Perioperative Transesophageal Echocardiographic Assessment of the Right Heart and Associated Structures: A Comprehensive Update and Technical Report

Chiari network diagnosis intraoperative based on echocardiography

We report a case of a Chiari network as a possible cause of intraoperative supraventricular tachycardia with potential cardiac flow obstruction and hemodynamic collapse. The intraoperative diagnostic analysis considered detects cardiac abnormalities associated to this congenital remnant and discard common intraoperative causes of hemodynamic alterations.

Right ventricular diastolic dysfunction and failure: a review

Right ventricular diastolic dysfunction and failure (RVDDF) has been increasingly identified in patients with cardiovascular diseases, including heart failure and other diseases with cardiac involvement. It is unknown whether RVDDF exists as a distinct clinical entity; however, its presence and degree have been shown to be a sensitive marker of end-organ dysfunction related to multiple disease processes including systemic hypertension, pulmonary hypertension, heart failure, and endocrine disease. In this manuscript, we review issues pertaining to RVDDF including anatomic features of the right ventricle, physiologic measurements, RVDDF diagnosis, underlying mechanisms, clinical impact, and clinical management. Several unique features of RVDDF are also discussed.

Chiari network diagnosis intraoperative based on echocardiography

We report a case of a Chiari network as a possible cause of intraoperative supraventricular tachycardia with potential cardiac flow obstruction and hemodynamic collapse. The intraoperative diagnostic analysis considered detects cardiac abnormalities associated to this congenital remnant and discard common intraoperative causes of hemodynamic alterations.

Application of a Series of Two-Dimensional Transesophageal Echocardiographic (2D TEE) Views Across Multiple Axes Improves the Accuracy of Tricuspid Annular Measurements

OBJECTIVES

Quantification of the tricuspid annulus (TA) is an important factor in determining the requirement for tricuspid annuloplasty in cardiac surgery. Three-dimensional echocardiography (3DE) has shown that the TA is biplanar with an antero-posterior longaxis and septo-lateral shortaxis, and that the commonly used 2D TEE (two-dimensional transesophageal echocardiography) four-chamber view (4ChV) underestimates the true TA longaxis. The authors hypothesized that the use of multiple 2D TEE TA views could attain greater TA long-axis measurements and smaller TA short-axis measurements than the 4ChV, and that the 4ChV has a significant but inconsistent bias relative to the maximal TA diameter measured by these views.

DESIGN

Prospective observational study.

SETTING

Adult tertiary teaching hospital.

PARTICIPANTS

45 adult patients.

INTERVENTIONS

Multiplanar 2D TEE assessment of the tricuspid annulus.

MEASUREMENTS AND MAIN RESULTS

Multiplanar assessment reliably produced larger TA long-axis measurements (93% of patients, 95% confidence interval: 81-98%) of (mean [95% confidence interval]) 40 mm (28-50 mm) compared with the 4ChV (34mm [25-44 mm], p < 0.0001) and smaller TA short-axis measurements (29 mm [20-38 mm], p < 0.0001) compared with the 4ChV. TA diameter by 4ChV assessment yielded an average bias of -5.6 mm, with 95% limits of agreement -15 to +3.9 mm compared with the largest TA long-axis measurement by multiplanar assessment.

CONCLUSIONS

Multiplanar 2D TEE assessment of the TA long- and short-axis consistently achieves larger and smaller measurements, respectively, than the 4ChV. The 4ChV also is not a reliable index of the TA longaxis. If the time, proficiency, or equipment required for 3DE TA assessment are unavailable, the use of multiple standard and non-standard 2D TEE TA views may offer an alternative for TA assessment.

Transesophageal Echocardiographic Estimation of Coronary Sinus Blood Flow for Predicting Favorable Postoperative Transit Time Coronary Graft Flow Measurements: A Pilot Study

BACKGROUND

Augmentation of coronary artery flow by surgical grafting increases coronary sinus blood flow (CSBF), which can be quantified on transesophageal echocardiography (TEE). However, transit time flowmetry (TTF) technology remains the most used intraoperative technique for coronary artery graft assessment. The purpose of the present pilot study was to evaluate the predictive value of TEE-based CSBF estimation for identifying favorable TTF graft measurements.

DESIGN

Prospective observational study.

SETTING

Single university hospital.

PATIENTS

Forty patients undergoing triple vessel coronary artery bypass grafting.

MEASUREMENTS AND MAIN RESULTS

CSBF was assessed on TEE examination before and after revascularization, estimating the percentage increase in CSBF (∆CSBF). Postoperative TTF graft measurements were averaged to compute mean diastolic filling (DF) and pulsatility index (PI). Subjects were grouped based on favorable (PI ≤ 3, DF ≥ 50%) and unfavorable (PI > 3, DF < 50%) parameters. The group with PI ≤ 3 (n = 32) had significantly higher ∆CSBF compared with the group with PI > 3 (n = 8) (38.22% ± 12.05%, 13.75% ± 3.37%, p < 0.001). ∆CSBF was higher in the DF ≥ 50% group (n = 35) (36.40 ± 12.99) in contrast to DF < 50% group (n = 5) (11.80 ± 2.59%). A strong negative and significantly positive correlation was observed between ∆CSBF with PI, DF (r = -0.903, 0.571, respectively, p < 0.001). A ∆CSBF ≥15.5% was found to predict a mean PI ≤ 3 and DF ≥ 50% with sensitivity and specificity of 100% and 62.5% for PI and 100% and 100% for DF. A ∆CSBF ≥19% demonstrated a sensitivity and specificity of 100% and 100%, 100% and 91.4% for prediction of PI ≤ 3 and DF ≥ 50%, respectively.

CONCLUSION

TEE-based demonstration of an augmented CSBF can ensure favorable TTF graft parameters, guiding the adequacy of surgical revascularization.

Role of echocardiography in the assessment of right ventricular function in the pediatric population

This review article summarizes the use of echocardiography in the evaluation of the right ventricle with special emphasis on pediatric patients. After reading this article, anesthesiologists will develop a better understanding of the anatomy and echocardiographic parameters for hemodynamic and functional assessment of the right ventricle. This knowledge will assist with the perioperative management of patients with cardiopulmonary disorder.

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.

Diagnosing pulmonic valve infective endocarditis with positron emission tomography-CT

Infective endocarditis (IE) affects the pulmonic valve in less than 2% of cases. Not only is pulmonary valve IE rare, it is also challenging to visualise with commonly used imaging modalities. In this vignette, we present a 50-year-old patient with a history of repaired Tetralogy of Fallot who underwent a prolonged hospitalisation and extensive work up for fever of unknown origin. Although we suspected IE as the source of his fevers, he had persistently negative transthoracic and transoesophageal echocardiograms. We were ultimately able to establish the diagnosis with the use of positron emission tomography-CT (PET-CT). Although PET-CT is not part of the traditional work up for IE, it can be a useful imaging modality when there is a high index of suspicion for IE with negative echocardiography findings.

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.