ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography:

Simulation-based training following a theoretical lecture enhances the performance of medical students in the interpretation and short-term retention of 20 cross-sectional transesophageal echocardiographic views: a prospective, randomized, controlled trial

Background

Both simulation-based training and video-based training serve as educational adjuncts for learning TEE among medical students. In the present study, we hypothesized that simulation-based training would better enhance the performance of medical students in the interpretation of 20 cross-sectional views compared to video-based training.

Methods

A total of 120 4th-year undergraduate medical students were enrolled in the present study. The study began with a pre-test of all the participants, followed by a 90-min theoretical lecture and a post-test. Subsequently, the participants were randomly divided into the video-based group (Group V) and simulation-based group (Group S). Next, Group V received 60 min of TEE video learning, while Group S received 60 min of TEE simulator training. After the respective training, both the groups undertook the retention-test 1 and retention-test 2, 1 week and 1 month later, respectively. The performance for each test was evaluated by five views, which were selected randomly and, respectively, from a set of 20 cross-sectional views. The primary outcome was the performance of the retention-test 1. Secondary outcomes included: (1) comparison the performances of the pre-test, post-test, and retention-test 2 between two groups; (2) comparison the performances of pre-test and post-test in the same group; (3) comparison the performances of retention-test 1, and retention-test 2 in the same group.

Results

Better performances were observed in Group S in both retention-test 1 (Group V: 63.2 [52.6, 77.6] vs. Group S: 89.5 [68.4, 100.0], P < 0.001) and retention-test 2 (Group V: 58.0 [48.0, 72.0] vs. Group S: 74.0 [64.0, 80.0], P < 0.001) compared to Group V. No statistically significant differences were observed in the performances of pre-test (Group V: 8.3 [4.2, 12.5] vs. Group S: 8.3 [4.2, 12.5], P = 0.825) or post-test (Group V: 46.2 [38.5, 57.7] vs. Group S: 44.2 [38.5, 56.7], P = 0.694) between the two groups. The improvement had been observed in the post-test, compared with pre-test in the same group, respectively (Group V in post-test: 46.2 [38.5, 57.7] vs. Group V in pre-test: 8.3 [4.2, 12.5], P < 0.001; Group S in post-test: 44.2 [38.5, 56.7] vs. Group S in pre-test: 8.3 [4.2, 12.5], P < 0.001). However, the performance in retention-test 2 was significantly reduced, compared with retention-test 1 in the same group, respectively (Group V in retention-test 2: 58.0 [48.0, 72.0] vs. Group V in retention-test 1: 63.2 [52.6, 77.6] P = 0.005; Group S in retention-test 2: 74.0 [64.0, 80.0] vs. Group S in retention-test 1: 89.5 [68.4, 100.0], P < 0.001).

Conclusions

Following a 90-min theoretical lecture, simulation-based training better enhanced the performance of medical students in the interpretation and short-term retention of 20 cross-sectional views compared to video-based training.

Trial registration

http://www.chictr.org.cn (ChiCTR2000033519, 3/June/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-021-02753-1.

Intraoperative Transesophageal Echocardiography During Cardiovascular Surgery in China

OBJECTIVE

To perform a comprehensive nationwide survey of more than 90% of all cardiovascular hospitals in China to assess the current 2018 status of transesophageal echocardiography (TEE) equipment, operating physicians, education, impact on surgery, and reimbursement.

DESIGN

In this nationwide survey, 716 cardiovascular hospitals in mainland China were included. A 15-question electronic survey was sent to these hospitals and the data were received directly from the questionnaire website for analysis.

SETTING

Cardiovascular hospitals in mainland China.

PARTICIPANTS

Departments of anesthesiology in cardiovascular hospitals in mainland China.

INTERVENTIONS

Answer a 15-question survey.

MEASUREMENTS AND MAIN RESULTS

About 90% of hospitals have acquired machines to perform TEEs with most of the machines controlled by the ultrasound department. Anesthesiologists performed intraoperative TEEs in 45% of the hospitals, but only 15% of the hospitals have anesthesiologists who have met the basic TEE training requirements. Most anesthesiologists (68%) believed TEE significantly contributed to patient care during cardiovascular surgeries. The overwhelming majority of surveyed hospital staff (93%) stated that they were planning to continue or start intraoperative TEE examinations in the future.

CONCLUSION

Many hospitals in China have acquired equipment to perform intraoperative TEE examinations during cardiovascular surgeries. However, the number of anesthesiologists who can perform TEEs independently still is not adequate. Standardized trainings, a formal certification process, and governmental payment model changes must be provided to ensure high-quality TEE services and better surgical outcomes in China.

Virtual Neonatal Echocardiographic Training System (VNETS): An Echocardiographic Simulator for Training Basic Transthoracic Echocardiography Skills in Neonates and Infants

There is a great need for training in pediatric echocardiography. In addition to physicians being trained in pediatric cardiology and echocardiography technologists, neonatologist, pediatric intensivists, and other health care professionals may be interested in such training. Since, there is limited opportunity of training on live patients, echocardiographic simulators may be of help. No simulator with complete range of echocardiographic modalities is available for neonates and infants. The aim of this project was to develop a mannequin-based echocardiographic simulator capable of simulating full range of pediatric 2D, color flow Doppler, spectral Doppler, and M-mode echocardiograms. A mannequin, a laptop computer, a magnetic tracking device, and a six-degree freedom (6DOF) sensor incorporated in a dummy transducer serve as the hardware platform of the simulator. We obtained six to seven 4D echocardiographic datasets in DICOM format through five acoustic windows from each infant along with a complete set of 2D video clips of color flow, Doppler, and M-mode. The 4D datasets are sliced into 3D slices using the visualization toolkit and are displayed as 2D echocardiograms through the information obtained by the 6DOF sensor. The coordinates from specific 3D slices triggers display of video clips of color flow, M-mode, and Doppler echocardiogram. Software written in C++ programming language controls the basic function of the program. The main simulator screen displays the full range of 2D echocardiograms including color flow Doppler, spectral Doppler, and M-mode from each acoustic window, whereas the side screen display the position and motion of the cutting planes through a 3D heart model. The system includes a software module to perform hemodynamic measurements from specific video clips images. Our hybrid, mannequin-based pediatric echocardiography simulator provides full range of pediatric echocardiography training experience. This simulator may help training in pediatric echocardiography for which there is a growing demand in clinical medicine.

Surgical Echocardiography of the MV: Focus on 3D

The mitral valve remains a complex structure where multiple forms of pathology can be seen. Mitral regurgitation continues to be one of the most common valvular diseases in the industrialized world. While intraoperative 2-dimensional transesophageal echocardiography has been commonplace for some time, 3-dimensional technology has emerged and has shown great benefit for diagnosis and guidance during mitral valve surgery. In the hands of a trained sonographer, high-quality real-time images can easily be obtained and correlate well with gross anatomical findings. The use of multiple angled views and color Doppler within 3-dimensional transesophageal echocardiography has become a valuable asset in the understanding and interpretation of the mitral valve for surgical interventions.

Transesophageal ultrasonography during orthotopic liver transplantation: Show me more

The first perioperative transesophageal echocardiography (TEE) guidelines published 21 years ago were mainly addressed to cardiac anesthesiologists. TEE has since expanded its role outside this setting and currently represents an invaluable tool to assess chamber sizes, ventricular hypertrophy, and systolic, diastolic, and valvular function in patients undergoing orthotopic liver transplantation (OLT). Right-sided microemboli, right ventricular dysfunction, and patent foramen ovale (PFO) are the most common intra-operative findings described during OLT. However, left ventricular outflow tract obstruction and left ventricular ballooning syndrome are more difficult to recognize and less frequent. Transesophageal ultrasonography (TEU) during OLT is also underused. Its applications are as follows: (1) assistance in the difficult placement of pulmonary arterial catheters; (2) help with catheterization of great vessels for external veno-venous bypass placement; (3) intra-operative evaluation of surgical liver anastomosis patency, if feasible, through the liver window; and (4) intra-operative investigation of "acute hypoxemia" due to pulmonary and cardiac issues using trans-esophageal lung ultrasound (TELU). The aims of this review are as follows: (1) to summarize the uses of TEE and TEU throughout all phases of OLT, and (2) to describe other new feasible applications.

Perioperative transesophageal echocardiography for non-cardiac surgery

PURPOSE

The use of transesophageal echocardiography (TEE) has evolved to include patients undergoing high-risk non-cardiac procedures and patients with significant cardiac disease undergoing non-cardiac surgery. Implementation of basic TEE education in training programs has increased across a broad spectrum of procedures in the perioperative arena. This paper describes the use of perioperative TEE in non-cardiac surgery and provides an overview of the basic TEE examination.

PRINCIPAL FINDINGS

Perioperative TEE is used to monitor hemodynamic parameters in non-cardiac procedures where there is a high risk of hemodynamic instability. Its use extends to include moderate-risk procedures for patients with significant cardiac diseases such as low ejection fraction, hypertrophic cardiomyopathy, severe valve lesions, or congenital heart disease. Vascular procedures involving the aorta, blunt trauma, and liver transplantation are all examples of procedures that may benefit from TEE. Transesophageal echocardiography examination allows assessment of volume status, ventricular function, diagnosis of gross valvular pathology and pericardial tamponade, as well as close monitoring of cardiac output, response to therapy, and the impact of ongoing surgical manipulation. In patients with unexplained and unexpected hemodynamic instability, "rescue TEE" can be used to help identify the underlying cause.

CONCLUSIONS

Perioperative TEE is emerging as a preferred tool to manage hemodynamics in high-risk procedures and in high-risk patients undergoing non-cardiac surgery. A rescue TEE examination protocol is a helpful approach for early identification of the etiology of hemodynamic instability.

Comparative Effectiveness and Harms of Intraoperative Transesophageal Echocardiography in Noncardiac Surgery: A Systematic Review

Intraoperative use of transesophageal echocardiography (TEE) has become commonplace in high-risk noncardiac surgeries but the balance of benefits and harms remains unclear. This systematic review investigated the comparative effectiveness and harms of intraoperative TEE in noncardiac surgery. We searched Ovid MEDLINE, PubMed, EMBASE, and the Cochrane Library from 1946 to March 2017. Two reviewers independently screened the literature for eligibility. Studies were assessed for the risk of selection bias, confounding, measurement bias, and reporting bias. Three comparative and 13 noncomparative studies were included. Intraoperative TEE was employed in a total of 1912 of 3837 patients. Studies had important design limitations. Data were not amenable to quantitative synthesis due to clinical and methodological diversity. Reported incidence of TEE complications ranged from 0% to 1.7% in patients undergoing various procedures (5 studies, 540 patients). No serious adverse events were observed for mixed surgeries (2 studies, 197 patients). Changes in surgical or medical management attributable to the use of TEE were noted in 17% to 81% of patients (7 studies, 558 patients). The only randomized trial of intraoperative TEE was grossly underpowered to detect meaningful differences in 30-day postoperative outcomes. There is lack of high-quality evidence of effectiveness and harms of intraoperative TEE in the management of non-cardiac surgeries. Evidence, however, indicates timely evaluation of cardiac function and structure, and hemodynamics. Future studies should be comparative evaluating confounder-adjusted impact on both intraoperative and 30-day postoperative clinical outcomes.

Use, Training, and Opinions About Effectiveness of Transesophageal Echocardiography in Adult Liver Transplantation Among Anesthesiologists in the United States

Study Objective. Describe transesophageal echocardiography (TEE) use, preparatory training and opinions about clinical importance, and future training pathways in a sample of liver transplant anesthesiologists. Design. Online survey questionnaire. Setting. Liver Transplant Centers in the United States. Participants. Director of Liver Transplant Anesthesia or designated alternate respondent. Results. A total of 79 Directors or alternates from 111 (71%) centers were identified. There were 56 responses (71%) representing 433 transplant anesthesiologists who cared for 63.3% of liver transplant cases performed in 2015. Basic TEE certification was reported more frequently (64%) than advanced (53.6%). At least one team member used TEE in over 90% of responding centers. Most respondents (83.9%) agreed TEE provided unique and valuable clinical information but were equally divided about future training pathways (on the job learning vs basic TEE certification). Conclusion. TEE use in liver transplantation is growing with a substantial increase in basic TEE certified users. Transplant anesthesiologists support basic certification but an equal number believe there should be more applied training at the site of care.

A Randomized Controlled Trial of Intra-Aortic Adenosine Infusion Before Release of the Aortic Cross-Clamp During Coronary Artery Bypass Surgery

OBJECTIVES

To assess the feasibility, safety, and potential useful effect of adenosine as a postconditioning agent in patients undergoing coronary artery bypass grafting surgeries.

DESIGN

Prospective randomized controlled study.

SETTING

University hospital.

PARTICIPANTS

The study comprised 60 patients scheduled for coronary artery bypass grafting surgery.

INTERVENTIONS

Adenosine (postconditioning group) or placebo (control group). Adenosine infusion (150 µg/kg/min) for 10 minutes via a cardioplegia needle into the aortic root was started 10 minutes before aortic cross-clamp removal.

MEASUREMENTS AND MAIN RESULTS

Compared with the control group, ejection fraction, fractional shortening, cardiac index (2.9 ± 0.3 v 2.2 ± 0.3 L/min/m², p = 0.032 at 60 min postbypass) and diastolic function indices were significantly better in the postconditioning group at most time points in the postbypass period. Cardiac troponin I and creatine kinase-MB release and the inotropic score were significantly lower in the postconditioning group at most time points in the postoperative period. The need for intra-aortic balloon and epicardial pacing were comparable in both groups, whereas incidence of arrhythmia, duration of postoperative mechanical ventilation, and intensive care unit and total hospital stays were significantly lower in the postconditioning group.

CONCLUSIONS

Adenosine postconditioning provided cardiac protection as evidenced by a favorable outcome on systolic and diastolic function indices, less cardiac troponin I and creatine kinase-MB release, lower incidence of arrhythmia, lower inotropic score, and shorter duration of postoperative mechanical ventilation and intensive care unit stay.

The Refinement of Risk Stratification for Atrial Thrombus or Spontaneous Echo Contrast in Nonvalvular Atrial Fibrillation

As for nonvalvular atrial fibrillation (NVAF) patients with left atrial thrombus or spontaneous echo contrast (LAT/SEC), we evaluated the additional predictive value of serum uric acid (SUA) and Left atrial diameter (LAD) for CHADS₂ and CHA₂DS₂-VASc, and explored the influence from the level of SUA and LAD to LAT/SEC in moderate risk group. Thus, we put forward the concept of a borderline high risk group to guide clinical anticoagulant therapy in patients with NVAF.A total of 284 NVAF patients without the history of anticoagulant prior to hospitalization were enrolled. They were divided into LAT/SEC group or No LAT/SEC group according to transesophageal echocardiography (TEE). Then, we explored and compared the additional predictive value of serological and ultrasonic indexes after combining them to CHADS₂/CHA₂DS₂-VASc.61 patients (21.48%) had LAT/SEC. SUA and LAD were the independent risk factors of LAT/SEC. After being added with LAD and SUA, the predictive value of CHADS₂ and CHA₂DS₂-VASc were increased much more than others. In the moderate risk group, the incidence of LAT/SEC rose significantly when SUA or LAD was higher than cut-off values.SUA and LAD enhanced the predictive ability of CHADS₂ and CHA₂DS₂-VASc for LAT/SEC as additional factors. For patients in moderate risk group, if SUA or LAD was higher than cut-off values, the risk of thromboembolism events would rise accompanied by the elevated risk of LAT/SEC.

Intraoperative assessment of transient and persistent regional left ventricular wall motion abnormalities in patients undergoing coronary revascularization surgery using real time three-dimensional transesophageal echocardiography: A prospective observational study

OBJECTIVE

To evaluate the feasibility of intraoperative real time three-dimensional echocardiography (RT3DE) for identification and quantification of transient and persistent regional wall motion abnormalities (RWMAs) in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG).

DESIGN

A prospective observational study SETTING: Single-center study in an academic tertiary care hospital PARTICIPANTS: A series of 42 patients undergoing elective CABG over a 2-year period were included.

INTERVENTION

After induction of anesthesia, a comprehensive transesophageal echocardiography (TEE) examination was performed to evaluate regional wall motion using two-dimensional wall motion score index (WMSI) and RT3D echocardiographic parameters at three specific time points during the operative phase.

MEASUREMENTS AND MAIN RESULTS

The 3D assessment of LV function was based on the quantification of change in LV chamber volume over time from each segment excursion. Patients were divided into two groups and subgroups based on TEE findings. There was significant mechanical dyssynchrony in patients with RWMAs (WMSI > 1; systolic dyssynchrony index [SDI] = 7.0 ± 3.66) as compared to the patients having normal wall motion (WMSI = 1; SDI = 2.0 ± 0.95; P = .001). Patients with contractile dysfunction were found to have low values of segmental excursion and high values of negative excursion on parametric imaging. Persistent RWMAs due to hibernating myocardium showed significant resolution of mechanical dyssynchrony after revascularization. Parametric imaging could detect transient RWMAs due to stunning and graft dysfunction. Early activating segments (EAS) on "timing bull's-eye" may represent hypercontractile segments and may influence inotrope administration.

CONCLUSION

The RT3DE is a valuable modality for precise quantification of regional wall motion during revascularization procedure.

Towards Robot-Assisted Echocardiographic Monitoring in Catheterization Laboratories : Usability-Centered Manipulator for Transesophageal Echocardiography

This paper proposes a robotic Transesophageal Echocardiography (TOE) system concept for Catheterization Laboratories. Cardiovascular disease causes one third of all global mortality. TOE is utilized to assess cardiovascular structures and monitor cardiac function during diagnostic procedures and catheter-based structural interventions. However, the operation of TOE underlies various conditions that may cause a negative impact on performance, the health of the cardiac sonographer and patient safety. These factors have been conflated and evince the potential of robot-assisted TOE. Hence, a careful integration of clinical experience and Systems Engineering methods was used to develop a concept and physical model for TOE manipulation. The motion of different actuators of the fabricated motorized system has been tested. It is concluded that the developed medical system, counteracting conflated disadvantages, represents a progressive approach for cardiac healthcare.

Intraoperative Detection of Persistent Endoleak by Detecting Residual Spontaneous Echocardiographic Contrast in the Aneurysmal Sac During Thoracic Endovascular Aortic Repair

Persistent endoleaks may lead to adverse events after endovascular aortic repair. We prospectively examined the relationship between intraoperative residual spontaneous echocardiographic contrast (SEC) within the aneurysmal sac and the incidence of postoperative endoleaks in 60 patients undergoing thoracic endovascular aortic repair. Patients with SEC had a higher incidence of postoperative endoleaks than did patients without SEC within a few days postoperatively (60.0% vs 12.5%, respectively; P < .001) and at 6 months postoperatively (40.0% vs 2.5%, respectively; P < .001). Intraoperative confirmation of the absence of SEC may identify patients at low risk for persistent endoleaks after thoracic endovascular aortic repair.

Intraoperative Transesophageal Echocardiography in the Operation of Ebstein's Anomaly: A Retrospective Study

Background:

Ebstein's anomaly (EA) has various spectrums in clinical and anatomic features. This study aimed to report the experience of two-dimensional intraoperative transesophageal echocardiography (2D-ITEE) during the EA surgery and to analyze the characteristics of the tricuspid valve (TV) by comparing the data from 2D-ITEE with the results from the surgery.

Methods:

2D-ITEE data of 164 patients with EA who were operated in the First Hospital of Tsinghua University between July 2004 and April 2014 were retrospectively analyzed in this study. 2D-ITEE was applied in all patients. Downward displacement distances were measured, and the numbers of downward displacement or absent leaflets were compared with that of the surgery and with that of the two-dimensional-transthoracic echocardiogram (2D-TTE). Data comparison was performed using the Chi-square test.

Results:

The anterior leaflet partial or total downward displacement was 37.76 ± 17.50 mm in 54 cases, absent in one patient; septal leaflet downward displacement was 29.07 ± 12.34 mm in 134 cases, absent in 17 cases; and posterior leaflet downward displacement was 43.18 ± 19.16 mm in 115 cases, absent in 34 cases. Statistically, there was no significant difference between the results from 2D-ITEE and that of 2D-TTE. The consistency rates of 2D-ITEE with operation for septal and posterior leaflets were 93.2% and 96.1%, respectively, while the rate for anterior was only 40.1%, which was significantly different. Color Doppler flow image showed severe regurgitation in 150 cases and moderate in 14 cases. After surgical correction, moderate regurgitation of TV was found in 58 cases with 2D-ITEE, repair was performed again until the effect was satisfied. No complication occurred relating to the use of 2D-ITEE.

Conclusions:

2D-ITEE could help diagnose anterior leaflet, evaluate the effect of TV repair, increase operational success rate, and reduce complication.

A novel method to estimate blood flow velocity in the left atrial appendage using enhanced computed tomography: role of Hounsfield unit density ratio at two distinct points within the left atrial appendage

Low blood flow velocity in the left atrial appendage (LAA) indicates a high risk of thromboembolism. Although transesophageal echocardiography (TEE) has been the standard method with which to evaluate the LAA blood flow velocity, a clinically noninvasive method is desired. We hypothesized that the ratio of the Hounsfield unit (HU) density at two distinct points within the LAA represents the blood flow velocity in the LAA. We retrospectively investigated 60 consecutive patients with atrial fibrillation (paroxysmal type, n = 29) who underwent enhanced computed tomography (CT) and TEE. The peak emptying flow velocity in the LAA (LAAPV) was evaluated using TEE. HU density was measured at proximal and distal sites of the LAA (LAAp and LAAd) on CT images. The LAAd/LAAp ratio was correlated with the LAAPV (P < 0.01, r = 0.69). Among several indices, the HU ratio was the most significant parameter associated with the LAAPV (β = 0.469, CI 28.602-68.286, P < 0.001). Receiver-operating characteristic analysis (area under the curve, 0.91) demonstrated that an HU density ratio cutoff of 0.32 discriminated a low LAAPV (<25 cm/s) with sensitivity of 90% and specificity of 84%. Flow velocity of the LAA can be estimated by the HU density ratio at distal and proximal sites within the LAA. Our method might be a feasible substitution for TEE to discriminate patients with a reduced LAAPV.

Assessment of mitral valve geometric deformity in patients with ischemic heart disease using three-dimensional echocardiography

BACKGROUND

A full understanding of the geometry of the nonplanar saddle-shaped mitral annulus can provide valuable information regarding the pathophysiology of mitral regurgitation (MR).

AIM OF THE WORK

To investigate mitral annular geometric deformities using three-dimensional echocardiography among patients with ischemic coronary illness with and without mitral regurgitation.

METHODS

Three-dimensional transesophageal echocardiographic data were acquired intraoperatively from patients with ischemic heart disease with or without associated mitral regurgitation who experienced coronary artery bypass grafting and normal control subjects. The mitral annulus was analyzed for differences in geometry using QLAB software.

RESULTS

Left ventricular ejection fraction was reduced in patients with ischemic heart disease and MR (n = 21; Group 1) and without MR (n = 7; Group 2) compared with that in normal subjects (n = 14; Group 3) (43.4% ± 11.8% and 35.9% ± 13.6% vs. 52.6% ± 9.3%, respectively; p = 0.015). Mitral annular height and mitral annular saddle-shaped nonplanarity were significantly lower in Group 1 compared to Group 2 and Group 3 (6.00 ± 1.07 mm, 7.96 ± 0.93 mm and 8.31 ± 1.12 mm; p < 0.0001) and (0.19 ± 0.04, 0.26 ± 0.04 and 0.26 ± 0.03; p < 0.0001) respectively while mitral annular ellipsicity and Mitral valve tenting volume were significantly higher in the same group (1) (114.82% ± 22.47%, 100.21% ± 9.87% and 97.29% ± 14.37%; p = 0.0421) and (2.73 ± 1.11, 2.20 ± 1.39 and 0.87 ± 0.67) respectively. Vena contracta diameter was inversely correlated with the mitral annular height (r = -0.82; p < 0.0001) and saddle-shaped nonplanarity of the annulus (r = -0.68; p < 0.0001).

CONCLUSION

Among patients with ischemic heart disease, there are significant increases in mitral valve tenting volume and height, and those with mitral regurgitation exhibited a reduced mitral annular height, a shallower saddle shape annulus and losses of ellipsicity of the annulus.

The evolution of diastolic function during liver transplantation

INTRODUCTION

The peroperative management of liver transplantation is still associated with many cardiocirculatory complications in which diastolic dysfunction may play a contributive role. Transoesophageal echocardiography is a monitoring device commonly used in liver transplantation allowing diastolic function assessment.

METHODS

We prospectively analysed the peroperative transoesophageal echocardiography recordings of 40 patients undergoing liver transplantation in order to describe changes in diastolic function at different steps of the surgery. The diastolic function marker we used was the lateral mitral annulus motion (E' wave velocity) obtained by tissue-Doppler imaging. In addition, we also studied the left ventricular filling pressure indices and systolic function.

RESULTS

As a whole, there was no global change in E' wave velocity throughout the surgery. However, 11 patients (27.5%) presented a decrease in E' wave velocity up to 15% that identified an occurrence of diastolic function alteration. In this group, other peroperative data were not different from other patients (amount of bleeding, fluid administration or vasopressive support). Conversely, this group experienced lower preoperative E' wave velocity values (9cm·s^-1 versus 12cm·s^-1, P=0.05) and an increased incidence of postoperative cardiorespiratory complications (OR=6 [1-56], P=0.02). Considering all patients, 18 patients had an E' wave velocity under 10cm·s^-1 at unclamping, characterizing a diastolic dysfunction according to the usual criteria. This dysfunction was not associated with cardiorespiratory complications.

CONCLUSION

This work investigated peroperative systematic echocardiographic evaluation of diastolic function during liver transplantation. Diastolic dysfunction occurs frequently during liver transplantation and could lead to postoperative cardiorespiratory complications.

McConnell's sign in intra-operative acute right ventricle ischaemia: An under-recognized aetiology

Transoesophageal echocardiography (TEE) has become a fundamental tool in modern cardiothoracic anaesthesia. It has an indisputable role in coronary valve surgery and revascularisations with severe impairment of ventricle function. It helps in making diagnoses that can optimise the surgical strategy and to minimal invasively dynamically monitor volaemia and cardiac function during the post-operative period, detecting complications unobservable by other methods. The McConnell sign, visualised using TEE as an akinesis of the right ventricular free wall, with a normal apex motility and enlargement of the right cavities, is characteristic of right ventricular (RV) dysfunction. This sign has a 77% sensitivity and 94% specificity for the diagnosis of acute pulmonary embolism (APE). The case is presented of a 53-year-old man scheduled for aortic valve and ascending aorta replacement surgery, with a history of severe valve aortic stenosis, aortic root and arch aneurysm, and with normal coronary arteries. Post-cardiopulmonary bypass (CBP), the patient presented with haemodynamic instability, with the TEE showing a typical image of the McConnell sign, with no pulmonary hypertension. This enabled making an early diagnosis of acute RV ischaemia, that led to a change in the surgical plan, the performing of coronary revascularisation surgery. As a result, the McConnell sign, which describes the characteristics of RV dysfunction, led to making a differential diagnosis between APE, RV infarction and acute myocardial ischaemia.

Novel Transoesophageal Echocardiographic Views Attain Superior Incident Angles for Tricuspid, but not Pulmonary, Valvular Doppler Interrogation

For accurate spectral Doppler valvular evaluation, intraoperative sonographers must use transoesophageal echocardiographic (TOE) views that offer optimal incident angles. We hypothesised that views added to the 2013 American Society of Echocardiography/Society of Cardiovascular Anesthesiologists (ASE/SCA) standard views and other novel views we have described of the tricuspid (TV) and pulmonary valves (PV) offered superior incident angles to those included in the origina 1999 ASE/SCA recommendations for comprehensive intraoperative TOE examination. We compared the acquisition feasibility and incident angles obtained by these views in 62 patients undergoing elective cardiac surgery, who received TOE monitoring as standard care. Overall, the 2013 ASE/SCA standard and novel views provided superior incident angles for the TV (28% and 66% of patients) whereas the 1999 ASE/SCA standard views provided superior incident angles for the PV (79% of patients, P <0.0001). The novel 90° mid-oesophageal modified bicaval view (90°MEMBC) and the 1999 ASE/SCA standard aortic arch short-axis view (AoArSAX) obtained best incident angles for the TV (mean [95% confidence interval] 13° [10°-16°]) and PV (5° [3°-7°]) respectively. PV view acquisition feasibility between the 1999 ASE/SCA standard, 2013 ASE/SCA standard and novel views was not significantly different (acquisition rate difference 11%, P >0.11). We conclude that the 2013 ASE/SCA TV standard and novel views obtained superior incident angles for the tricuspid, but not pulmonary valves. We recommend that ntraoperative sonographers consider the use of these views, particularly when incident angles obtained with standard views are suboptimal.

Simulation-based training in echocardiography

The knowledge gained from echocardiography is paramount for the clinician in diagnosing, interpreting, and treating various forms of disease. While cardiologists traditionally have undergone training in this imaging modality during their fellowship, many other specialties are beginning to show interest as well, including intensive care, anesthesia, and primary care trainees, in both transesophageal and transthoracic echocardiography. Advances in technology have led to the development of simulation programs accessible to trainees to help gain proficiency in the nuances of obtaining quality images, in a low stress, pressure free environment, often with a functioning ultrasound probe and mannequin that can mimic many of the pathologies seen in living patients. Although there are various training simulation programs each with their own benefits and drawbacks, it is clear that these programs are a powerful tool in educating the trainee and likely will lead to improved patient outcomes.

Iatrogenic aortic dissection after minimally invasive aortic valve replacement: a case report

BACKGROUND

As minimally invasive cardiac and vascular procedures are on the rise, the incidence of iatrogenic acute aortic dissection (IAAD) will increase. Cardiovascular professionals should be aware about the risk factors, means of prevention and best management options for IAAD in the perioperative setting.

CASE PRESENTATION

We present the successful clinical management of a complicated case of IAAD after minimally invasive aortic valve replacement.

CONCLUSION

High index of suspicion is required for prompt diagnosis of IAAD; collaboration of the whole perioperative team is imperative for management of this catastrophe.

The Use of Standard Gastrointestinal Endoscopic Ultrasound to Assess Cardiac Anatomy

In this prospective observational study, conducted at an academic medical center, we evaluated the feasibility of performing a basic transesophageal echocardiography (TEE) examination using endoscopic ultrasound (EUS) technology to determine what cardiac structures could be assessed. This may be potentially beneficial during hemodynamic emergencies in the endoscopy suite resulting from hypovolemia, depressed ventricular function, aortic dissection, pericardial effusions, or aortic stenosis. Of the 20 patients enrolled, 18 underwent EUS with a linear echoendoscope for standard clinical indications followed by a cardiac assessment performed under the guidance of a TEE-certified cardiac anesthesiologist. Eight of the 20 standard views of cardiovascular structures per the 1999 American Society of Echocardiography/Society of Cardiovascular Anesthesiologists guidelines for TEE could be obtained using the linear echoendoscope. The following cardiac valvular structures were visualized: aortic valve (100%), mitral valve (100%), tricuspid valve (33%), and pulmonic valve (11%). Left ventricular and right ventricular systolic function could be assessed in 89% and 67% of patients, respectively. Other structures such as the ascending and descending aorta, pericardium, left atrial appendage, and interatrial septum were identified in 100% of patients. Doppler-dependent functions could not be assessed. Given that the EUS images were not directly compared with TEE in these patients, we cannot comment definitively on the quality of these assessments and further studies would need to be performed to make a formal comparison. Based on this study, EUS technology can consistently assess the mitral valve, aortic valve, aorta, pericardium, and left ventricular function. Given its limitations, EUS technology, although not a substitute for formal echocardiography, could be a helpful early diagnostic tool in an emergency setting.

Intraoperative Echocardiography: Support for Decision Making in Cardiac Surgery

Intraoperative echocardiography (including transesophageal echocardiography, epiaortic ultrasound and epicardial echocardiography) is commonly performed in North American hospitals during cardiac anesthesia. Several authors have reported on the positive impact of intraoperative echocardiography on patients’ outcomes. Transesophageal echocardiography is useful in identifying anatomic and functional abnormalities either before or after cardiopulmonary bypass and helps to make decisions in the care of high-risk and unstable patients. In minimally invasive and robotically assisted surgery, transesophageal echocardiography is essential in order to guide cannulation of venous and arterial vessels for cardiopulmonary bypass and in providing immediate assessment of the quality of the performed repair. Intraoperative echocardiography can also detect complications associated with the performed procedure and can be an excellent hemodynamic monitor in unstable patients. In this paper different scenarios where intraoperative echocardiography is useful are reviewed, some clinical cases are shown to illustrate, and a review of related literature is reported.

Evaluation of Mitral Regurgitation

Transesophageal echocardiography (TEE) provides high-resolution images of the mitral valve apparatus, permitting detailed evaluation of its structure and function. Mitral valve evaluation is invaluable during mitral valve repair surgery, providing insight into the mechanism of valve dysfunction and formulation of a plan for repair. TEE provides immediate detection of inadequate repair after bypass and allows correction during the same operative setting. Intraoperative TEE is a valuable tool for improving patient outcome and offers the cardiovascular anesthesiologist a role in perioperative surgical decisions.

Central venous catheter tip migration due to tracheal extubation: a prospective randomized study

Considerable numbers of patients undergo central venous catheterization (CVC) under mechanical ventilation. We hypothesized that the return of spontaneous breathing and tracheal extubation could be associated with distal CVC tip migration towards intracardiac positions due to decreasing intrathoracic pressures and subsequent readjustment of mediastinal organs. Patients scheduled for cardiac surgery were randomized for right or left internal jugular vein (IJV) CVC placement under general anesthesia and mechanical ventilation. CVC tips were positioned at the cavoatrial junction and measured at the time of placement, postoperatively under mechanical ventilation, and after tracheal extubation until 48 h after surgery. Measurement methods included intravascular electrocardiography (ECG) P-wave amplitude, transesophageal echocardiography, and chest radiography (CXR). Out of 70 patients, 60 were eligible for final statistical analysis (31 right and 29 left IJV CVC). According to ECG interpretation, CVC tip positions remained below the pericardiac reflection point in the distal superior vena cava over the course of the three measurement intervals. The ECG revealed significant proximal migration of CVC tips from the time of placement to the time of tracheal extubation (1.19 ± 0.55 vs. 0.62 ± 0.31 mV; P < 0.001). A CXR using CVC tip to carina distances revealed no significant tip migrations in the time between postoperative assessment and following tracheal extubation (5.1 ± 1.7 vs. 5.3 ± 1.5 cm; P = 0.196). In patients with CVCs positioned at the cavoatrial junction, tracheal extubation was not associated with significant postoperative CVC tip malposition, but tended to undergo proximal migration. This trend should be considered particularly in left-sided thoracocervical puncture approaches to avoid unfavorable CVC tip positions.

[Perioperative transesophageal echocardiography in non-cardiac surgery. Update]

AIM

The aim of this article is to impart knowledge concerning focused transesophageal echocardiographic examination (TEE) for non-cardiac surgery which is an essential part of perioperative monitoring. It allows a rapid echocardiographic examination without interference with the surgical field or under limited transthoracic examination conditions. New recommendations for a comprehensive perioperative TEE examination with expanded standard views and the recently published consensus statement for a shortened baseline examination were crucial for this study.

MATERIAL AND METHODS

The background is the peer-reviewed literature from PubMed.

RESULTS

Apart from cardiac surgery TEE has two main applications: firstly, the evaluation of patients developing acute life-threatening hemodynamic instability in the operating room, in the emergency room or in the intensive care unit (ICU). Secondly, TEE is used as planned intraoperative monitoring when severe hemodynamic, pulmonary or neurological complications are expected because of the type of surgery or due to the cardiopulmonary medical history of the patient. In 2013 a total of 11 relevant standard views were defined for the basic perioperative TEE examination in non-cardiac surgery. These 11 views should be performed for each patient. Appropriate extension to a comprehensive examination may be necessary if complex pathology is obvious.

DISCUSSION

Even in non-cardiac surgery TEE is an important tool allowing clarification of a life-threatening perioperative hemodynamic instability within a few minutes. Furthermore, the hemodynamic management of high-risk patients can be facilitated. Appropriate qualification and continuous training are necessary in order to assure the competence of the examiner.

Critical Care Basic Ultrasound Learning Goals for American Anesthesiology Critical Care Trainees: Recommendations from an Expert Group

OBJECTIVE

In this review, we define learning goals and recommend competencies concerning focused basic critical care ultrasound (CCUS) for critical care specialists in training.

DESIGN

The narrative review is, and the recommendations contained herein are, sponsored by the Society of Critical Care Anesthesiologists. Our recommendations are based on a structured literature review by an expert panel of anesthesiology intensivists and cardiologists with formal training in ultrasound. Published descriptions of learning and training routines from anesthesia-critical care and other specialties were identified and considered. Sections were written by groups with special expertise, with dissent included in the text.

RESULTS

Learning goals and objectives were identified for achieving competence in the use of CCUS at a specialist level (critical care fellowship training) for diagnosis and monitoring of vital organ dysfunction in the critical care environment. The ultrasound examination was divided into vascular, abdominal, thoracic, and cardiac components. For each component, learning goals and specific skills were presented. Suggestions for teaching and training methods were described.

DISCUSSION

Immediate bedside availability of ultrasound resources can dramatically improve the ability of critical care physicians to care for critically ill patients. Anesthesia--critical care medicine training should have definitive expectations and performance standards for basic CCUS interpretation by anesthesiology--critical care specialists. The learning goals in this review reflect current trends in the multispecialty critical care environment where ultrasound-based diagnostic strategies are already frequently applied. These competencies should be formally taught as part of an established anesthesiology-critical care medicine graduate medical education programs.

Real-time magnetic resonance imaging-guided transcatheter aortic valve replacement

OBJECTIVES

To demonstrate the feasibility of Real-time magnetic resonance imaging (rtMRI) guided transcatheter aortic valve replacement (TAVR) with an active guidewire and an MRI compatible valve delivery catheter system in a swine model.

METHODS

The CoreValve system was minimally modified to be MRI-compatible by replacing the stainless steel components with fluoroplastic resin and high-density polyethylene components. Eight swine weighing 60-90 kg underwent rtMRI-guided TAVR with an active guidewire through a left subclavian approach.

RESULTS

Two imaging planes (long-axis view and short-axis view) were used simultaneously for real-time imaging during implantation. Successful deployment was performed without rapid ventricular pacing or cardiopulmonary bypass. Postdeployment images were acquired to evaluate the final valve position in addition to valvular and cardiac function.

CONCLUSIONS

Our results show that the CoreValve can be easily and effectively deployed through a left subclavian approach using rtMRI guidance, a minimally modified valve delivery catheter system, and an active guidewire. This method allows superior visualization before deployment, thereby allowing placement of the valve with pinpoint accuracy. rtMRI has the added benefit of the ability to perform immediate postprocedural functional assessment, while eliminating the morbidity associated with radiation exposure, rapid ventricular pacing, contrast media renal toxicity, and a more invasive procedure. Use of a commercially available device brings this rtMRI-guided approach closer to clinical reality.

Peri-operative assessment of right heart function: role of echocardiography

The right heart contributes significantly to overall cardiac function. Right ventricular (RV) haemodynamics and function have been defined to be physiologically different from the left ventricle, and yet independently associated with outcomes in a spectrum of conditions. In particular, RV function has been shown to influence prognosis of patients undergoing surgery. The assessment of right heart function during the intra-operative and immediate postoperative periods plays an important role in the clinical management of patients having surgery. While a number of techniques are available for the assessment of the right heart intra-operatively, echocardiography remains the prime choice being least invasive, relatively safe, readily accessible and cost-effective. Advancements in the field of echocardiographic have improved ability to assess right heart function. This review examines the role echocardiography and advances in this imaging modality in the assessment of right heart function within the peri-operative setting.

Manual Skill Acquisition During Transesophageal Echocardiography Simulator Training of Cardiology Fellows: A Kinematic Assessment

OBJECTIVE

To investigate whether a transesophageal echocardiography (TEE) simulator with motion analysis can be used to impart proficiency in TEE in an integrated curriculum-based model.

DESIGN

A prospective cohort study.

SETTING

A tertiary-care university hospital.

PARTICIPANTS

TEE-naïve cardiology fellows.

INTERVENTIONS

Participants underwent an 8-session multimodal TEE training program. Manual skills were assessed at the end of sessions 2 and 8 using motion analysis of the TEE simulator's probe. At the end of the course, participants performed an intraoperative TEE; their examinations were video captured, and a blinded investigator evaluated the total time and image transitions needed for each view. Results are reported as mean±standard deviation, or median (interquartile range) where appropriate.

MEASUREMENTS AND MAIN RESULTS

Eleven fellows completed the knowledge and kinematic portions of the study. Five participants were excluded from the evaluation in the clinical setting because of interim exposure to TEE or having participated in a TEE rotation after the training course. An increase of 12.95% in post-test knowledge scores was observed. From the start to the end of the course, there was a significant reduction (p<0.001 for all) in the number of probe. During clinical performance evaluation, trainees were able to obtain all the required echocardiographic views unassisted but required a longer time and had more probe transitions when compared with an expert.

CONCLUSION

A curriculum-based approach to TEE training for cardiology fellows can be complemented with kinematic analyses to objectify acquisition of manual skills during simulator-based training.

Acute right ventricular dysfunction: real-time management with echocardiography

In critically ill patients, the right ventricle is susceptible to dysfunction due to increased afterload, decreased contractility, or alterations in preload. With the increased use of point-of-care ultrasonography and a decline in the use of pulmonary artery catheters, echocardiography can be the ideal tool for evaluation and to guide hemodynamic and respiratory therapy. We review the epidemiology of right ventricular failure in critically ill patients; echocardiographic parameters for evaluating the right ventricle; and the impact of mechanical ventilation, fluid therapy, and vasoactive infusions on the right ventricle. Finally, we summarize the principles of management in the context of right ventricular dysfunction and provide recommendations for echocardiography-guided management.

Left septal atrial tachycardia after open-heart surgery: relevance to surgical approach, anatomical and electrophysiological characteristics associated with catheter ablation, and procedural outcomes

BACKGROUND

Septal atrial tachycardia (AT) can occur in patients without structural heart disease and in patients with previous catheter ablation of atrial fibrillation. We aimed to assess septal AT that occurs after open-heart surgery.

METHODS AND RESULTS

This study comprised 20 consecutive patients undergoing catheter ablation of macroreentrant AT after open-heart surgery. Relevance to surgical approach, mechanisms, anatomic and electrophysiological characteristics, and outcomes were assessed. Septal AT was identified in 7 patients who had all undergone mitral valve surgery. All septal ATs were localized in the left atrial septum, whereas 10 of 13 nonseptal ATs originated from the right atrium. Patients with left septal AT had a thicker fossa ovalis (median, 4.0; 25th-75th percentile, 3.6-4.2 versus 2.3; 1.6-2.6 mm; P=0.006) and broader area of low voltage (<0.3 mV) in the septum than patients with nonseptal AT (82; 76-89 versus 31; 28%-36%; P=0.02). Repeated gradual prolongations of the tachycardia cycle length without change of the septal circuit were observed in all patients with septal AT (70; 63-100 versus 15; 10-40 ms; P=0.0008). Although ablation terminated all ATs, recurrence of targeted ATs was more frequent in patients with left septal AT during 30-month follow-up (71 versus 0%; P=0.001).

CONCLUSIONS

Left septal AT after open-heart surgery was characterized by a thicker septum, more scar burden in the septum, and repeated prolongations of the tachycardia cycle length during ablation. Such an arrhythmogenic substrate may interfere with transmural lesion formation by ablation and may account for higher likelihood of recurrence of left septal AT.

Effects of antegrade versus integrated blood cardioplegia on left ventricular function evaluated by echocardiographic real-time 3-dimensional speckle tracking

OBJECTIVE

The objective of this study was to evaluate left ventricular free wall and interventricular septal function by 2-dimensional transthoracic echocardiography and live/real-time 3-dimensional transthoracic speckle tracking echocardiography before and after on-pump cardiac surgery and to assess the effect of mode of cardioplegia delivery.

METHODS

A total of 22 patients were studied 1 day before and 4 to 5 days after surgery. Cold blood cardioplegia was delivered by intermittent antegrade infusion or by the integrated method. The latter includes a combination of intermittent antegrade and retrograde cardioplegia with a terminal warm amino acid-enriched reperfusion.

RESULTS

The overall group displayed significant deterioration of septal function after surgery by 2-dimensional transthoracic echocardiography, as assessed by wall motion score index, yet subgroup analysis by 3-dimensional transthoracic speckle tracking echocardiography permitted distinction of outcomes achieved by antegrade or integrated delivery methods. Analysis after surgery showed that only the antegrade group displayed statistically significant deterioration in the strain parameters of some of the segments of the septum and free wall when strain was measured in the free wall and septum in the longitudinal, circumferential, and radial modes of deformation (P < .05). In contrast, only the integrated group displayed significant improvement in global radial, circumferential, and longitudinal strain (P < .05).

CONCLUSIONS

These findings by 3-dimensional transthoracic speckle tracking echocardiography indicate that integrated cardioplegia offers superior myocardial protection of the left ventricular free wall and septum compared with the antegrade mode of cardioplegia delivery.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2013

This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs that require a precise prescription with respect to type, dose, and duration. The final theme is patient safety in the cardiac perioperative environment. A recent expert scientific statement has focused attention on this issue because most perioperative errors are preventable. It is likely that clinical research in this area will blossom because this is a major opportunity for improvement in our specialty. The patient care processes identified in these research highlights will further improve perioperative outcomes for our patients.