Faculty Bibliography

IMPORTANCE/OBJECTIVE:Advanced airway management is a critical component of cardiopulmonary resuscitation. The use of video laryngoscopy has become increasingly common, but their effect on intubation success and patient outcomes during cardiac arrest remains uncertain. METHODS:We conducted a systematic review commissioned by the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force. Following PRISMA and ILCOR methodology, we searched PubMed, Embase, and Web of Science through October 2025 for randomized controlled trials (RCTs) and non-randomized studies comparing tracheal intubation with video laryngoscopy versus direct laryngoscopy during cardiac arrest. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 and Risk Of Bias In Non-randomized Studies of Interventions tools, and certainty of evidence was rated using Grading of Recommendations Assessment, Development and Evaluation methodology. Critical outcomes included first pass tracheal intubation success, overall tracheal intubation success, return of spontaneous circulation, survival, and survival with good neurologic outcome. RESULTS:From 13,031 screened records, 16 studies (3 RCTs, 13 observational) were included. Across three RCTs enrolling 331 patients, very low-certainty evidence showed no difference between video and direct laryngoscopy for first-pass tracheal intubation success (RR 0.88, 95% CI 0.63-1.22) or overall intubation success (RR 1.00, 95% CI 0.90-1.12). Observational studies (n = 29,595) generally favored video laryngoscopy for both outcomes. Very low-certainty data from observational studies showed no consistent difference in return of spontaneous circulation (ROSC) or survival. Rates of esophageal intubation were lower with video laryngoscopy in all studies reporting this outcome (RCT: 4.3% vs 0%; observational data: 5.6% vs 1.4%). CONCLUSIONS:Among adults undergoing tracheal intubation during cardiac arrest, use of video laryngoscopes may improve process outcomes such as first-pass success and reduced esophageal intubation, but there is no evidence of improved ROSC or patient survival. The overall certainty of evidence is very low.

The incidence of maternal cardiac arrest is rising, paralleling the escalating maternal morbidity and mortality rates in the United States. Effective management of cardiac arrest in pregnancy requires timely initiation of a resuscitative cesarean delivery when indicated. Understanding the history, indications, maternal physiology, and surgical principles of resuscitative cesarean delivery is essential for all clinicians caring for pregnant patients. Resuscitative measures during maternal cardiac arrest have evolved through the centuries-beginning as a burial practice for both mother and baby, evolving further to attempt fetal salvage, and now, to maternal rescue. During this evolution, performing resuscitative cesarean delivery was most effective if initiated within 4 minutes of maternal cardiac arrest. This concept led to the term "4-minute rule" or the principle of initiating a resuscitative cesarean delivery within 4 minutes of arrest to optimize maternal and fetal outcomes. Furthermore, the terminology has also progressed. "Resuscitative cesarean delivery" is now preferred over "perimortem cesarean delivery," emphasizing the goal of maternal resuscitation rather than fetal salvage. Successful maternal resuscitation may occur from resuscitative cesarean delivery due to relieving aortocaval compression by the gravid uterus, thus restoring venous return and cardiac output. Additional benefits include an autotransfusion effect from the uteroplacental circulation and improved oxygenation. Due to this aspect of maternal physiology, resuscitative cesarean delivery is indicated when maternal cardiac arrest occurs at 20 weeks' gestation or greater, or when the fundus is at the level of the umbilicus and should be considered immediately upon cardiac arrest in term patients or in those arriving pulseless from the prehospital setting. Rapid bedside initiation of resuscitative cesarean delivery is critical; transporting the patient to the operating room causes harmful delays. Training multidisciplinary teams to perform resuscitative cesarean delivery at the site of arrest can improve adherence to the "4-minute rule" and survival rates. Surgical technique prioritizes speed and simplicity, favoring a vertical midline skin incision and a vertical uterine incision to minimize vascular injury and facilitate rapid uterine evacuation. Postprocedure, recovery is optimized by proper wound management via broad-spectrum antibiotics and consideration of delayed wound closure, stabilization of uterine hemostasis, and careful application of critical care in the postpartum setting. In summary, resuscitative cesarean delivery is a critical, life-saving intervention during maternal cardiac arrest, providing physiological decompression, enhancing maternal resuscitation efforts, and improving neonatal outcomes. Resuscitative cesarean delivery substantially improves the chances of maternal return of spontaneous circulation and fetal survival in cases of maternal cardiac arrest. Given the persistent rise in maternal morbidity and mortality, increased awareness and readiness to perform resuscitative cesarean delivery using protocolized training and interdisciplinary coordination are imperative to improving maternal and perinatal outcomes in the modern healthcare landscape.

OBJECTIVE:To evaluate whether artificial intelligence (AI)-based software was associated with enhanced identification of eight second-trimester fetal ultrasound findings suspicious for congenital heart defects (CHDs) among obstetrician-gynecologists (ob-gyns) and maternal-fetal medicine specialists. METHODS:A dataset of 200 fetal ultrasound examinations from 11 centers, including 100 with at least one suspicious finding, was retrospectively constituted (singleton pregnancy, 18-24 weeks of gestation, patients aged 18 years or older). Only examinations containing two-dimensional grayscale cines with interpretable four-chamber, left ventricular outflow tract, and right ventricular outflow tract standard views were included. Seven ob-gyns and seven maternal-fetal medicine specialists reviewed each examination in randomized order both with and without AI assistance and assessed the presence or absence of each finding suspicious for CHD with confidence scores. Outcomes included readers' performance in identifying the presence of any finding and each finding at the examination level, as measured by the area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. In addition, reading time and confidence were evaluated. RESULTS:The detection of any suspicious finding significantly improved for AI-aided compared with unaided readers with a significantly higher AUROC (0.974 [95% CI, 0.957-0.990] vs 0.825 [95% CI, 0.741-0.908], P=.002), sensitivity (0.935 [95% CI, 0.892-0.978] vs 0.782 [95% CI, 0.686-0.878]), and specificity (0.970 [95% CI, 0.949-0.991] vs 0.759 [95% CI, 0.630-0.887]). AI assistance also resulted in a significant decrease in clinician interpretation time and increase in clinician confidence score (226 seconds [95% CI, 218-234] vs 274 seconds [95% CI, 265-283], P<.001; 4.63 [95% CI, 4.60-4.66] vs 3.90 [95% CI, 3.85-3.95], P<.001, respectively). CONCLUSION/CONCLUSIONS:The use of AI-based software to assist clinicians was associated with enhanced identification of findings suspicious for CHD on prenatal ultrasonography.

OBJECTIVE:To evaluate the performance of an artificial intelligence (AI)-based software to identify second-trimester fetal ultrasound examinations suspicious for congenital heart defects. METHODS:The software analyzes all grayscale two-dimensional ultrasound cine clips of an examination to evaluate eight morphologic findings associated with severe congenital heart defects. A data set of 877 examinations was retrospectively collected from 11 centers. The presence of suspicious findings was determined by a panel of expert pediatric cardiologists, who determined that 311 examinations had at least one of the eight suspicious findings. The AI software processed each examination, labeling each finding as present, absent, or inconclusive. RESULTS:Of the 280 examinations with known severe congenital heart defects, 278 (sensitivity 0.993, 95% CI, 0.974-0.998) had at least one of the eight suspicious findings present as determined by the fetal cardiologists, highlighting the relevance of these eight findings. We then evaluated the performance of the AI software, which identified at least one finding as present in 271 examinations, that all eight findings were absent in five examinations, and was inconclusive in four of the 280 examinations with severe congenital heart defects, yielding a sensitivity of 0.968 (95% CI, 0.940-0.983) for severe congenital heart defects. When comparing the AI to the determination of findings by fetal cardiologists, the detection of any finding by the AI had a sensitivity of 0.987 (95% CI, 0.967-0.995) and a specificity of 0.977 (95% CI, 0.961-0.986) after exclusion of inconclusive examinations. The AI rendered a decision for any finding (either present or absent) in 98.7% of examinations. CONCLUSION/CONCLUSIONS:The AI-based software demonstrated high accuracy in identification of suspicious findings associated with severe congenital heart defects, yielding a high sensitivity for detecting severe congenital heart defects. These results show that AI has potential to improve antenatal congenital heart defect detection.

The incidence of twin pregnancies has been rising, largely attributable to increasing use of artificial reproductive techniques. Ultrasound plays a critical role in establishing the chorionicity and amnionicity of multiple gestations, a key predictor of the expected risk and complications, along with guiding future clinical and imaging follow-up examinations and intervals. People carrying multiple gestations will typically undergo more ultrasound examinations (and occasionally fetal MRI) than those carrying singletons, at minimum including a first trimester dating scan, nuchal translucency scan at 11 to 14 weeks, an anatomy scan at 18 to 22 weeks, and other scans in the second and third trimesters for growth and surveillance. This document clarifies the most appropriate imaging guidelines for multiple gestations for seven clinical scenarios/variants, which range from initial imaging, follow-up imaging, growth and surveillance for uncomplicated multiple gestations, and those complicated by a known abnormality or discordance between fetuses. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

BACKGROUND:There is an increasing prevalence of durable mechanical circulatory supported patients in both the in-and-out of hospital communities. The scientific literature regarding the approach to patients supported by durable mechanical circulatory devices who suffer acutely impaired perfusion has not been well explored. METHODS:The International Liaison Committee on Resuscitation Advanced, Basic, and Pediatric Life Support Task Forces conducted a scoping review of the literature using a population, context, and concept framework. RESULTS:A total of 32 publications that included patients who were receiving durable mechanical circulatory support and required acute resuscitation were identified. Most of the identified studies were case reports or small case series. Of these, 11 (34.4%) included patients who received chest compressions. A number of studies reported upon delays in the application of chest compressions resulting from complexity due to the expected pulselessness in some patients with continuous flow left-ventricular assist devices as well as from concern regarding potential dislodgement of the mechanical circulatory support device. Three observational studies identified worse outcomes in durable mechanical circulatory support receiving patients with cardiac arrest and acutely impaired perfusion who received chest compressions as compared to those who did not, however those studies were at high risk of bias. Of 226 patients across 11 studies and two published scientific abstracts who sustained cardiac arrest while supported by durable MCS and underwent chest compressions, there were no reported instances of device dislodgement and 71 (31.4%) patients had favorable outcomes. CONCLUSIONS:There is a scarcity of evidence to inform the resuscitation of patients with durable mechanical circulatory support (MCS) experiencing acute impairment in perfusion and cardiac arrest. Reports indicate that delays in resuscitation often stem from rescuers' uncertainty about the safety of administering chest compressions. Notably, no instances of device dislodgement have been documented following chest compressions, suggesting that the risk of harm from timely CPR in these patients is minimal.

Trafficking and persistence of fetal microchimeric cells (fMCs) and circulating extracellular vesicles (EVs) have been observed in animals and humans, but their consequences in the maternal body and their mechanistic contributions to maternal physiology and pathophysiology are not yet fully defined. Fetal cells and EVs may help remodel maternal organs after pregnancy-associated changes, but the cell types and EV cargos reaching the mother in preterm pregnancies after exposure to various risk factors can be distinct from term pregnancies. As preterm delivery-associated maternal complications are rising, revisiting this topic and formulating scientific questions for future research to reduce the risk of maternal morbidities are timely. Epidemiological studies report maternal cardiovascular risk as one of the major complications after preterm delivery. This paper suggests a potential link between fMCs and circulating EVs and adverse maternal cardiovascular outcomes post-pregnancies, the underlying mechanisms, consequences, and methods for and how this link might be assessed.

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Purpose of review: We review the epidemiology, risk factors, presentation, pathophysiology, diagnosis, peripartum management, and postpartum follow-up of chronic hypertension, hyperlipidemia, acute myocardial infarction, stroke, heart failure, pulmonary embolism, and atrial fibrillation. Recent findings: We discuss pathophysiology and evidence-based management for chronic hypertension, hyperlipidemia, acute myocardial infarction, stroke, heart failure, pulmonary embolism, and atrial fibrillation. Summary: It is essential for providers and patients to understand how cardiovascular diseases cause complications in pregnancy and to identify when patients require screening before conception and throughout the pregnancy. While primary care physicians, obstetricians, and cardiologists, should all have a general understanding of cardiovascular diseases during pregnancy, for higher risk patients it is important to create a multi-disciplinary cardio-obstetrics team for preconception planning, and for risk reduction during and after pregnancy. Shared decision-making regarding risks and benefits is crucial to improve maternal morbidity and mortality in the United States.