1
|
Kim KK, Krause M, Brandes IF, Khanna AK, Bartels K. Transesophageal echocardiography for perioperative management in thoracic surgery. Curr Opin Anaesthesiol 2021; 34:7-12. [PMID: 33315644 DOI: 10.1097/aco.0000000000000947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures. RECENT FINDINGS Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion. SUMMARY Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.
Collapse
Affiliation(s)
- Kevin K Kim
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Martin Krause
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Ivo F Brandes
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University, School of Medicine, Winston-Salem, North Carolina, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| |
Collapse
|
2
|
Mauermann E, Vandenheuvel M, François K, Bouchez S, Wouters P. Right Ventricular Systolic Assessment by Transesophageal Versus Transthoracic Echocardiography: Displacement, Velocity, and Myocardial Deformation. J Cardiothorac Vasc Anesth 2020; 34:2152-2161. [PMID: 32423734 DOI: 10.1053/j.jvca.2020.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE First, to compare tricuspid annular displacement and velocity in transthoracic and transesophageal echocardiography (TTE, TEE) using conventional angle-dependent technologies. Second, to evaluate both alternative TEE views as well as an alternative technology (speckle tracking) for overcoming proposed differences in TTE and TEE. DESIGN Prospective, comparative, cross-over study with a randomized order of image acquisition. SETTING University hospital. PARTICIPANTS Adults undergoing cardiac surgery. INTERVENTIONS Postinduction standardized image acquisition and analysis in TTE and TEE by 2 echocardiographers. MEASUREMENTS AND MAIN RESULTS The authors measured tricuspid annular plane systolic excursion (TAPSE) by M-mode and velocity by tissue Doppler (S') in the apical 4-chamber TTE view and midesophageal 4-chamber TEE view (AP4C, ME4C). They then examined (1) the same measurements in alternative TEE views with proposed better ultrasound angulation; and (2) speckle tracking-based endpoints (TAPSE by speckle tracking, strain, and strain rate). Data were available in 24 of 25 patients. Conventional TAPSE by M-mode and velocity by tissue Doppler (TDI) were underestimated in the ME4C compared with the AP4C reference (mean ± standard deviation: TAPSE: 13.1 ± 3.8 mm v 17.3 ± 4.0 mm; S': 6.7 ± 2.1 cm/s v 9.1 ± 2.2 cm/s; both p < 0.001). Neither a modified deep transgastric view (TAPSE 14.5 ± 4.7 mm, p = 0.017; S' 6.8 ± 1.8 cm/s, p < 0.001) nor a transgastric right ventricular inflow view (TAPSE 12.3 ± 4.0 mm, p = 0.001; S' 6.0 ± 1.3 cm/s, p < 0.001) was similar to the AP4C. Speckle tracking TAPSE was unbiased but with high variability (mean bias = -0.3 mm, 95% limits of agreement = -9.1 to 8.4); strain and strain rate were higher in TEE than for TTE (-17.7 ± 3.6 v -12.6 ± 2.1, p < 0.001; -1.0 ± 0.2/s v -0.7 ± 0.1/s, p < 0.001). CONCLUSIONS Right ventricular displacement, velocity, and myocardial deformation measured by TEE versus TTE are different. Neither alternative transesophageal echocardiography views nor speckle tracking-based deformation is promising; TAPSE by speckle tracking is unbiased but imprecise.
Collapse
Affiliation(s)
- Eckhard Mauermann
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium; Department of Anesthesiology, University Hospital Basel, Basel, Switzerland.
| | - Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Katrien François
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
3
|
Vandenheuvel M, Bouchez S, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters? Anesthesiol Clin 2019; 37:697-712. [PMID: 31677686 DOI: 10.1016/j.anclin.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.
Collapse
Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Eckhard Mauermann
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium; Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Spitalstrasse 21, Basel 4031, Switzerland.
| |
Collapse
|
4
|
Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements. Anesthesiol Clin 2019; 37:675-695. [PMID: 31677685 DOI: 10.1016/j.anclin.2019.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article reviews transesophageal echocardiography-based assessment of perioperative right ventricular function and failure, including catheter-based methods, three-dimensional echocardiography, and their combination to make pressure-volume loops. It outlines right ventricular pathophysiology, multiple assessment methods, and their relationship to analogous transthoracic echocardiogram measurements. technologies used and developed for transthoracic or left ventricular assessment show significant limitations when applied to transesophageal assessment of the right ventricle. The article provides an overview of right ventricular assessment modalities that can be used in transesophageal echocardiography. Ultimately, clinicians must know limitations of measurements, synthesize information, and assess it in the clinical context.
Collapse
|
5
|
Mauermann E, Vandenheuvel M, François K, Bouchez S, Wouters P. A Novel Speckle-Tracking Based Method for Quantifying Tricuspid Annular Velocities in TEE. J Cardiothorac Vasc Anesth 2019; 33:2636-2644. [DOI: 10.1053/j.jvca.2019.05.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/27/2019] [Accepted: 05/27/2019] [Indexed: 11/11/2022]
|
6
|
Tan Z, Roscoe A, Rubino A. Transesophageal Echocardiography in Heart and Lung Transplantation. J Cardiothorac Vasc Anesth 2019; 33:1548-1558. [DOI: 10.1053/j.jvca.2019.01.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Indexed: 02/04/2023]
|
7
|
Turner KR. Right Ventricular Failure After Left Ventricular Assist Device Placement—The Beginning of the End or Just Another Challenge? J Cardiothorac Vasc Anesth 2019; 33:1105-1121. [DOI: 10.1053/j.jvca.2018.07.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Indexed: 12/19/2022]
|
8
|
Lung recruitment improves right ventricular performance after cardiopulmonary bypass: A randomised controlled trial. Eur J Anaesthesiol 2018; 34:66-74. [PMID: 27861261 DOI: 10.1097/eja.0000000000000559] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Atelectasis after cardiopulmonary bypass (CPB) can affect right ventricular (RV) performance by increasing its outflow impedance. OBJECTIVE The aim of this study was to determine whether a lung recruitment manoeuvre improves RV function by re-aerating the lung after CPB. DESIGN Randomised controlled study. SETTING Single-institution study, community hospital, Córdoba, Argentina. PATIENTS Forty anaesthetised patients with New York Heart Association class I or II, preoperative left ventricular ejection fraction at least 50% and Euroscore 6 or less scheduled for cardiac surgery with CPB. INTERVENTIONS Patients were assigned to receive either standard ventilation with 6 cmH2O of positive end-expiratory pressure (PEEP; group C, n = 20) or standard ventilation with a recruitment manoeuvre and 10 cmH2O of PEEP after surgery (group RM, n = 20). RV function, left ventricular cardiac index (CI) and lung aeration were assessed by transoesophageal echocardiography (TOE) before, at the end of surgery and 30 min after surgery. MAIN OUTCOME MEASURES RV function parameters and atelectasis assessed by TOE. RESULTS Haemodynamic data and atelectasis were similar between groups before surgery. At the end of surgery, CI had decreased from 2.9 ± 1.1 to 2.6 ± 0.9 l min m in group C (P = 0.24) and from 2.8 ± 1.0 to 2.6 ± 0.8 l min m in group RM (P = 0.32). TOE-derived RV function parameters confirmed a mild decrease in RV performance in 95% of patients, without significant differences between groups (multivariate Hotelling t-test P = 0.16). Atelectasis was present in 18 patients in group C and 19 patients in group RM (P = 0.88). After surgery, CI decreased further from 2.6 to 2.4 l min m in group C (P = 0.17) but increased from 2.6 to 3.7 l min m in group RM (P < 0.001). TOE-derived RV function parameters improved only in group RM (Hotelling t-test P < 0.001). Atelectasis was present in 100% of patients in group C but only in 10% of those in group RM (P < 0.001). CONCLUSION Atelectasis after CPB impairs RV function but this can be resolved by lung recruitment using 10 cmH2O of PEEP. TRIAL REGISTRATION Protocol started on October 2014.
Collapse
|
9
|
Beck DR, Foley L, Rowe JR, Moss AFD, Weitzel NS, Reece TB, Fullerton DA, Cleveland JC, Bartels K. Right Ventricular Longitudinal Strain In Left Ventricular Assist Device Surgery-A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2017; 31:2096-2102. [PMID: 29103855 DOI: 10.1053/j.jvca.2017.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Right ventricular (RV) failure is common after left ventricular assist device (LVAD) surgery and is associated with higher mortality. Measurement of longitudinal RV strain using speckle-tracking technology is a novel approach to quantify RV function. The authors hypothesized that depressed peak longitudinal RV strain measured by intraoperative transesophageal echocardiography (TEE) examinations would be associated with adverse outcomes after LVAD surgery. DESIGN Retrospective cohort study. SETTING Tertiary academic medical center. PARTICIPANTS Following Institutional Review Board approval, the authors retrospectively identified adult patients who underwent implantation of non-pulsatile LVAD. Exclusion criteria included inadequate TEE images and device explantation within 6 months for heart transplantation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The postoperative adverse event outcome was defined as a composite of one or more of death within 6 months, ≥14 days of inotropes, mechanical RV support, or device thrombosis. Intraoperative TEE images were analyzed for peak RV free wall longitudinal strain by two blinded investigators. Simple logistic regression was used to assess the relationship between adverse outcome and the mean of the strain measurements of the two raters. Agreement between the raters was assessed by intra-class correlation (0.62) and Pearson correlation coefficient (0.63). Of the 57 subjects, 21 (37%) had an adverse outcome. The logistic regression indicated no significant association between RV peak longitudinal strain and adverse events. CONCLUSIONS In this retrospective study of patients undergoing non-pulsatile LVAD implantation, peak longitudinal strain of the RV free wall was not associated with adverse outcomes within 6 months after surgery. Additional quantitative echocardiographic measures for intraoperative RV assessment should be explored.
Collapse
Affiliation(s)
- Daniel R Beck
- Department of Anesthesiology, University of Colorado Denver, School of Medicine, Aurora, CO; VA Eastern Colorado Healthcare, Denver, CO
| | - Lisa Foley
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, School of Medicine, Aurora, CO
| | - Jackson R Rowe
- Department of Anesthesiology, University of Colorado Denver, School of Medicine, Aurora, CO
| | - Angela F D Moss
- Adult and Child Center for Health Outcomes and Delivery Science, University of Colorado, School of Medicine, Aurora, CO
| | - Nathaen S Weitzel
- Department of Anesthesiology, University of Colorado Denver, School of Medicine, Aurora, CO
| | - T Brett Reece
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, School of Medicine, Aurora, CO
| | - David A Fullerton
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, School of Medicine, Aurora, CO
| | - Joseph C Cleveland
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, School of Medicine, Aurora, CO
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado Denver, School of Medicine, Aurora, CO.
| |
Collapse
|
10
|
Bartels K, Brown RD, Fox DL, Bull TM, Neary JM, Dorosz JL, Fonseca BM, Stenmark KR. Right Ventricular Longitudinal Strain Is Depressed in a Bovine Model of Pulmonary Hypertension. Anesth Analg 2016; 122:1280-6. [PMID: 26974020 DOI: 10.1213/ane.0000000000001215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pulmonary hypertension and resulting right ventricular (RV) dysfunction are associated with significant perioperative morbidity and mortality. Although echocardiography permits real-time, noninvasive assessment of RV function, objective and comparative measures are underdeveloped, and appropriate animal models to study their utility are lacking. Longitudinal strain analysis is a novel echocardiographic method to quantify RV performance. Herein, we hypothesized that peak RV longitudinal strain would worsen in a bovine model of pulmonary hypertension compared with control animals. METHODS Newborn Holstein calves were randomly chosen for induction of pulmonary hypertension versus control conditions. Pulmonary hypertension was induced by exposing animals to 14 days of hypoxia (equivalent to 4570 m above sea level or 430 mm Hg barometric pressure). Control animals were kept at ambient pressure/normoxia. At the end of the intervention, transthoracic echocardiography was performed in awake calves. Longitudinal wall strain was analyzed from modified apical 4-chamber views focused on the RV. Comparisons between measurements in hypoxic versus nonhypoxic conditions were performed using Student t test for independent samples and unequal variances. RESULTS After 14 days at normoxic versus hypoxic conditions, 15 calves were examined with echocardiography. Pulmonary hypertension was confirmed by right heart catheterization and associated with reduced RV systolic function. Mean systolic strain measurements were compared in normoxia-exposed animals (n = 8) and hypoxia-exposed animals (n = 7). Peak global systolic longitudinal RV strain after hypoxia worsened compared to normoxia (-10.5% vs -16.1%, P = 0.0031). Peak RV free wall strain also worsened after hypoxia compared to normoxia (-9.6% vs -17.3%, P = 0.0031). Findings from strain analysis were confirmed by measurement of tricuspid annular peak systolic excursion. CONCLUSIONS Peak longitudinal RV strain detected worsened RV function in animals with hypoxia-induced pulmonary hypertension compared with control animals. This relationship was demonstrated in the transthoracic echocardiographic 4-chamber view independently for the RV free wall and for the combination of the free and septal walls. This innovative model of bovine pulmonary hypertension may prove useful to compare different monitoring technologies for the assessment of early events of RV dysfunction. Further studies linking novel RV imaging applications with mechanistic and therapeutic approaches are needed.
Collapse
Affiliation(s)
- Karsten Bartels
- From the *Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado; †Cardiovascular Pulmonary Research and Developmental Lung Biology Laboratories, University of Colorado School of Medicine, Aurora, Colorado; ‡Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; §Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; ∥Department of Animal and Food Sciences, Texas Tech University, Lubbock, Texas; and ¶Department of Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Plakke MJ, Maxwell CD, Bottiger BA. Intraoperative Monitoring of Pulmonary Artery Physiology With Transesophageal Echocardiography in a Patient With an Extensive Pulmonary Aneurysm Undergoing Partial Nephrectomy. ACTA ACUST UNITED AC 2016; 7:108-11. [PMID: 27580409 DOI: 10.1213/xaa.0000000000000359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgical patients with pulmonary hypertension present a significant challenge to the anesthesiologist. Continuous perioperative monitoring of pulmonary artery (PA) pressure is recommended and most often accomplished with a PA catheter. Placement of a PA catheter may be difficult or contraindicated, and in these cases, transesophageal echocardiography is a useful alternative to monitor dynamic PA physiology. In this case, we used intraoperative transesophageal echocardiography to detect changes in peak PA pressure and guide clinical treatment in a patient with pulmonary hypertension and an extensive PA aneurysm undergoing partial nephrectomy.
Collapse
Affiliation(s)
- Michael J Plakke
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | | | | |
Collapse
|
12
|
Poth JM, Beck DR, Bartels K. Ultrasonography for haemodynamic monitoring. Best Pract Res Clin Anaesthesiol 2014; 28:337-51. [DOI: 10.1016/j.bpa.2014.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 08/05/2014] [Accepted: 08/27/2014] [Indexed: 01/10/2023]
|