Intraoperative Echocardiography Research Articles

Iatrogenic Narrowing of Inferior Vena Cava after Atrial Septal Defect Closure: The Role of Intraoperative Echocardiography

ABSTRACT Single-patch closure of a superior sinus venosus atrial septal defect (SVASD) may be complicated with narrowing of inferior vena cava (IVC). If the pressure gradient across the narrowed portion of superior vena cava (SVC) exceeds 6 mm Hg, widening of SVC lumen is considered. No such guidelines are available in literature for narrowing of inferior vena cava in cardiac surgical patients. We describe an incident of inferior narrowing of inferior vena cava in a 10-year-old girl, who was operated for closure of an inferior type of ostium secundum ASD (OSASD). There was hepatic venous dilatation accompanied with gradient of 3 mm Hg at the junction of inferior vena cava and right atrium (RA). The cardiopulmonary bypass was reestablished and the surgical closure of the septal defect was revised to rectify the problem. How to cite this article Gadhinglajkar S, Sreedhar R, Lovhale P, Mathew T, Tapdia N. Iatrogenic Narrowing of Inferior Vena Cava after Atrial Septal Defect Closure: The Role of Intraoperative Echocardiography. J Perioper Echocardiogr 2015;3(2):48-51.

Hemodynamic Evaluation of Acute Mitral Valve Insufficiency Model induced by Chordae Tendinae Rupture in Normal Dogs

The study was to observe hemodynamic alterations of cardiac function to design a model of canine mitral valve insufficiency (MVI) based on chordae tendinae rupture (CTR). Ten healthy beagles with normal heart function were used in this study. To measure hemodynamics, the patient monitor was equipped for invasive blood pressure and a Swan-Ganz catheter. Hemodynamic alterations were checked promptly during CTR procedures. MVI model was made by transection of the chordae tendinae with small arthroscopy hook knife through 5 t h intercostal open chest. Color Doppler at the level of the mitral valve showed high-velocity regurgitant flow immediately after CTR at intraoperative echocardiography. In hemodynamic measurements, pulmonary capillary wedge pressure (PCWP) was significantly increased, while mean arterial pressure (MAP), venous pressure (VP), pulmonary arterial pressure (PAP), cardiac output (CO) and cardiac index (CI) were significantly decreased after CTR. It was known that the left atrium was overloaded by regurgitant volume from the left ventricle. In conclusion, the MVI model induced by CTR technique in this study should be used as suitable one for the effective research of canine mitral valve disease. Further study should be needed to measure the chronic alternation of mitral valve in the model.

Impact of hemodynamic monitoring on clinical outcomes.

In recent years, there has been a tremendous growth in available hemodynamic monitoring devices to support clinical decision-making in the operating room and intensive care unit. In addition to the "tried and true" heart rate and blood pressure monitors, there are several newer applications of existing technologies including arterial waveform analysis, intraoperative and bedside critical care echocardiography, esophageal Doppler, and tissue oximetry, among others. Several monitoring devices demonstrate positive effect on outcomes, especially when used in conjunction with specific goal-directed therapy protocols to achieve a desired clinical effect. Other devices remain in the validation stage, awaiting comprehensive comparison to established techniques. While these new technologies offer promising advances in intraoperative and critical care, they are often quite costly and many devices lack strong evidence for widespread adoption into clinical practice. In this review, we highlight the current data on clinical outcomes with the use of available hemodynamic monitoring devices.

Root Remodeling and Aortic Valve Repair for Unicuspid Aortic Valve

Unicuspid aortic valve (UAV) anatomy is occasionally encountered in adolescents or young adults and not infrequently associated with aneurysm of the ascending aorta and aortic root. To manage both defects without aortic valve replacement we propose a combination of remodeling of the aortic root combined with bicuspidization of the UAV. Between 1 December 2007 and November 2013, 25 patients (23 males; mean age, 38 ± 12 years; range, 21 to 65 years) with aortic regurgitation as a result of UAV and aortic root dilatation underwent remodeling of the aortic root and bicuspidization of the UAV. The dilated aortic root tissue was resected, leaving the wall adjacent to the normal commissure and at 180 degrees orientation and similar height for the new commissure. The graft was configured to create two symmetric tongues of graft and sutured to the remnants of the aortic root wall. The dysplastic right coronary cusp was resected, and autologous pericardial patches augmented the deficiency of cusp tissue between the left and noncoronary cusps. A suture annuloplasty was used in 20 cases. All patients were followed clinically and echocardiographically at 3, 6, and 12 months and at yearly intervals. Cumulative follow-up was 677 months (mean, 27 ± 18 months). No early or late death occurred. Intraoperative echocardiography revealed minimal or no aortic regurgitation in all patients; at discharge, systolic mean gradient was 6 ± 3 mm Hg. There was no bleeding or thromboembolic event during the follow-up. One patient exhibited endocarditis and underwent reoperation. Two patients experienced relevant recurrent aortic regurgitation for limited suture dehiscence between the patch and the cusp and were reoperated on between 16 and 32 months postoperatively. One patient underwent biologic valve replacement, and two valves were re-repaired. At 5 years, freedom from reoperation and aortic valve replacement was 81% and 91%, respectively. In the presence of UAV and aortic root dilatation, the concept of valve bicuspidization and root remodeling can be applied with satisfactory hemodynamic results. The hemodynamic function of an aortic valve preserved by this concept is good. If sufficient stability can be achieved, aortic valve replacement can be avoided in young patients with aortic regurgitation caused by UAV and root aneurysm.

Pulmonary endarterectomy: Part II. Operation, anesthetic management, and postoperative care.

Chronic thromboembolic pulmonary hypertension (CTEPH) results from recurrent or incomplete resolution of pulmonary embolism. CTEPH is much more common than generally appreciated. Although pulmonary embolism (PE) affects a large number of Americans, chronic pulmonary thromboembolic hypertension remains underdiagnosed. It is imperative that all patients with pulmonary hypertension (PH) be screened for the presence of CTEPH since this form of PH is potentially curable with pulmonary endarterectomy (PEA) surgery. The success of this procedure depends greatly on the collaboration of a multidisciplinary team approach that includes pulmonary medicine, cardiothoracic surgery, and cardiac anesthesiology. This review, based on the experience of more than 3000 pulmonary endarterectomy surgeries, is divided into 2 parts. Part I focuses on the clinical history and pathophysiology, diagnostic workup, and intraoperative echocardiography. Part II focuses on the surgical approach, anesthetic management, postoperative care, and complications.

Application fields of intraoperative transesophageal 3D echocardiography

Intraoperative transesophageal echocardiography (TEE) is an established diagnostic tool and has to be regarded as the standard of care for intraoperative monitoring and cardiac surgical decision-making. Furthermore, intraoperative TEE is also used for monitoring and assessment of hemodynamic changes and the detection of previously unknown pathologies. In the past few years 3D-TEE has extended the spectrum of 2D-TEE by allowing pathomorphological features to be more easily and intuitively linked to the anatomy of the heart and the great vessels. Thus, a comprehensive 2D-TEE examination is favorably complemented by focused 3D-TEE. Especially during mitral valve surgery, 3D-TEE has proven its superiority in the diagnosis of the underlying pathology as demonstrated by a large number of studies in this field. This review presents the available data about the role of intraoperative 3D-TEE echocardiography and introduces practical fields of application.

Pulmonary endarterectomy: part I. Pathophysiology, clinical manifestations, and diagnostic evaluation of chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) results from recurrent or incomplete resolution of pulmonary embolism. CTEPH is much more common than generally appreciated. Although pulmonary embolism (PE) affects a large number of Americans, chronic pulmonary hypertension (PH) remains underdiagnosed. It is imperative that all patients with PH be screened for the presence of CTEPH since this form of PH is potentially curable with pulmonary thromboendarterectomy (PTE) surgery. The success of this procedure depends greatly on the collaboration of a multidisciplinary team approach that includes pulmonary medicine, cardiothoracic surgery, and cardiac anesthesiology. This review, based on the experience of more than 3000 pulmonary endarterectomy surgeries, is divided into 2 parts. Part I focuses on the clinical history and pathophysiology, diagnostic workup, and intraoperative echocardiography. Part II focuses on the surgical approach, anesthetic management, postoperative care, and complications.

Intraoperative Three-Dimensional Versus Two-Dimensional Echocardiography for Left Ventricular Assessment

Intraoperative Three-Dimensional Versus Two-Dimensional Echocardiography for Left Ventricular Assessment

Intraoperative Echocardiography for Patients Undergoing Lung Transplantation

Intraoperative Echocardiography for Patients Undergoing Lung Transplantation

Intraoperative Three-Dimensional Versus Two-Dimensional Echocardiography for Left Ventricular Assessment

Three-dimensional (3D) transesophageal echocardiography (TEE) technology is now widely used intraoperatively in cardiac surgery. Left ventricular (LV) measurements with 3D transthoracic echocardiography correlate better with cardiac magnetic resonance measurements compared with traditional two-dimensional (2D) transthoracic echocardiography. In this study, we compared intraoperative 3D TEE against 2D TEE regarding quantitative indices of LV function. We performed 2D TEE and 3D TEE examinations on 156 patients scheduled for elective cardiac surgery. Two-dimensional TEE images of midesophageal 4-, 2-chamber, and long-axis views were acquired. LV volumes and ejection fraction (EF) were calculated by Simpson's method. Three-dimensional full-volume images were recorded to calculate by a semiautomated procedure LV volumes (indexed to body surface area) and EF. 3D and 2D LV dimensions and function, image quality, time for acquisition/analyses, and reproducibility were compared by the Wilcoxon matched-pairs signed-ranks test. Pairwise differences between 3D and 2D data were compared using 95% prediction intervals (PIs) and Bland-Altman methodology. 3D volumes were also plotted against 2D volumes in scatter plots using a 3-zone error grid. There was no significant difference between 3D and 2D in the estimation of EF (P = 0.227; median pairwise difference, -0.4% [95% PIs, -8.6% to 8.8%]). 3D LV indexed end-diastolic volumes (iEDVs) and end-systolic volumes (iESVs) were larger than 2D iEDVs (P < 0.001; median pairwise difference, 3.3 mL/m [95% PIs, -9.4 to 14.1 mL/m] and iESV: P < 0.001; median pairwise difference, 1.4 mL/m [95% PIs, -5.2 to 10.1 mL/m]). In the vast majority of cases (98.8% of cases for iEDV and 92.8% of cases for iESV), the difference between 2D and 3D TEE indexed volumes did not alter classification into normal, mildly to moderately dilated, or severely dilated volumes, as demonstrated by the 3-zone error grid analysis. Acquisition of 3D TEE image and analysis were not feasible in 4 patients (2.5%) for whom a quantitative 2D assessment of the LV was also impossible. 3D and 2D quality image was similar (P = 0.206). There was no difference in 3D versus 2D acquisition time (P = 0.805; pairwise difference = 2 seconds [95% PIs, -20 to 35 seconds]), but 3D analysis required more time (P < 0.001; pairwise difference = 117 seconds [95% PIs, 66 to 197 seconds]). Differences in repeated 3D versus 2D indexed volumes were not statistically significant, both considering interobserver reproducibility (iEDV: P = 0.125; pairwise difference, 0.26 ± 1.76 mL [95% PIs, -3.58 to 3.73 mL] and iESV: P = 0.126; pairwise difference, -0.16 ± 1.67 mL [95% PIs, -3.96 to 3.69 mL]) and intraobserver reproducibility (iEDV: P = 0.975; pairwise difference, -0.02 ± 1.20 mL [95% PIs, -2.32 to 2.08 mL] and iESV: P = 0.228; pairwise difference, -0.19 ± 1.13 mL [95% PIs, -2.47 to 2.53 mL]). Intraoperative 3D TEE quantification of LV global function, image acquisition time, and reproducibility was not statistically different when compared with 2D TEE. It was however associated with calculation of larger LV volumes and a longer analysis time. Nevertheless, the 3-zone error grid analysis of the LV indexed volumes showed that the difference between 3D and 2D measurements does not affect the LV classification as normal, mildly to moderately dilated, or severely dilated.

Intraoperative Echocardiography for Patients Undergoing Lung Transplantation

Intraoperative Echocardiography for Patients Undergoing Lung Transplantation

Impact and Cost Effectiveness of Routine Intraoperative Transthoracic and Transesophageal Echocardiography on Surgical Decision Making in Pediatric Cardiac Surgery

ABSTRACTIntroductionCongenital heart diseases (CHD) present with wide spectrum of lesions leading to diagnostic dilemmas and it is quite possible to miss correct diagnosis during preoperative transthoracic echocardiography (TTE) in an inadequately sedated child, especially in a busy outpatient setting. It is a routine practice in our center to do baseline TTE after induction of anesthesia followed by pre and postcardiopulmonary bypass (CPB) transesophageal echocardiography (TEE) in all CHD patients thus helping us review our surgical plan.Materials and methodsAll pediatric patients &lt;18 years undergoing cardiac surgery from January 2013 to December 2013 at our tertiary care center in whom perioperative echocardiograhy was done were included. Appropriate sized TTE and TEE probes were used with the Philips iE33 echocardiography platform (Philips, Andover, MA).ResultsOut of total 352 pediatric cardiac surgical patients, perioperative echocardiography was done in 347(98.5%) patients. Baseline TTE showed new findings leading to change in surgical plan in 11 (3.1%) patients while additional new findings in baseline TEE were seen in 9 (2.6%). Post bypass TEE showed residual lesions requiring a CPB rerun in 19 (5.5%) patients. Intraoperative echocardiography was found to be cost effective with an estimated savings per patient of ₹ 3950 to 5373($61 - 83).ConclusionIntraoperative echocardiography is an important tool in armamentarium of perioperative physician which can be used to review diagnosis and help to formulate an informed surgical plan. Post-bypass transesophageal echocardiography is also useful as it identifies the residual lesions and establishes anatomical correction, which ultimately translates to lesser redo surgeries and a better postoperative outcome.How to cite this articleMishra A, Madhavan JS, Ghuman BPS, Raj R, Kumar A, Dutta V, Negi S, Tandon Y, Kumar A, Arya VK, Kumar B, Jayant A, Puri GD. Impact and Cost Effectiveness of Routine Intraoperative Transthoracic and Transesophageal Echocardiography on Surgical Decision Making in Pediatric Cardiac Surgery. J Perioper Echocardiogr 2014;2(1):3-9.

Preliminary evaluation of a microtransesophageal probe in neonates and young infants undergoing surgery for congenital heart disease.

Background:The larger size of the currently available transesophageal echocardiography (TEE) probes limits their use to relatively older infants undergoing cardiac surgery. In very young neonates and infants, epicardial echocardiogram is used to assess postoperative residual defects. Recently, a miniaturized microTEE probe compatible in neonates has been introduced for clinical use. We evaluated the use of this probe in small infants undergoing cardiac surgery.Materials and Methods:Thirty-three consecutive neonates and infants undergoing cardiac surgery at our institution were included in the study. Intraoperative echocardiography with Philips s8-3t microTEE probe done using IE33 platform was utilized to study the preoperative anatomy and assess postoperative results.Results:Thirty-three patients aged 3 days-2 years (mean 5.1 months) and weighing 2.5-11 kg (mean 4.4 kg) underwent perioperative evaluation using the microTEE probe. Good quality two-dimensional and color Doppler images were obtained in all patients. There were no complications related to the probe insertion or manipulation. The findings on microTEE led to revision of surgery in five patients. Certain echocardiographic parameters that could never be recorded with epicardial echocardiogram could be easily seen in microTEE.Conclusion:On preliminary evaluation, the microTEE probe provided good quality images in very small infants who were not amenable for transesophageal echocardiographic evaluation so far. The probe could be used safely in small infants without complications. It appears to be a promising imaging modality in the perioperative assessment of young infants undergoing cardiac surgery, in whom intraoperative epicardial echocardiography is currently the only tool.

Sutureless Perceval Aortic Valve Replacement in Aortic Homograft

We report a case of aortic valve replacement with a sutureless valve in a degenerated aortic homograft. This technique allows rapid aortic valve replacement in a heavily calcified aortic root. It avoids the problems of postoperative prosthetic disinsertion frequently encountered after aortic valve replacement in a calcified annulus. It is particularly suitable in redo procedures for homograft degeneration. It avoids performing a redo Bentall operation with its known morbidity.

The Contemporary Role of Intraoperative Echocardiography: Is it Underused or Overused?

Intraoperative echocardiography has become an invaluable diagnostic and monitoring tool. Especially during cardiac surgery, transesophageal echocardiography has a high capability to influence surgical decisions and the hemodynamic management of the patients. Based on current practice guidelines and studies, this article provides an analysis of the contemporary role of intraoperative transesophageal echocardiography.

Triple-orifice repair in severe barlow disease with multiple-jet regurgitation: report of mid-term experience

Methods From March 2003 till December 2012, 28 patients (mean age 53.8+/6 years, 16 males) affected by severe Barlow disease with multiple jets were submitted to MR. Preoperative transesophageal echo (TEE) in all the cases showed at least 2 regurgitant jets, involving one or both leaflets in more than one segment. In all the patients, a triple-orifice valve (TOV) repair with annuloplasty was performed. Intraoperative TEE and postoperative transthoracic echocardiography (TT) were carried out to evaluate results of the TOV repair.

Three-dimensional Echocardiography Is Not Essential for Intraoperative Assessment of Mitral Regurgitation

The problem is not what you see on intraoperative echocardiography; it is what you do not see. Intraoperative transesophageal echocardiography and 3-dimensional (3D) echocardiography provide useful information for the surgeon performing mitral valve surgery, but they are not indispensable. We should consider the outstanding results of the pioneer of mitral valve repair, Professor Alain Carpentier. A report of very late results (>20 years) of the earliest series (1970–1984) of mitral valve repair is informative.1 Even without the availability of intraoperative transesophageal echocardiography, the late results were outstanding. At 20 years, freedom from reoperation was 96.9% for patients with posterior leaflet prolapse and 86.2% for patients with anterior prolapse. At the last follow-up (median, 17 years) 15% had moderate or worse mitral regurgitation. An experienced mitral valve surgeon can achieve durable high-quality results without any echocardiography, so 3D echocardiography is not essential. Response by Tsang and Lang on p 658 What is essential for mitral valve surgery? The fundamental elements from the surgical standpoint are the same whether the procedure is performed through a sternotomy or a minimally invasive incision or is robotically assisted. Achieving good surgical exposure is paramount.2 Numerous surgical techniques, including the type and location of venous cannulation, the atrial incision, retraction of the atrial wall, sutures to help rotate the valve and improve visualization, and occasionally the use of an instrument pushing from outside the heart to facilitate exposure of commissures or the anterior leaflet, are routine practice to optimally visualize the valve. Unless the surgeon is expert in the first step of the procedure, results will be compromised. A perfect 3D echocardiography image of the valve will not compensate for poor exposure. Although real-time 3D color echocardiography is useful, there is nothing more realistic than real-time 3D color visualization through 2.5-power loupes by the …

Cardiac echinococcosis

Cardiac echinococcosis is an extremely rare disease, seen worldwide. Some clinical characteristics are unknown, and treatment modalities are unclear. 41 patients diagnosed with cardiac or pericardial echinococcosis underwent surgery. We evaluated the patients echocardiographically in 8 different categories: cardiac echinococcosis lesions located within the heart, imaging appearance of each lesion, activity of the cysts, mode of cardiac echinococcosis, and number of cardiac lesions per patient. The surgical technique was reevaluated according to the intraoperative echocardiographic findings, especially according to the mode of the lesion. The hydatid cysts were located in the ventricular wall in 34 cases, the right atrium in 2, the noncoronary sinus Valsalva of the aorta in 1, between the aorta and the pulmonary bifurcation in 1, and in the pericardium alone in 4 cases. In 1 case, septal rupture occurred and the patient died. Relapse was seen in 1 patient who was operated on due to multiple ventricular and pericardial cysts; this patient underwent a second operation 6 years and 8 months after the initial surgery. Recent echocardiographic developments and application of intraoperative echocardiography enables a detailed classification for extirpation, and allows successful treatment.

Intraoperative Transeophageal Echocardiography to Diagnose an Anomalous Circumflex Artery

We describe a 43-year-old male presenting for hemiarch replacement and possible aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) demonstrated an atypical coronary vessel, enabling proper diagnosis of an anomalous circumflex artery and appropriate operative planning.

Effect of on-pump versus off-pump coronary bypass surgery on cardiac function assessed by intraoperative transesophageal echocardiography

To compare cardiac function assessed by intraoperative transesophageal echocardiography in patients undergoing cardiac revascularization with or without cardiopulmonary bypass. Forty-one patients scheduled for elective, isolated cardiac revascularization (21 on-pump and 20 off-pump) were prospectively analyzed. Patients were matched for demographic (age and gender), anthropometric (BMI), clinical (co-morbidities, EuroScore) and laboratory variables (blood counts, renal function, left ventricular function). Transesophageal echocardiography was performed after induction of anesthesia, protamine sulfate administration, and chest closure. Left ventricular wall motion score index, end-diastolic area, fractional area change, right ventricular area change and end-diastolic area were assessed. Troponin I and C-reactive protein concentrations were measured. Regarding echocardiographic parameters of left and right ventricular function no significant differences between on-pump and off-pump groups at any point-of-time measurements were found. Troponin I and C-reactive protein were higher in on-pump as compared to off-pump group (p=0.001 and p=0.002; p=0.003 and p=0.001, respectively). In elective patients scheduled for cardiac revascularization there were no difference in cardiac performance assessed by intraoperative echocardiography regardless of surgical method used.