premiums across states, ranging from 21 (Minnesota) to 163 (Illinois). Rhode Island experienced the greatest increase in change from 2013 to 2023 (63%), whereas Oregon experienced the greatest decrease (50%). CONCLUSIONS: This study finds significant variation in Medicare-based surgeon compensation relative to malpractice insurance costs across the US. This discrepancy highlights the challenges faced by surgical practices due to inconsistent insurance cost and decreases in reimbursement rates.