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A Hybrid Catheter Localisation Framework in Echocardiography Based on Electromagnetic Tracking and Deep Learning Segmentation. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:2119070. [PMID: 36248919 PMCID: PMC9560838 DOI: 10.1155/2022/2119070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/23/2022]
Abstract
Interventional cardiology procedure is an important type of minimally invasive surgery that deals with the catheter-based treatment of cardiovascular diseases, such as coronary artery diseases, strokes, peripheral arterial diseases, and aortic diseases. Ultrasound imaging, also called echocardiography, is a typical imaging tool that monitors catheter puncturing. Localising a medical device accurately during cardiac interventions can help improve the procedure's safety and reliability under ultrasound imaging. However, external device tracking and image-based tracking methods can only provide a partial solution. Thus, we proposed a hybrid framework, with the combination of both methods to localise the catheter tip target in an automatic way. The external device used was an electromagnetic tracking system from North Digital Inc (NDI), and the ultrasound image analysis was based on UNet, a deep learning network for semantic segmentation. From the external method, the tip's location was determined precisely, and the deep learning platform segmented the exact catheter tip automatically. This novel hybrid localisation framework combines the advantages of external electromagnetic (EM) tracking and the deep learning-based image method, which offers a new solution to identify the moving medical device in low-resolution ultrasound images.
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Zhao Y, Yuan ZY, Zhang HY, Yang X, Qian D, Lin JY, Zhu T, Song HB. 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. BMC MEDICAL EDUCATION 2021; 21:336. [PMID: 34107936 PMCID: PMC8191119 DOI: 10.1186/s12909-021-02753-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/17/2021] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Yang Zhao
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Department of Anesthesiology, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Zong-Yi Yuan
- Department of Oral and Maxillofacial, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Han-Ying Zhang
- Department of Anesthesiology, Pidu District People's Hospital, 156# East Street, Pitong Town, Pidu District, Chengdu, Sichuan, 611730, People's Republic of China
| | - Xue Yang
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Duo Qian
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Department of Anesthesiology, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jing-Yan Lin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Department of Anesthesiology, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Hai-Bo Song
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
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Zhou L, Gu JW, Wang Y, Ye JJ, Wang F, Wang TT, Jiang B, Na LS. The Application of Transesophageal Echocardiography in Mitral Valve Repair With Tendon Reconstruction. Front Surg 2020; 7:599746. [PMID: 33392243 PMCID: PMC7772144 DOI: 10.3389/fsurg.2020.599746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/24/2020] [Indexed: 11/18/2022] Open
Abstract
Objective: To investigate whether tendon reconstruction during mitral valve repair can be effectively guided by transesophageal echocardiography (TEE), using the mid-esophageal bi-commissure view, bicaval view and the aortic valve–mitral valve transition short-axis view. Methods: A total of 40 patients that underwent mitral valve repair with artificial tendineae were recruited. Before the operation, conventional transthoracic echocardiography was used to determine whether mitral valve repair would be possible. Following intraoperative anesthesia, two-dimensional and three-dimensional TEE reconstructions were used to assess the state of the valve and tendon and to make a repair plan. Results: TEE accurately diagnosed single functional tendon rupture and predicted single artificial tendon implantation in 88% of cases (23/26). TEE accurately diagnosed single functional tendon rupture and predicted the implantation of two artificial tendons in 100% of cases (4/4). TEE accurately diagnosed two or more functional tendon ruptures and predicted the implantation of two artificial tendons in 100% of cases (5/5). The length of the tendon cord predicted by TEE (2.45 ± 0.15 mm) was not significantly different (P > 0.05) from the length of the cord that was actually implanted (2.31 ± 0.11 mm). TEE also accurately predicted the size of the annuloplasty ring in 86% of cases (33/38), with differences of 2 mm or less compared to the size of the ring that was actually implanted. Conclusion: Both the mid-esophageal bi-commissure view, bicaval view and the short-axis view of the aortic valve–mitral valve transition can reduce the difficulty of tendon reconstruction by helping to determine what length of tendon and what size of artificial annulus are required.
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Affiliation(s)
- Li Zhou
- Department of Cardiac Functions Examination, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ji-Wei Gu
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yun Wang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Jing-Jing Ye
- Department of Cardiac Functions Examination, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Fang Wang
- Department of Cardiac Functions Examination, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ting-Ting Wang
- Department of Cardiac Functions Examination, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Bo Jiang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Li-Sha Na
- Department of Cardiac Functions Examination, General Hospital of Ningxia Medical University, Yinchuan, China
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Li J, Li Q, Alqahtany FS, Algahtani FH, Kim HJ, Li Y, Ock Kim Y. Evaluating the novel parameters for assessing the LAA function and thrombus formation with nonvalvular atrial fibrillation. Saudi J Biol Sci 2020; 28:560-565. [PMID: 33424339 PMCID: PMC7783836 DOI: 10.1016/j.sjbs.2020.10.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/28/2022] Open
Abstract
The dysfunction of left atrial appendage (LAA) is prone to form thrombus when atrial fibrillation (AF) sustained more than 48 h. Traditional 2D-TEE (transesophageal echocardiography) can not accurate evaluate the function of LAA. The purpose of this study is to analyze the relationship of LAA function parameters and thrombus formation in patients with non-valvular atrial fibrillation (NVAF) by real-time three-dimensional transesophageal echocardiography (RT-3D-TEE). High risk patients can be identified according to the characteristics of ultrasonic index in patients with left atrial appendage thrombosis, which has important clinical value and significance in the risk assessment, guiding treatment and judging prognosis. We examined the relationship between the echocardiographic parameters of LAA function and the incidence of thrombus in 102 NVAF patients. They underwent RT-3D-TEE and left atrial appendage thrombus (LAAT)/severe spontaneous echocardiographic contrast (SSEC) was found in 67 patients (thrombus group) but absent in the remaining 35 patients (non-thrombus group). After measured by QLAB software, the LAA functional parameters were significantly associated with LAAT/SEC formation. Univariate analysis indicated that AF time, LAD, LVEF, LAA-OAmax, LAAVmax, LAAVI and LAAEF demonstrated a positive association (P < 0.05). However, logistic regression analysis identified that AF time (OR:1.73, P < 0.05)、LAAEF (OR:4.09, P < 0.01)and LAAVI (OR:3.28, P < 0.01) were independent predictors of LAAT/SSEC. In patients with nonvalvular atrial fibrillation, echocardiographic parameters of LAA function are significantly associated with LAAT/SSEC.
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Affiliation(s)
- Jian Li
- Department of Cardiology, The First Hospital of Harbin City&The First Affiliated Hospital of Harbin Medical University, PR China
| | - Quan Li
- The First Affiliated Hospital of Heilongjiang University Of Chinese Medicine, PR China
| | - Fatmah S Alqahtany
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Farjah H Algahtani
- Department of Medicine, Division of Oncology/Hematology, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hak-Jae Kim
- Department of Clinical Pharmacology, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Yang Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical UniversityThe Heilongjiang Academy of Medical Science, PR China
| | - Young Ock Kim
- Department of Clinical Pharmacology, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
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Si X, Ma J, Cao DY, Xu HL, Zuo LY, Chen MY, Wu JF, Guan XD. Transesophageal echocardiography instead or in addition to transthoracic echocardiography in evaluating haemodynamic problems in intubated critically ill patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:785. [PMID: 32647710 PMCID: PMC7333121 DOI: 10.21037/atm.2020.04.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Transesophageal echocardiography (TEE) performed by intensivists is increasingly used in critically ill patients. However, TEE is usually not the preferred monitoring tool, especially when transthoracic echocardiography (TTE) appears to have addressed the clinical problems. As a result, it remains largely unknown whether TEE is a clinically valuable replacement or supplement for TTE as a primary tool in evaluating haemodynamic problems in critically ill surgical patients. The purpose of this study was to assess the diagnostic and therapeutic value of TEE instead or in addition to TTE in critically ill surgical patients with hemodynamic instability. Methods A prospective observational study was conducted. A total of 68 consecutive patients were enrolled from December 2016 to February 2018. TEE was routinely performed in addition to TTE, and the imaging data from TTE and TEE were successively disclosed to two different primary physicians, who reported any resulting changes in management. The two physicians were required to reach a consensus if there was any disagreement. The results of the additional TEE examination were compared with the clinical findings and TTE information. The image quality of TTE views was classified as a good (score 2), suboptimal (score 1) or poor view (score 0). According to the scores of TTE images, the patients were divided into two groups: patients with adequate TTE views (score ≥6) and inadequate TTE views (score <6). Results The results of additional TEE examination were classified into four categories. TEE failed to provide additional information about the initial diagnosis and therapy (class 1) in 26 patients (38.2%). Of the remaining 42 patients (61.8%), TEE instead or in addition to TTE revealed new findings or led to significant changes in therapy, as TTE supplied inadequate information. TEE used in addition to TTE led to a new diagnosis without therapeutic implications (class 2) in 11 patients (16.2%) and made a major clinical contribution leading to a therapeutic change (class 3) in 23 patients (33.8%). TEE used instead of TTE determined the diagnosis and therapy in 8 patients (11.8%) whose haemodynamic problems could not be addressed by TTE (class 4). In total, TEE had critical therapeutic benefits (class 3 and 4) that was not provided by TTE in 31 patients (45.6%). Of particular concern was that TEE had a higher proportion of therapeutic benefits to patients with inadequate TTE views than those with adequate TTE views (54.3% vs. 27.3%, P=0.036). Conclusions TEE as a feasible clinical tool is useful for critically ill surgical patients with hemodynamic instability, especially for the patients with inadequate TTE views. TEE instead or in addition to TTE could provide valuable information for diagnosis, which may bring significant therapeutic benefits.
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Affiliation(s)
- Xiang Si
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Jie Ma
- Department of Critical Care Medicine, Jiangmen Central Hospital, Jiangmen 529030, China
| | - Dai-Yin Cao
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Hai-Lin Xu
- Transplantation Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Ling-Yun Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Min-Ying Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Jian-Feng Wu
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xiang-Dong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
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Siassi B, Ebrahimi M, Noori S, Sheng S, Ghosh D, Seri I. Virtual Neonatal Echocardiographic Training System (VNETS): An Echocardiographic Simulator for Training Basic Transthoracic Echocardiography Skills in Neonates and Infants. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2018; 6:4700113. [PMID: 30464863 PMCID: PMC6242698 DOI: 10.1109/jtehm.2018.2878724] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/13/2018] [Accepted: 09/03/2018] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Bijan Siassi
- Los Angeles County University of Southern California Medical CenterLos AngelesCA90033USA
| | - Mahmood Ebrahimi
- Los Angeles County University of Southern California Medical CenterLos AngelesCA90033USA
| | - Shahab Noori
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los AngelesDepartment of PediatricsKeck School of Medicine, University of Southern CaliforniaLos AngelesCA90027USA
| | - Shuyang Sheng
- Los Angeles County University of Southern California Medical CenterLos AngelesCA90033USA
| | - Debjit Ghosh
- Los Angeles County University of Southern California Medical CenterLos AngelesCA90033USA
| | - Istvan Seri
- First Department of PediatricsFaculty of MedicineSemmelweis UniversityBudapestH-1083Hungary
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Fayad A, Shillcutt SK. Perioperative transesophageal echocardiography for non-cardiac surgery. Can J Anaesth 2018; 65:381-398. [PMID: 29150779 PMCID: PMC6071868 DOI: 10.1007/s12630-017-1017-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/09/2017] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Ashraf Fayad
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
| | - Sasha K Shillcutt
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
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Bolliger D, Poltera C, Cheung AT, Couture P, Michaux I, Poelaert J, Preisman S, Skarvan K, Buse GL, Seeberger MD. Assessment of Left Ventricular Dimensions by Transoesophageal Echocardiography in Patients During Coronary Artery Bypass Surgery. Turk J Anaesthesiol Reanim 2017; 45:367-373. [PMID: 29359077 PMCID: PMC5772417 DOI: 10.5152/tjar.2017.25483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 07/10/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Normative values of left ventricular (LV) end-diastolic area and diameter (EDA and EDD) for intraoperative transoesophageal echocardiography (TEE) have not been established. We aimed to define the ranges of LV EDA and EDD for intraoperative TEE examinations in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS A MEDLINE search for studies reporting LV EDA and EDD in CABG patients was performed. Individual-level dataset from 333 anaesthetised and mechanically ventilated patients with preserved LV function (study population) were received from 8 studies. EDA and calculated EDD values in the study population were compared with summary mean EDD values obtained by transthoracic echocardiography (TTE) in 2 studies of 500 awake patients with coronary artery disease (CAD). Further, the influence of prespecified factors on EDD was evaluated through a multivariate regression model. RESULTS LV EDA and EDD values measured by TEE in anaesthetised CABG patients were 16.7±4.7 cm2 and 4.6±0.6 cm, respectively. EDD values measured by TEE in anaesthetised patients were 10% to 13% less those measured by TTE in 2 studies of awake patients (p<0.001). Body surface area, age and fractional area change but not sex were factors that affected LV EDD. CONCLUSION LV EDD values measured by intraoperative TEE in anaesthetised and mechanically ventilated CABG patients were 10% to 13% less than those measured by TTE in awake CAD patients. This finding indicates that independent normative values specific for intraoperative TEE should be established for guiding intraoperative clinical decisions.
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Affiliation(s)
- Daniel Bolliger
- Department of Anesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Corsin Poltera
- Department of Anesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Albert T. Cheung
- Department of Anesthesia, University of Pennsylvania, Philadelphia, USA
| | - Pierre Couture
- Department of Anesthesiology, Montreal Heart Institution, University of Montréal, Montréal, Quebec, Canada
| | - Isabelle Michaux
- Department of Intensive Care Medicine, Mont-Godinne University Hospital, Université Catholique de Louvain, Yvoir, Belgium
| | - Jan Poelaert
- Department of Anesthesiology and Perioperative Medicine, University Hospital-Free University of Brussels, Brussels, Belgium
| | - Sergey Preisman
- Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Karl Skarvan
- Department of Anesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Manfred D. Seeberger
- University of Basel, Medical School, Basel, Switzerland; and Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, Zurich, Switzerland
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Sarin K, Chauhan S, Bisoi AK, Kapoor PM, Gharde P, Choudhury A. Relationship between perioperative left atrial appendage doppler velocity estimates and new-onset atrial fibrillation in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass. Ann Card Anaesth 2017; 20:403-407. [PMID: 28994674 PMCID: PMC5661308 DOI: 10.4103/aca.aca_73_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Literature search reveals that postoperative atrial fibrillation (POAF) occurs in 15%-40% of coronary artery bypass graft (CABG) patients. Although several risk models exist for predicting the development of POAF, few have studied left atrial appendage (LAA) velocity. We hypothesize that an association between LAA velocity and development of POAF exists. DESIGN AND METHODS Single institution university hospital prospective observational clinical study performed between May 2016 and November 2016 in 96 adult patients undergoing CABG surgery utilizing cardiopulmonary bypass (CPB). Transesophageal echocardiography was performed perioperatively to measure LAA velocity and left atrial (LA) size after anesthetic induction, post-CPB and during the postoperative period before extubation. Student's t-test was used for inter-group comparisons. Data are expressed as mean ± (standard deviation). The value of P < 0.05 was considered statistically significant. RESULTS A total of 95 patients (69 males and 26 females) completed the study and were included in the final analysis. Of these, 21 (22%) (15 males and 5 females) developed POAF. The patient group which developed POAF was compared with the group that did not develop POAF. On comparing mean age of patients in each group (59 years in patients with no POAF and 63.71 years in patients with POAF, P = 0.04). LA volume indexed in POAF group (34.13 ml/m2) compared with that in group with no POAF (34.82 ml/m2) resulted in P = 0.04. Mean LAA velocities (pre-CPB, post-CPB, postoperative Intensive Care Unit) in group with no POAF were 41.06, 56.33, and 60.44 cm/s, respectively, whereas in the other group with POAF the values were 39.68, 55.04, and 58.09 cm/s, respectively. No statistical significance was noted (P > 0.05). Comparison of comorbidities also did not yield any significant results (P > 0.05). CONCLUSIONS Decreasing LAA velocity does not appear to independently predict the development of POAF in patients undergoing CABG surgery with the use of CPB. There is, however, a positive correlation of POAF with age and LA volume.
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Affiliation(s)
- Kunal Sarin
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Chauhan
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay K Bisoi
- Department of CTVS, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Parag Gharde
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Arindam Choudhury
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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Pahl C, Ebelt H, Sayahkarajy M, Supriyanto E, Soesanto A. Towards Robot-Assisted Echocardiographic Monitoring in Catheterization Laboratories : Usability-Centered Manipulator for Transesophageal Echocardiography. J Med Syst 2017; 41:148. [PMID: 28812247 DOI: 10.1007/s10916-017-0786-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Christina Pahl
- Biomechatronics Group, Faculty of Mechanical Engineering, Technische Universitaet Ilmenau, 98693, Ilmenau, Germany. .,Faculty of Biosciences and Medical Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Malaysia.
| | - Henning Ebelt
- Klinik für Innere Medizin II/ Kardiologie und Internistische Intensivmedizin Katholisches Krankenhaus, "St. Johann Nepomuk", Haarbergstrasse 72, 99097, Erfurt, Germany
| | - Mostafa Sayahkarajy
- Faculty of Biosciences and Medical Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Malaysia
| | - Eko Supriyanto
- Advanced Diagnostics and Progressive Human Care Research Group, IJN-UTM Cardiovascular Engineering Centre, Faculty of Biosciences and Medical Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Malaysia
| | - Amiliana Soesanto
- Department Cardiology & Vascular Medicine, Faculty of Medicine Universitas Indonesia/ National Cardiovascular Center "Harapan Kita", 11420, Jakarta, Indonesia
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Tang XJ, Bao M, Zhao H, Wang LY, Wu QY. Intraoperative Transesophageal Echocardiography in the Operation of Ebstein's Anomaly: A Retrospective Study. Chin Med J (Engl) 2017. [PMID: 28639568 PMCID: PMC5494916 DOI: 10.4103/0366-6999.208233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Xiu-Jie Tang
- Heart Center, First Hospital of Tsinghua University, Beijing 100016, China
| | - Min Bao
- Department of Cardiovascular, Capital Institute of Pediatrics, Beijing 100020, China
| | - He Zhao
- Department of Cardiovascular, Capital Institute of Pediatrics, Beijing 100020, China
| | - Lian-Yi Wang
- Heart Center, First Hospital of Tsinghua University, Beijing 100016, China
| | - Qing-Yu Wu
- Heart Center, First Hospital of Tsinghua University, Beijing 100016, China
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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. Heart Vessels 2017; 32:893-901. [PMID: 28130587 DOI: 10.1007/s00380-016-0931-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 12/09/2016] [Indexed: 10/20/2022]
Abstract
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.
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El Sebaie MH, Abdelatti M, Zarea A, Farag A, Hashem A, Fadel A. Assessment of mitral valve geometric deformity in patients with ischemic heart disease using three-dimensional echocardiography. Egypt Heart J 2017; 69:13-20. [PMID: 29622950 PMCID: PMC5839364 DOI: 10.1016/j.ehj.2016.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/14/2016] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Maha H. El Sebaie
- Cardiology Department, Zagazig University, Egypt
- King Abdulla Medical City, Saudi Arabia
| | - M.N. Abdelatti
- Anesthesia Department, King Abdulla Medical City, Saudi Arabia
| | - A.A. Zarea
- Anesthesia Department, King Abdulla Medical City, Saudi Arabia
| | - A.M. Farag
- Anesthesia Department, King Abdulla Medical City, Saudi Arabia
| | - A.A. Hashem
- Anesthesia Department, King Abdulla Medical City, Saudi Arabia
| | - A.M. Fadel
- Anesthesia Department, King Abdulla Medical City, Saudi Arabia
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Patil TA, Nierich A. Transesophageal echocardiography evaluation of the thoracic aorta. Ann Card Anaesth 2016; 19:S44-S55. [PMID: 27762248 PMCID: PMC5100242 DOI: 10.4103/0971-9784.192623] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/20/2016] [Indexed: 11/04/2022] Open
Abstract
Transesophageal echocardiography (TEE) can be used to identify risk factors such as aortic atherosclerosis [2] before any sort of surgical manipulations involving aorta and its related structures. TEE has become an important noninvasive tool to diagnose acute thoracic aortic pathologies. TEE evaluation of endoleaks helps early detection and immediate corrective interventions. TEE is an invaluable imaging modality in the management of aortic pathology. TEE has to a large extent improved the patient outcomes.
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Affiliation(s)
- T. A. Patil
- Seniore Consultant, Department of Anaesthesia, Fortis Hospital, Bengaluru, Karnataka, India
| | - Arno Nierich
- Cardiothoracic Anaesthesiologist Intensivist, Isala Sophia, Zwolle, Netherlands
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Ramadan ME, Buohliqah L, Crestanello J, Ralston J, Igoe D, Awad H. Iatrogenic aortic dissection after minimally invasive aortic valve replacement: a case report. J Cardiothorac Surg 2016; 11:136. [PMID: 27557530 PMCID: PMC4997721 DOI: 10.1186/s13019-016-0531-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/23/2016] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Mohamed Ehab Ramadan
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, N411 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Lamia Buohliqah
- Department of Otolaryngology - Head & Neck Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Juan Crestanello
- Department of Surgery, Division of Cardiac Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - James Ralston
- Perfusion Services, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - David Igoe
- Perfusion Services, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Hamdy Awad
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, N411 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.
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Central venous catheter tip migration due to tracheal extubation: a prospective randomized study. J Clin Monit Comput 2016; 31:951-959. [PMID: 27469608 DOI: 10.1007/s10877-016-9914-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
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.
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Abstract
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.
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18
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Poelaert JI, Bouchez S. Perioperative echocardiographic assessment of mitral valve regurgitation: a comprehensive review. Eur J Cardiothorac Surg 2016; 50:801-812. [DOI: 10.1093/ejcts/ezw196] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/04/2016] [Indexed: 12/15/2022] Open
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Real-time magnetic resonance imaging-guided transcatheter aortic valve replacement. J Thorac Cardiovasc Surg 2015; 151:1269-77. [PMID: 26725711 DOI: 10.1016/j.jtcvs.2015.11.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 10/08/2015] [Accepted: 11/15/2015] [Indexed: 12/31/2022]
Abstract
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.
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Peng YG, Song H, Wang E, Wang W, Liu J. Essential training steps to achieving competency in the basic intraoperative transesophageal echocardiography examination for Chinese anesthesiologists. Front Med 2014; 9:123-8. [PMID: 25337689 DOI: 10.1007/s11684-014-0366-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 07/29/2014] [Indexed: 11/30/2022]
Abstract
Guidelines for the intraoperative transesophageal echocardiography (TEE) examination have defined a detailed standard for medical professionals, particularly anesthesiologists, on how a TEE exam should proceed. Over the years, TEE has gained substantial popularity and emerged as a preferred monitoring modality to aid in perioperative management and decision making during hemodynamic instability situations or critical care settings. TEE training pathways and practice guidelines have been well established in western countries and many regions of the world. However, TEE training and practice information for anesthesiologists are lacking in China. As innovative technologies develop, other educational models have emerged to aid in obtaining competency in basic TEE exam. Hence, establishing a consensus on the ideal TEE training approach for anesthesiologists in China is urgently needed. Developing an effective curriculum that can be incorporated into an anesthesiology resident's overall training is also necessary to provide knowledge and skills toward competency in basic TEE exam. With evolving medical system reforms and increasing demands for intraoperative hemodynamic monitoring to accommodate surgical innovations, anesthesiology professionals are increasingly obliged to perform intraoperative TEE exams in their current and future practices. To overcome obstacles and achieve significant progress in using the TEE modality to help in intraoperative management and surgical decision making, publishing basic TEE training guidelines for China's anesthesiologists is an important endeavor.
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Affiliation(s)
- Yong G Peng
- Department of Anesthesiology, College of Medicine, University of Florida Shands Hospital, Gainesville, FL, 32610, USA,
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21
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Abstract
Transesophageal echocardiography (TEE) has been established as a very valuable asset for patient monitoring during cardiac surgery. The value of perioperative TEE for patients undergoing noncardiac surgery is less clear. This article reviews the technical aspects of TEE and comments on the potential benefit of using TEE as a monitoring modality apart from cardiac surgery. Based on patient's comorbidities and/or injury pattern, TEE is a fast and minimally invasive approach to obtain important hemodynamic information, especially useful in a hemodynamically unstable patient. However, certain requirements for the use of the technique are necessary, most important the development of sufficient echocardiographic skills by the anesthesiologists. Indications, skill requirements, and possible complications of the technique are reviewed.
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Song Y, Shim JK, Sun JM, Lee B, Kwak YL. Echocardiographic detection of left atrial mobile calcium debris of trido valve surgery: a case report. Korean J Anesthesiol 2014; 66:314-6. [PMID: 24851169 PMCID: PMC4028561 DOI: 10.4097/kjae.2014.66.4.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/08/2013] [Accepted: 04/03/2013] [Indexed: 11/12/2022] Open
Abstract
Calcification of the cardiac chambers is among the challenges associated with reoperative cardiac surgeries by increasing the risk of systemic embolization. We experienced a case of an unexpected detected mass by intraoperative transesophageal echocardiography during weaning from cardiopulmonary bypass in a patient undergoing trido mitral and tricuspid valve replacement surgery. The surgically removed mass was identified as calcified tissue. This case shows the importance of careful echocardiographic evaluation of the left heart in patients undergoing repeat valve surgery given their greater potential for embolic sources.
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Affiliation(s)
- Young Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Min Sun
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Bora Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Ender J, Sgouropoulou S. Value of transesophageal echocardiography (TEE) guidance in minimally invasive mitral valve surgery. Ann Cardiothorac Surg 2013; 2:796-802. [PMID: 24349984 DOI: 10.3978/j.issn.2225-319x.2013.10.09] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 08/20/2013] [Indexed: 11/14/2022]
Abstract
The role of intraoperative transesophageal echocardiography (TEE) has increased tremendously since its first use in 1979. Today intraoperative TEE is a class I indication for surgical mitral valve reconstruction for evaluation of mitral valve pathology, graduation of mitral regurgitation and detection of potential risk factors as well as post-repair assessment. Real-time three-dimensional TEE offers anatomical visualization of the mitral valve apparatus, fundamental for virtual surgical planning of proper annuloplasty ring size. As minimally invasive and even off-pump techniques for mitral valve repair become more popular, image guidance by intraoperative TEE will play an essential role.
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Affiliation(s)
- Jörg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heartcenter Leipzig, University Leipzig, Germany
| | - Sophia Sgouropoulou
- Department of Anesthesiology and Intensive Care Medicine, Heartcenter Leipzig, University Leipzig, Germany
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Transesophageal Echocardiography in Healthy Young Adult Male Baboons ( Papio hamadryas anubis): Normal Cardiac Anatomy and Function in Subhuman Primates Compared to Humans. PROGRESS IN PEDIATRIC CARDIOLOGY 2013; 35:109-120. [PMID: 24707162 DOI: 10.1016/j.ppedcard.2013.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Implantable, viable tissue engineered cardiovascular constructs are rapidly approaching clinical translation. Species typically utilized as preclinical large animal models are food stock ungulates for which cross species biological and genomic differences with humans are great. Multiple authorities have recommended developing subhuman primate models for testing regenerative surgical strategies to mitigate xenotransplant inflammation. However, there is a lack of specific quantitative cardiac imaging comparisons between humans and the genomically similar baboons (Papio hamadryas anubis). This study was undertaken to translate to baboons transesophageal echocardiographic functional and dimensional criteria defined as necessary for defining cardiac anatomy and function in the perioperative setting. Seventeen young, healthy baboons (approximately 30 kg, similar to 5 year old children) were studied to determine whether the requisite 11 views and 52 measurement parameters could be reliably acquired by transesophageal echocardiography (TEE). The obtained measurements were compared to human adult normative literature values and to a large relational database of pediatric "normal heart" echo measurements. Comparisons to humans, when normalized to BSA, revealed a trend in baboons toward larger mitral and aortic valve effective orifice areas and much larger left ventricular muscle mass and wall thickness, but similar pulmonary and tricuspid valves. By modifying probe positioning relative to human techniques, all recommended TEE views except transgastric could be replicated. To supplement, two transthoracic apical views were discovered that in baboons could reliably replace the transgastric TEE view. Thus, all requisite echo views could be obtained for a complete cardiac evaluation in Papio hamadryas anubis to noninvasively quantify cardiac structural anatomy, physiology, and dimensions. Despite similarities between the species, there are subtle and important physiologic and anatomic differences when compared to human.
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Cioccari L, Baur HR, Berger D, Wiegand J, Takala J, Merz TM. Hemodynamic assessment of critically ill patients using a miniaturized transesophageal echocardiography probe. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R121. [PMID: 23786797 PMCID: PMC4056104 DOI: 10.1186/cc12793] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 06/20/2013] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Hemodynamic management in intensive care patients guided by blood pressure and flow measurements often do not sufficiently reveal common hemodynamic problems. Trans-esophageal echocardiography (TEE) allows for direct measurement of cardiac volumes and function. A new miniaturized probe for TEE (mTEE) potentially provides a rapid and simplified approach to monitor cardiac function. The aim of the study was to assess the feasibility of hemodynamic monitoring using mTEE in critically ill patients after a brief operator training period. METHODS In the context of the introduction of mTEE in a large ICU, 14 ICU staff specialists with no previous TEE experience received six hours of training as mTEE operators. The feasibility of mTEE and the quality of the obtained hemodynamic information were assessed. Three standard views were acquired in hemodynamically unstable patients: 1) for assessment of left ventricular function (LV) fractional area change (FAC) was obtained from a trans-gastric mid-esophageal short axis view, 2) right ventricular (RV) size was obtained from mid-esophageal four chamber view, and 3) superior vena cava collapsibility for detection of hypovolemia was assessed from mid-esophageal ascending aortic short axis view. Off-line blinded assessment by an expert cardiologist was considered as a reference. Inter-rater agreement was assessed using Chi-square tests or correlation analysis as appropriate. RESULTS In 55 patients, 148 mTEE examinations were performed. Acquisition of loops in sufficient quality was possible in 110 examinations for trans-gastric mid-esophageal short axis, 118 examinations for mid-esophageal four chamber and 125 examinations for mid-esophageal ascending aortic short axis view. Inter-rater agreement (Kappa) between ICU mTEE operators and the reference was 0.62 for estimates of LV function, 0.65 for RV dilatation, 0.76 for hypovolemia and 0.77 for occurrence of pericardial effusion (all P<0.0001). There was a significant correlation between the FAC measured by ICU operators and the reference (r=0.794, P (one-tailed)<0.0001). CONCLUSIONS Echocardiographic examinations using mTEE after brief bed-side training were feasible and of sufficient quality in a majority of examined ICU patients with good inter-rater reliability between mTEE operators and an expert cardiologist. Further studies are required to assess the impact of hemodynamic monitoring by mTEE on relevant patient outcomes.
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Ramsingh D, Alexander B, Cannesson M. Clinical review: Does it matter which hemodynamic monitoring system is used? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:208. [PMID: 23672729 PMCID: PMC3745643 DOI: 10.1186/cc11814] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hemodynamic monitoring and management has greatly improved during the past decade. Technologies have evolved from very invasive to non-invasive, and the philosophy has shifted from a static approach to a functional approach. However, despite these major changes, the critical care community still has potential to improve its ability to adopt the most modern standards of research methodology in order to more effectively evaluate new monitoring systems and their impact on patient outcome. Today, despite the huge enthusiasm raised by new hemodynamic monitoring systems, there is still a big gap between clinical research studies evaluating these monitors and clinical practice. A few studies, especially in the perioperative period, have shown that hemodynamic monitoring systems coupled with treatment protocols can improve patient outcome. These trials are small and, overall, the corpus of science related to this topic does not yet fit the standard of clinical research methodology encountered in other specialties such as cardiology and oncology. Larger randomized trials or quality improvement processes will probably answer questions related to the real impact of these systems.
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[Real-time 3 dimensional full volume data set : benefits in problem focused intraoperative transesophageal echocardiography]. Anaesthesist 2012; 61:875-82. [PMID: 23080355 DOI: 10.1007/s00101-012-2088-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 08/31/2012] [Accepted: 09/03/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Comprehensive intraoperative transesophageal echcardiography (TEE) includes various measurements for quantification of cardiac chambers and valves based on multiple two dimensional (2D) standard views. Due to shortness of time during cardiac surgery most centres in Germany only carry out problem focussed intraoperative examinations which does not allow the complete repertoire of measurements to be exhausted. The aim of this study was to investigate which measurements for cardiac chamber and valve quantification can be performed with the acquisition of a real-time 3D full volume (RT-3D-FV) data set and to compare these measurements with those based on standard 2D views. MATERIALS AND METHODS In patients undergoing elective surgical mitral valve repair a comprehensive 2D TEE examination according to the guidelines of the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) was performed after induction of anesthesia. Additionally, a RT-3D-FV TEE data set based on the midesophageal four chamber view was recorded (iE 33, Philips, Netherlands). All measurements of the 2D TEE and the RT-3D-FV dataset (Qlab) were performed offline by two independent examiners. RESULTS After approval by the local ethic committee and obtaining written informed consent 50 patients (31 male and 19 female) with a mean age of 59.4 ± 11.5 years were enrolled in this study. All measurements recommended for chamber and valve quantification could be performed on the basis of the RT-3D-FV data set except for measurements of the sinus of Valsalva and the sinotubular junction. There was good correlation between the results of the two methods. CONCLUSIONS For intraoperative problem focussed TEE examinations the acquisition of an additional RT-3D-FV TEE data set allows accurate measurement of most of the recommended chamber and valve quantification parameters.
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Peng YG, Janelle GM. Emergent limited perioperative transesophageal echocardiography: should new guidelines exist for limited echocardiography training for anesthesiologists? Front Med 2012; 6:332-7. [PMID: 22837064 DOI: 10.1007/s11684-012-0212-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 06/12/2012] [Indexed: 11/29/2022]
Abstract
Bedside limited echocardiography, or focused cardiac ultrasound, continues to gain popularity in many emergency rooms, intensive care units, and operating rooms as a rapid method of assessing unstable patients. Effective monitoring of cardiovascular function in conditions like cardiac arrest or near-arrest is the crucial step to guide successful resuscitative efforts. Transesophageal echocardiography (TEE) has emerged as one of the preferred cardiac diagnostic and monitoring modalities in the intraoperative setting due to the fact that it is less invasive than many other monitors, is immediately accessible, and allows for continuous real-time monitoring of cardiac function. However, the minimum training requirements needed for the anesthesia provider to obtain the competency, knowledge, and skills for basic certification in perioperative TEE far exceed those developed for other medical specialties. We believe there is an urgent need to develop (1) practical guidelines for emergent perioperative TEE use for anesthesiologists and (2) a requisite educational curriculum to teach the basic skills necessary to aid in the diagnosis and treatment of cardiac arrest or near-arrest scenarios. The measures elucidated in this report summarize the efforts of the Department of Anesthesiology at the University of Florida in establishing the necessary steps to make this process not only practical, but accessible to all trainees.We hope that these collective efforts will provide more trainees the confidence in utilizing TEE to aid in establishing a diagnosis in critical situations.
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Affiliation(s)
- Yong G Peng
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254 JHMHSC, Gainesville, FL 32610-0254, USA.
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Heß H, Eibel S, Mukherjee C, Kaisers UX, Ender J. Quantification of mitral valve regurgitation with color flow Doppler using baseline shift. Int J Cardiovasc Imaging 2012; 29:267-74. [PMID: 22752361 DOI: 10.1007/s10554-012-0084-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 06/11/2012] [Indexed: 11/27/2022]
Abstract
Vena contracta width (VCW) and effective regurgitant orifice area (EROA) are well established methods for evaluating mitral regurgitation using transesophageal echocardiography (TEE). For color-flow Doppler (CF) measurements Nyquist limit of 50-60 cm/s is recommended. Aim of the study was to investigate the effectiveness of a baseline shift of the Nyquist limit for these measurements. After a comprehensive 2-dimensional (2D) TEE examination, the mitral regurgitation jet was acquired with a Nyquist limit of 50 cm/s (NL50) along with a baseline shift to 37.5 cm/s (NL37.5) using CF. Moreover a real time 3-dimensional (RT 3D) color complete volume dataset was stored with a Nyquist limit of 50 cm/s (NL50) and 37.5 cm/s (NL37.5). Vena contracta width (VCW) as well as proximal isovelocity surface area (PISA) derived EROA were measured based on 2D TEE and compared to RT 3D echo measurements for vena contracta area (VCA) using planimetry method. Correlation between VCA 3D NL50 and VCW NL50 was 0.29 (p < 0.05) compared to 0.6 (p < 0.05) using NL37.5. Correlation between VCA 3D NL50 and EROA 2D NL50 was 0.46 (p < 0.05) vs. 0.6 (p < 0.05) EROA 2D NL37.5. Correlation between VCA 3D NL37.5 and VCW NL50 was 0.45 (p < 0.05) compared to 0.65 (p < 0.05) using VCW NL37.5. Correlation between VCA 3D NL37.5 and EROA 2D NL50 was 0.41 (p < 0.05) vs. 0.53 (p < 0.05) using EROA 2D NL37.5. Baseline shift of the NL to 37.5 cm/s improves the correlation for VCW and EROA when compared to RT 3D NL50 planimetry of the vena contracta area. Baseline shift in RT 3D to a NL of 37.5 cm/s shows similar results like NL50.
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Affiliation(s)
- Hannah Heß
- Department of Anesthesiology and Intensive Care Medicine, Heartcenter, University Leipzig, Leipzig, Germany
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Abstract
Surgical replacement of aortic valves is the gold standard for therapy of high grade aortic valve stenosis. However, the changes in demography confront the responsible medical discipline with an increasingly higher risk profile of patients which necessitates the development of new less invasive alternative forms of treatment for the surgical therapy of aortic valve stenosis. This developmental process has progressed from mini-thoracotomy to transcatheter aortic valve implantation (TAVI). The TAVI procedure is a new therapeutic option for treatment of patients with high grade aortic valve stenosis and high perioperative morbidity and mortality risks with conventional aortic valve replacement. Because TAVI can be carried out while the heart is still beating and without a sternotomy or heart-lung maschine, this procedure is particularly suitable for elderly multimorbid patients and/or patients with previous cardiac surgery. The initial results of large prospective multicenter studies underline the value of TAVI in the modern treatment of high risk patients with symptomatic aortic valve stenosis. In addition to an understanding of the surgical procedure, anesthetists must have precise knowledge of the perioperative anesthesia management and possible complications of the procedure.
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Kasper J, Bolliger D, Skarvan K, Filipovic M, Seeberger M. O-30 Evaluation of additional transoesophageal echocardiographic views for examination of the tricuspid and the pulmononary valve. J Cardiothorac Vasc Anesth 2011. [DOI: 10.1053/j.jvca.2011.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ender J, Eibel S, Mukherjee C, Mathioudakis D, Borger MA, Jacobs S, Mohr FW, Falk V. Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography. ACTA ACUST UNITED AC 2011; 12:445-53. [PMID: 21546375 PMCID: PMC3117468 DOI: 10.1093/ejechocard/jer042] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Aims We sought to investigate the additional value of real-time three-dimensional transoesophageal echocardiography (RT 3D TOE)-guided sizing for predicting annuloplasty ring size during mitral valve repair. Methods and results In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively. The digitally stored loops were imported into a software for mitral valve assessment. The annuloplasty ring size was predicted by superimposing computer-aided design (CAD) models of annuloplasty rings onto Live 3D zoom loops, measurement of the intercommissural distance, or the height of the anterior mitral leaflet. The surgeon implanted the annuloplasty ring according to the usual surgical technique and was blinded to the echocardiographic measurement results. Pre-operative correlation between the selected ring size with mitral valve assessment and the actual implanted annuloplasty ring size was 0.91. The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75. The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height. Conclusion Superimposition of annuloplasty ring CAD models on the Live 3D zoom loops of the mitral valve using mitral valve assessment is superior to two-dimensional measurements of the intercommissural distance or the height of the anterior mitral leaflet in predicting correct annuloplasty ring size.
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Affiliation(s)
- J Ender
- Department of Anaesthesiology and Intensive Care Medicine II, Leipzig Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany.
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Kamra K, Russell I, Miller-Hance WC. Role of transesophageal echocardiography in the management of pediatric patients with congenital heart disease. Paediatr Anaesth 2011; 21:479-93. [PMID: 21481076 DOI: 10.1111/j.1460-9592.2011.03570.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Transesophageal echocardiography (TEE) has become a critical diagnostic and perioperative management tool for patients with congenital heart disease (CHD) undergoing cardiac and noncardiac surgical procedures. This review highlights the role of TEE in routine management of pediatric cardiac patient population with focus on indications, views, applications and technological advances.
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Affiliation(s)
- Komal Kamra
- Department of Anesthesiology, Stanford University, Lucile Packard Children’s Hospital, Palo Alto, CA, USA.
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Vergnat M, Jassar AS, Jackson BM, Ryan LP, Eperjesi TJ, Pouch AM, Weiss SJ, Cheung AT, Acker MA, Gorman JH, Gorman RC. Ischemic mitral regurgitation: a quantitative three-dimensional echocardiographic analysis. Ann Thorac Surg 2011; 91:157-64. [PMID: 21172506 DOI: 10.1016/j.athoracsur.2010.09.078] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 09/27/2010] [Accepted: 09/30/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND A comprehensive three-dimensional echocardiography based approach is applied to preoperative mitral valve (MV) analysis in patients with ischemic mitral regurgitation (IMR). This method is used to characterize the heterogeneous nature of the pathologic anatomy associated with IMR. METHODS Intraoperative real-time three-dimensional transesophageal echocardiograms of 18 patients with IMR (10 with anterior, 8 with inferior infarcts) and 17 patients with normal MV were analyzed. A customized image analysis protocol was used to assess global and regional determinants of annular size and shape, leaflet tethering and curvature, relative papillary muscle anatomy, and anatomic regurgitant orifice area. RESULTS Both mitral annular area and MV tenting volume were increased in the IMR group as compared with patients with normal MV (mitral annular area=1,065±59 mm2 versus 779±44 mm2, p=0.001; and MV tenting volume=3,413±403 mm3 versus 1,696±200 mm3, p=0.001, respectively). Within the IMR group, patients with anterior infarct had larger annuli (1,168±99 mm2) and greater tenting volumes (4,260±779 mm3 versus 2,735±245 mm3, p=0.06) than the inferior infarct subgroup. Papillary-annular distance was increased in the IMR group relative to normal; these distances were largest in patients with anterior infarcts. Whereas patients with normal MV had very consistent anatomic determinants, annular shape and leaflet tenting distribution in the IMR group were exceedingly variable. Mean anatomic regurgitant orifice area was 25.8±3.0 mm2, and the number of discrete regurgitant orifices varied from 1 to 4. CONCLUSIONS Application of custom analysis techniques to three-dimensional echocardiography images allows a quantitative and systematic analysis of the MV, and demonstrates the extreme variability in pathologic anatomy that occurs in patients with severe IMR.
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Affiliation(s)
- Mathieu Vergnat
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Jassar AS, Brinster CJ, Vergnat M, Robb JD, Eperjesi TJ, Pouch AM, Cheung AT, Weiss SJ, Acker MA, Gorman JH, Gorman RC, Jackson BM. Quantitative mitral valve modeling using real-time three-dimensional echocardiography: technique and repeatability. Ann Thorac Surg 2011; 91:165-71. [PMID: 21172507 DOI: 10.1016/j.athoracsur.2010.10.034] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 10/13/2010] [Accepted: 10/18/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Real-time three-dimensional (3D) echocardiography has the ability to construct quantitative models of the mitral valve (MV). Imaging and modeling algorithms rely on operator interpretation of raw images and may be subject to observer-dependent variability. We describe a comprehensive analysis technique to generate high-resolution 3D MV models and examine interoperator and intraoperator repeatability in humans. METHODS Patients with normal MVs were imaged using intraoperative transesophageal real-time 3D echocardiography. The annulus and leaflets were manually segmented using a TomTec Echo-View workstation. The resultant annular and leaflet point cloud was used to generate fully quantitative 3D MV models using custom Matlab algorithms. Eight images were subjected to analysis by two independent observers. Two sequential images were acquired for 6 patients and analyzed by the same observer. Each pair of annular tracings was compared with respect to conventional variables and by calculating the mean absolute distance between paired renderings. To compare leaflets, MV models were aligned so as to minimize their sum of squares difference, and their mean absolute difference was measured. RESULTS Mean absolute annular and leaflet distance was 2.4±0.8 and 0.6±0.2 mm for the interobserver and 1.5±0.6 and 0.5±0.2 mm for the intraobserver comparisons, respectively. There was less than 10% variation in annular variables between comparisons. CONCLUSIONS These techniques generate high-resolution, quantitative 3D models of the MV and can be used consistently to image the human MV with very small interoperator and intraoperator variability. These data lay the framework for reliable and comprehensive noninvasive modeling of the normal and diseased MV.
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Affiliation(s)
- Arminder Singh Jassar
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Mestres CA, Fita G, Azqueta M, Miró JM. Role of echocardiogram in decision making for surgery in endocarditis. Curr Infect Dis Rep 2011; 12:321-8. [PMID: 21308513 DOI: 10.1007/s11908-010-0124-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Infective endocarditis is a serious disease that carries significant morbidity and mortality. Adequate treatment is based on a high degree of clinical suspicion, accurate microbiologic diagnosis, and high-quality imaging. Echocardiography has been shown to be a fundamental tool for diagnosis and management. Currently accepted Duke criteria include blood cultures and echocardiography. Transthoracic and transesophageal echocardiography play a critical role in the decision-making process, especially when surgical treatment is contemplated. Because infective endocarditis is considered a medical and surgical disease, and considering that the current rate of surgery is about 50%, echocardiography has definite value in preoperative diagnosis and surgical planning, intraoperative confirmation of lesions and quality of repair or replacement before and after cardiopulmonary bypass, and postoperative assessment.
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Affiliation(s)
- Carlos-A Mestres
- Department of Cardiovascular Surgery, Hospital Clinic-IDIBAPS, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain,
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Sellevold O. Eksamen skjerper. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:340. [DOI: 10.4045/tidsskr.10.1186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Case report: transesophageal echocardiography detected severe regional wall motion abnormalities signifying failed reimplantation of an anomalous left main coronary artery. Can J Anaesth 2010; 58:290-5. [PMID: 21181565 DOI: 10.1007/s12630-010-9443-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 12/03/2010] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Anomalous coronary arteries comprise a spectrum ranging from benign to fatal. The most ominous lesion that occurs is the left main coronary artery (LMCA) originating from the opposite aortic sinus. This defect usually presents as sudden death in a healthy young adult immediately after exercise. We report a case of reimplantation of an anomalous LMCA, discovered in a 15-yr-old girl during investigations for atypical chest pain. CLINICAL FEATURES The intraoperative transesophageal echocardiography (TEE) confirmed that the anomalous LMCA originated from the right aortic sinus. The anomalous LMCA was reimplanted to the left aortic sinus, but the patient could not be weaned from cardiopulmonary bypass because of severe hypotension. The TEE demonstrated severe regional wall motion abnormalities (RWMA) in the territory of the LMCA with akinesis of the septal, antero-septal, anterior, and lateral walls. Using TEE, flow could not be seen in the reimplanted LMCA, hence, the differential diagnosis was established as failed reimplantation of the LMCA, coronary air embolism, or poor myocardial preservation, but the latter two causes were extremely unlikely. Surgical inspection of the reimplanted LMCA did not reveal a correctable problem. A left internal mammary artery to proximal left anterior descending (LAD) artery graft was completed with resolution of the previous RWMA. Recovery of function in the lateral wall confirmed retrograde flow from the LAD into the circumflex artery. CONCLUSIONS Transesophageal echocardiography was critical in rapidly determining the cause of hemodynamic instability following this uncommon operation. Despite the availability of newer techniques to detect and quantify RWMA, the assessment of wall motion and contractility remains subjective.
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Jerath A, Vegas A, Meineri M, Silversides C, Feindel C, Beattie S, Corrin M, Tait G. An interactive online 3D model of the heart assists in learning standard transesophageal echocardiography views. Can J Anaesth 2010; 58:14-21. [DOI: 10.1007/s12630-010-9410-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022] Open
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40
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Mahmood F, Gorman JH, Subramaniam B, Gorman RC, Panzica PJ, Hagberg RC, Lerner AB, Hess PE, Maslow A, Khabbaz KR. Changes in mitral valve annular geometry after repair: saddle-shaped versus flat annuloplasty rings. Ann Thorac Surg 2010; 90:1212-20. [PMID: 20868816 DOI: 10.1016/j.athoracsur.2010.03.119] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 03/17/2010] [Accepted: 03/22/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Saddle-shaped annuloplasty rings are being increasingly used during mitral valve (MV) repair to conform the mitral annulus to a more nonplanar shape and possibly reduce leaflet stress. In this study utilizing three-dimensional transesophageal echocardiography we compared the effects of rigid flat rings with those of the saddle rings on the mitral annular geometry. Specifically we measured the changes in nonplanarity angle (NPA) before and after MV repair. METHODS Geometric analysis on 38 patients undergoing MV repair for myxomatous and ischemic mitral regurgitation with full flat rings (n = 18) and saddle rings (n = 18) were performed. The acquired three-dimensional volumetric data were analyzed utilizing the "Image Arena" software (TomTec GmBH, Munich, Germany). Specifically, the degree of change in the NPA was calculated and compared before and after repair for both types of rings. RESULTS Both types of annuloplasty rings resulted in significant changes in the geometric structure of the MV after repair. However, saddle rings lead to a decrease in the NPA (7% for ischemic and 8% for myxomatous MV repairs) (ie, made the annulus more nonplanar), whereas flat rings increased the NPA (7.9% for ischemic and 11.8% for myxomatous MV repairs) (ie, made the annulus less nonplanar); p value 0.001 or less. CONCLUSIONS Implantation of saddle-shaped rings during MV repair surgery is associated with augmentation of the nonplanar shape of the mitral annulus (ie, decreases NPA). This favorable change in the mitral annular geometry could possibly confer a structural advantage to MV repairs with the saddle rings.
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Affiliation(s)
- Feroze Mahmood
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Wang Y, Gao CQ, Wang JL, Yang M. The Role of Intraoperative Transesophageal Echocardiography in Robotic Mitral Valve Repair. Echocardiography 2010; 28:85-91. [DOI: 10.1111/j.1540-8175.2010.01274.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Feneck R, Kneeshaw J, Fox K, Bettex D, Erb J, Flaschkampf F, Guarracino F, Ranucci M, Seeberger M, Sloth E, Tschernich H, Wouters P, Zamorano J. Recommendations for reporting perioperative transoesophageal echo studies. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:387-93. [DOI: 10.1093/ejechocard/jeq043] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Gripari P, Tamborini G, Barbier P, Maltagliati AC, Galli CA, Muratori M, Salvi L, Sisillo E, Alamanni F, Pepi M. Real-time three-dimensional transoesophageal echocardiography: a new intraoperative feasible and useful technology in cardiac surgery. Int J Cardiovasc Imaging 2010; 26:651-60. [PMID: 20352342 DOI: 10.1007/s10554-010-9622-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Accepted: 03/11/2010] [Indexed: 10/19/2022]
Abstract
A new generation of transoesophageal echocardiographic probes with a novel matrix array technique has been recently introduced, allowing three-dimensional (3D) presentation of cardiac structures in real-time. This new tool may potentially provide fast and complete 3D information about cardiac structures improving spatial orientation and overcoming limitations of offline 3D technologies. The aim of this study was to demonstrate the feasibility and usefulness of real-time 3D transoesophageal echocardiography (TOE) for the intraoperative evaluation of cardiac surgery procedures. One-hundred patients underwent transoesophageal echocardiographic examination during cardiac surgery as a part of their routine clinical practice. In the intraoperative pre- and post-cardiopulmonary bypass periods complete 2D and 3D transoesophageal examinations were performed. Feasibility and duration of examinations, and immediate additional anatomical value of 3D versus 2D-TOE were annotated intraoperatively. Image quality, additional clinical value of 3D- compared to standard 2D-TOE and the accuracy in the description of mitral valve pathology by a surgeon and an echocardiographer were evaluated off-line. No complications related to transoesophageal examination occurred and successful intubation was achieved in all 100 patients. Therefore, 200 examinations were performed and analysed considering the pre- and post-cardiopulmonary bypass periods. The mean number of acquisitions per patient was 16 +/- 14, including 3D real-time, zoom, full-volume and colour full volume modalities. The duration of the 3D examination was 16 +/- 10 min and the mean image quality score 2.8 +/- 0.7 (in a scale 1-4). In 36 out of 100 cases (36%) 3D-TOE provided additional anatomical information. The surgeon evaluated 3D images easier and more accurately than 2D images (88% vs. 76% in the evaluation of mitral valve scallop). Real-time 3D TOE may be used routinely for the intraoperative evaluation of cardiac surgery. Imaging with this new probe facilitates intraoperative evaluation of several surgical procedures with an additional clinical value in selected cases.
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Affiliation(s)
- Paola Gripari
- Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Via Parea 4, Milan, Italy.
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Sung TY, Kim SH, Kim DK, Yoon TG, Kim TY, Lim JA, Woo NS. Abrupt formation and spontaneous resolution of a right atrial thrombus detected by intraoperative transesophageal echocardiography during replacement of an abdominal aortic aneurysm. J Anesth 2010; 24:456-9. [PMID: 20238231 DOI: 10.1007/s00540-010-0923-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 02/11/2010] [Indexed: 11/25/2022]
Abstract
Intraoperative formation of a thrombus in the right atrium and its management has occasionally been reported. However, spontaneous resolution of right atrial thrombi, without any event, is rare. We report a case of abrupt right atrial thrombus formation and spontaneous resolution, with no events, detected by transesophageal echocardiography during the replacement of an abdominal aortic aneurysm.
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Affiliation(s)
- Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Hwayang-dong, Gwangjin-gu, Seoul, 143-729, Korea
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Mahmood F, Subramaniam B, Gorman JH, Levine RM, Gorman RC, Maslow A, Panzica PJ, Hagberg RM, Karthik S, Khabbaz KR. Three-dimensional echocardiographic assessment of changes in mitral valve geometry after valve repair. Ann Thorac Surg 2010; 88:1838-44. [PMID: 19932245 DOI: 10.1016/j.athoracsur.2009.07.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 06/27/2009] [Accepted: 07/02/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND Application of annuloplasty rings during mitral valve (MV) repair has been shown to significantly change the mitral annular geometry. Until recently, a comprehensive two-dimensional echocardiographic evaluation of annular geometric changes was difficult owing to its nonplanar orientation. In this study, an analysis of the three-dimensional intraoperative transesophageal echocardiographic evaluation of the MV annulus is presented before and immediately after repair. METHODS We performed three-dimensional geometric analysis on 75 patients undergoing MV repair during coronary artery bypass graft surgery for mitral regurgitation or myxomatous mitral valve disease. Geometric analysis of the MV was performed before and immediately after valve repair with full rings and annuloplasty bands. The acquired three-dimensional volumetric data were analyzed in the operating room. Specific measurements included annular diameter, leaflet lengths, the nonplanarity angle, and the circularity index. Before and after repair data were compared. RESULTS Complete echocardiographic assessment of the MV was feasible in 69 of 75 patients (92%) within 2 to 3 minutes of acquisition. Placement of full rings resulted in an increase in the nonplanarity angle or a less saddle shape of the native mitral annulus (137 +/- 14 versus 146 +/- 14; p = 0.002. By contrast, the nonplanarity angle did not change significantly after placement of partial rings. CONCLUSIONS Mitral annular nonplanarity can be assessed in the operating room. Application of full annuloplasty rings resulted in the mitral annulus becoming more planar. Partial annuloplasty bands did not significantly change the nonplanarity angle. Neither of the two types of rings restored the native annular planarity.
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Affiliation(s)
- Feroze Mahmood
- Department of Anesthesia and Critical Care and Pain Management, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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George L. Review of intraoperative TOE. Australas J Ultrasound Med 2009; 12:30-36. [PMID: 28191053 PMCID: PMC5024836 DOI: 10.1002/j.2205-0140.2009.tb00051.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lenore George
- Department of Anaesthesia Westmead Hospital Sydney New South Wales 2145 Australia
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Nakahira J, Ohnishi Y, Nohmi T, Sawai T, Kuro M. Usefulness of transesophageal echocardiography for identifying the precise location of a left ventricular rupture in a patient with collapsed cardiac chamber. J Anesth 2009; 23:108-10. [PMID: 19234832 DOI: 10.1007/s00540-008-0702-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 09/29/2008] [Indexed: 11/30/2022]
Abstract
We report an emergent case of cardiac tamponade due to rupture of the left ventricle. Preload and intracardiac volume were decreased by percutaneous cardiopulmonary support (PCPS), which led to the collapse of the cardiac chamber. The collapsed cardiac chamber made it difficult to diagnose cardiac abnormalities by preoperative transthoracic echocardiography (TTE). On loading fluid infusion and transfusion as volume load to improve the hemodynamic status, transesophageal echocardiography (TEE) revealed several leakages in the left ventricular myocardium. Continuous careful observation on TEE led us to a confident diagnosis of left ventricular rupture. The diagnosis by TEE also led to the employment of the appropriate procedure. TEE is useful for detecting an abnormality due to the location of the cardiac chamber and echocardiographic probe. We also note that continuous careful observation led to the employment of the appropriate procedure.
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Affiliation(s)
- Junko Nakahira
- Department of Anesthesiology, National Cardiovascular Center, Suita, Japan
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48
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[Traumatic thoracic aorta rupture: preclinical assessment, diagnosis and treatment options]. Anaesthesist 2009; 57:782-93. [PMID: 18463834 DOI: 10.1007/s00101-008-1375-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.
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Zanatta P, Bosco E, Salandin V, Salvador L, Valfrè C, Sorbara C. Microbubbles detection during cardiopulmonary bypass with transoesophageal echocardiography: a case report. CASES JOURNAL 2008; 1:141. [PMID: 18775067 PMCID: PMC2542348 DOI: 10.1186/1757-1626-1-141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 09/05/2008] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Microembolic signals are usually detected with transcranial doppler during cardiac surgery.This report focuses on suggesting the transesophageal echocardiography as a different diagnostic approach to detect microemboli during cardiopulmonary bypass. CASE PRESENTATION A 58 year old male patient, caucasian race, was operated on video assisted minimally invasive mitral valve repair using right minithoracotomy approach. His past medical history included an uncontrolled hypertension, dyslipidemia, insulin dependent diabetes mellitus, carotid arteries stenosis. The extracorporeal circulation was performed with femoral-femoral artery and venous approach. Negative pressure for vacuum assist venous drainage was applied in order to facilitate venous blood return. The patient had a brain monitoring with bilateral transcranial doppler of middle cerebral arteries and a double channels electroencephalogram. A three dimensional transesophageal echocardiography to evaluate the mitral valve repair was performed.During the cardiopulmonary bypass a significant microembolic activity was detected in the middle cerebral arteries spectrum velocities due to gas embolism from venous return. Simultaneous recording of microbubbles was also observed on the descending thoracic aorta transesophageal echo views. CONCLUSION During the aortic cross-clamping time the transesophageal echocardiography can be useful as an alternative method to assess the amount of gas embolism coming from cardiopulmonary bypass. These informations can promote immediate interaction between perfusionist, surgeon and anesthesiologist to perform adequate manoeuvres in order to reduce the microembolism during extracorporeal circulation.
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Affiliation(s)
- Paolo Zanatta
- Anesthesia and Intensive Care Department, Treviso Regional Hospital, Piazzale Ospedale n degrees 1, 31100 Treviso, Italy.
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Jung PH, Rieber J, Stork S, Hoyer C, Erhardt I, Nowotny A, Voelker W, Weidemann F, Ertl G, Klauss V, Angermann CE. Effect of contrast application on interpretability and diagnostic value of dobutamine stress echocardiography in patients with intermediate coronary lesions: comparison with myocardial fractional flow reserve. Eur Heart J 2008; 29:2536-43. [DOI: 10.1093/eurheartj/ehn204] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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