Intraoperative Echocardiography Research Articles

Feasibility of Intraoperative 3-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Aortic Valve Replacement: A Prospective Observational Pilot Study

To assess the feasibility of intraoperative 3-dimensional speckle-tracking-based myocardial deformation analysis for evaluation of twist, torsion, and strain using speckle tracking, and to investigate the immediate changes in these parameters after aortic valve replacement. Prospective observational study SETTING: Single-center study at a tertiary academic cardiac center PARTICIPANTS: Forty-nine patients undergoing minimally invasive surgical aortic valve replacement INTERVENTIONS: Acquisition of full-volume images of the left ventricle after induction of anesthesia and at the end of surgery using transesophageal echocardiography (TEE), and analysis of the datasets using 3D speckle-tracking-based myocardial deformation analysis (Tomtec Arena). Of the 49 complete volume datasets, 30 (61%) had quality sufficient for speckle tracking. No significant differences were observed between the examinations in terms of ejection fraction (EF) (p = 0.177), global longitudinal strain (GLS) (p = 0.276), circumferential strain (CS) (p = 0.238), twist (p = 0.970), or torsion (p = 0.417). 3D speckle-tracking-based myocardial deformation analysis from intraoperative TEE datasets is feasible in >60% of patients with aortic valve stenosis. There were no statistically significant differences in GLS, CS, twist, or torsion between the intraoperative examinations.

A Multi-Country Survey on the Availability of Intraoperative Use of Echocardiography for Noncardiac Surgery.

This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

Perioperative management and outcomes for posterior spinal fusion in patients with Friedreich ataxia: A single-center, retrospective study.

Friedreich ataxia is a rare genetic disorder associated with progressive mitochondrial dysfunction leading to widespread sequelae including ataxia, muscle weakness, hypertrophic cardiomyopathy, diabetes mellitus, and neuromuscular scoliosis. Children with Friedreich ataxia are at high risk for periprocedural complications during posterior spinal fusion due to their comorbidities. To describe our single-center perioperative management of patients with Friedreich ataxia undergoing posterior spinal fusion. Adolescent patients with Friedreich ataxia presenting for spinal deformity surgery between 2007 and 2023 were included in this retrospective case series performed at the Children's Hospital of Philadelphia. Perioperative outcomes were reviewed along with preoperative characteristics, intraoperative anesthetic management, and postoperative medical management. Seventeen patients were included in the final analysis. The mean age was 15 ± 2 years old and 47% were female. Preoperatively, 35% were wheelchair dependent, 100% had mild-to-moderate hypertrophic cardiomyopathy with preserved systolic function and no left ventricular outflow tract obstruction, 29% were on cardiac medications, and 29% were on pain medications. Intraoperatively, 53% had transesophageal echocardiography monitoring; 12% had changes in volume status on echo but no changes in function. Numerous combinations of total intravenous anesthetic agents were used, most commonly propofol, remifentanil, and ketamine. Baseline neuromonitoring signals were poor in four patients and one patient lost signals, resulting in 4 (24%) wake-up tests. The majority (75%) were extubated in the operating room. Postoperative complications were high (88%) and ranged from minor complications like nausea/vomiting (18%) to major complications like hypotension/tachycardia (29%) and need for extracorporeal membrane oxygenation support in one patient (6%). Patients with Friedreich ataxia are at high risk for perioperative complications when undergoing posterior spinal fusion and coordinated multidisciplinary care is required at each stage. Future research should focus on the utility of intraoperative echocardiography, optimal anesthetic agent selection, and targeted fluid management to reduce postoperative cardiac complications.

Intraoperative Echocardiography: Guide to Decision-Making.

This review aims to provide a concise overview of key recommendations, with a specific focus on common challenges faced by intraoperative echocardiographers when dealing with frequently encountered valvular pathologies and mechanical circulatory support. It offers valuable insights for medical practitioners in this field. The American Society of Echocardiography (ASE) and the American College of Cardiology/American Heart Association (ACC/AHA) have released updated comprehensive guidelines for the use of transesophageal echocardiography (TEE) for the assessment of cardiac structures and implanted devices to help guide intraoperative decision-making. Transesophageal echocardiography (TEE) is a regularly employed intraoperative diagnostic and monitoring tool, offering various modalities for the rapid evaluation of valvular and aortic pathology, hemodynamic disturbances, and cardiac function. It is particularly valuable in assessing and placing mechanical circulatory support (MCS) devices, providing views often challenging to obtain through transthoracic echocardiography. Additionally, intraoperative TEE can be used for decision-making in patients with valvular disease allowing incorporation of patient-specific and situational factors. Echocardiographers can employ this information in real-time to help guide surgical treatment selection such as repair, replacement, or deferral of intervention.

Left atrial strain predicts the rhythm outcome in patients with persistent atrial fibrillation undergoing left atrial cryoablation during minimally invasive mitral valve repair.

Patients with atrial fibrillation (AF) have lower left atrial (LA) strain, which is a predictor for LA function. Here, we evaluated the prognostic value of LA strain to predict the rhythm outcome in patients with persistent AF undergoing LA cryoablation concomitant to minimally invasive mitral valve repair. Between 01/2016 and 12/2020, 72 patients with persistent AF underwent LA cryoablation during minimally invasive mitral valve surgery. All patients received a complete LA lesion set and left atrial appendage (LAA) closure with a clip. All patients received preoperative transthoracic echocardiography (TTE) with LA and left ventricular strain measurements. Preoperative LA and LV strain analysis was correlated with postoperative rhythm outcome. The mean age of the patients was 66.9 ± 7.2 years, of whom 42 (58%) were male patients. No major ablation-related complications occurred in any of the patients. Successful LAA closure was confirmed by intraoperative echocardiography in all patients. The 1-year survival rate was 97%. Freedom from AF at 12 months was 72% and 68% off antiarrhythmic drugs. Preoperative LA strain values were statistically significantly higher in patients with freedom from AF at 12 months of follow-up (12.7% ± 6.9% vs. 4.9% ± 4.1%, p = 0.006). Preoperative LV strain value was not associated with postoperative rhythm outcome. In multivariate logistic regression analysis, LA strain (p < 0.001) and AF duration (p = 0.017) were predictors for freedom from AF at 12 months of follow-up. In our study, LA strain analysis predicted the rhythm outcome in patients with persistent AF undergoing concomitant surgical AF ablation. In the future, LA strain might be a useful tool to guide decision-making on ablation strategies in patients with persistent AF.

Minimally Invasive Approach versus Sternotomy for Bentall Procedure: A Single-Center Experience

Background. The need for minimally invasive Bentall surgery for the treatment of aortic lesions with aortic insufficiency is increasing; however, comparative studies on the safety of the minimally invasive Bentall procedure and sternotomy Bentall procedure are lacking. Methods. Clinical data of 56 patients who underwent the Bentall procedure performed by the same surgical team at our center between December 2018 and December 2021 were retrospectively analyzed and followed up for 6 months after discharge. After dividing the patients into a right anterior chest minimally invasive Bentall surgery (RAT-Bentall) group (n = 13) and a conventional sternotomy Bentall surgery (C-Bentall) group (n = 43), intraoperative and early postoperative clinical data and echocardiography at 6 months after discharge were compared. Results. Compared with the C-Bentall group, the RAT-Bentall group had a lower postoperative visual analogue scale (VAS) pain score [(3.00 ± 2.08) VS (5.77 ± 1.84), P&lt;0.001] and a shorter CSICU hospital stay [(1.90 ± 0.52) VS (2.51 ± 1.58) d, P&lt;0.001] and postoperative hospital stay [(7.62 ± 1.81) VS (10.42 ± 2.45) d, P=0.035]. The incidence of postoperative complications and echocardiographic at 6-month follow-up after discharge was not statistically different between the two groups. Conclusion. The RAT-Bentall procedure is safe and effective. Compared with the sternotomy Bentall procedure, it can reduce postoperative pain as well as patients’ CSICU and postoperative hospital stay. Therefore, this technology is worth promoting and applying.

Short and mid-term outcomes of valve-sparing, aortic root reimplantation (David’s procedure)

BackgroundIn the current study, we aimed to report the short- and mid-term outcomes of patients undergoing valve-sparing aortic root reimplantation (VSARR) and our center’s experience with the procedure.MethodsForty patients with aortic root aneurysms underwent VSARR at our center from 2010 until 2022. We retrospectively reviewed the medical records of these patients and extracted the relevant data. After carefully examining the aortic valve, the surgeon decided to perform Bentall or David’s procedure during the operation.ResultsThe study population comprised 31 (77.5%) men and nine (22.5%) women, with a mean age of 55.35 ± 15.40. One patient developed hemodynamic instability post-surgery in the hospital and died from multi-organ failure. Another patient had severe AI in the intraoperative echocardiography, and aortic valve replacement with a prosthetic graft was performed during the same operation. In pre-operation echocardiography, 25 (62.5%) patients had severe, nine (22.5%) had moderate, and six (15%) had mild AI. In the in-hospital post-operation follow-up echo, AI was improved, and no patients had severe AI (P < 0.001). Only eight patients had moderate AI in post-one-year follow-up echo exams, while the rest had mild AI.ConclusionDavid’s procedure showed excellent mid-term results in our center, with only one in-hospital mortality.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: Intraoperative Echocardiography Reporting

To identify trends in the reporting of intraoperative transesophageal echocardiographic (TEE) data in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) and the Adult Cardiac Anesthesiology (ACA) module by period, practice type, and geographic distribution, and to elucidate ongoing areas for practice improvement. A retrospective study. STS ACSD. Procedures reported in the STS ACSD between July 2017 and December 2021 in participating programs in the United States. None MEASUREMENTS AND MAIN RESULTS: Intraoperative TEE is reported for 73% of all procedures in ACSD. Although the intraoperative TEE data reporting rate increased from 2017 to 2021 for isolated coronary artery bypass graft surgery, it remained low at 62.2%. The reporting of relevant echocardiographic variables across a wide range of procedures has steadily increased over the study period but also remained low. The reporting in the ACA module is high for most variables and across all anesthesia care models; however, the overall contribution of the ACA module to the ACSD remains low. This progress report suggests a continued need to raise awareness regarding current practices of reporting intraoperative TEE in the ACSD and the ACA, and highlights opportunities for improving reporting and data abstraction.

Abstract 17016: Mitral Valve Prolapse Induces Localized Left Ventricular Fibrosis in a Novel Large Animal Model

Background: Mitral valve prolapse (MVP) has recently been associated with localized left ventricular (LV) fibrosis linked to malignant arrhythmia and sudden cardiac death. However, fibrosis mechanisms remain unknown, with no large animal model to distinguish mechanical and genetic influences. Goals: We tested the hypothesis that surgically induced MVP leads to localized myocardial fibrosis in LV regions mechanically linked to the mitral valve, aiming to establish a reproducible large animal model of MVP as a platform for mechanistic studies. Methods: In 6 adolescent sheep, MVP was created surgically by replacing primary chordae tendineae to P2 with longer artificial chords. Intraoperative echocardiography and LV pressure-volume loops were obtained. After 7 months recovery, cardiac MRI with gadolinium and T1-mapping were done before end-of-study surgery with repeat echo and pressure-volume loops. Three sham surgery sheep were similarly studied. Myocardial samples from valve-linked papillary muscle and inferobasal LV and control septal regions were analyzed by histology. Bulk RNA was sequenced on samples from 3 MVP and 3 sham sheep. Results: All 6 MVP sheep showed pronounced localized LV fibrosis in valve-linked regions but not control regions on MRI, with replacement fibrosis by Masson’s trichrome stain. Sham sheep had no fibrosis, with similar LV function and contractility at end-of-study. RNA sequencing revealed gene expression differences between the two LV regions in MVP sheep and the valve-linked regions of MVP vs sham sheep. Conclusions: In a novel surgically created large animal model of MVP, localized fibrosis is induced in formerly healthy LV myocardium. This suggests a mechanical mechanism is sufficient to create the localized LV fibrosis associated with arrhythmia in MVP patients. This model provides a platform to study fibrosis mechanisms and investigate therapeutic approaches to avoid catastrophic events in MVP patients.

Abstract 15834: The Utility of Intra-Operative Coronary Doppler Profiles in Predicting Early and Late Major Adverse Cardiovascular Events After Arterial Switch Operation

Introduction: Coronary artery transfer is the most important technical point in the arterial switch operation (ASO). Intra-operative echocardiography identifies aberrancies in coronary artery Doppler profiles guiding immediate surgical management. Objective: We sought to determine whether abnormal intra-operative coronary artery Doppler profiles are associated with major adverse cardiovascular events (MACE; death, transplantation, heart failure, arrhythmia, need for coronary re-intervention) following ASO at 30-days, 5 &amp; 10 years. Methods: Single centre retrospective review of patients undergoing ASO between 2009 - 2022. Transesophageal or epicardial intra-operative coronary artery Doppler profiles were analysed. Patient variables were abstracted from records. Freedom from MACE was estimated using Kaplan-Meier methods. Results: 347 patients were included. Coronary anatomy was usual (1LCx2R) in 237 (68%), single sinus ostia in 24 (7%), intramural in 14 (4 %). Overall 30-day MACE was 11.2% [8.3%, 15.1%], increasing to 25% [12.1, 47.4%] with single sinus ostia &amp; 35.7% [16.7%, 65.7%] with intramural. Overall 5 &amp; 10-year MACE was 16.5% [12.9, 20.9%], 33.8% [18.5%, 56.4%] with single sinus ostia &amp; 50.0% [27.8%, 77.1%] with intramural. A higher probability of MACE was seen with coronary Doppler reverse flow, absence of normal pattern (Table 1) and a higher peak velocity (Figure 1). Overall 30-day mortality was 1.2% [95%CI 0.4%, 3.0%] and at 5 &amp; 10 years was 6.5% [4.3%, 9.8%]. Conclusions: Intra-operative abnormal coronary artery Doppler profiles during ASO may identify those at highest risk of early and late adverse events, guiding follow-up surveillance strategies.

Abstract 18676: Aneurysmectomy or No Aneurysmectomy - An Unknown Heart Failure Terrain

Case Report: A 40-year male with a history of traumatic inferoapical ventricular septal rupture after a motor vehicle accident status post patch repair and left ventricular thrombus on Rivaroxaban presented to the ED with hemoptysis. The patient on arrival was hemodynamically stable. CTA revealed a new 6.9 cm left ventricular pseudoaneurysm and an echocardiogram revealed an EF of 30% with a pseudoaneurysm involving the entire distal septum, lateral wall, and apex and a ventricular septal rupture into the intraventricular septum. Cardiac MRI revealed a pseudoaneurysm from the inferoseptal wall measuring 9.6 x 6.9 x 10.0 cm and a stroke volume of 123 mL. A right heart catheterization revealed no evidence of left-to-right shunting. Given heart failure with reduced ejection fraction in the setting of a pseudoaneurysm and the complexity of aneurysm repair, advanced heart failure and cardiothoracic surgery teams were consulted for conventional surgical and transplant evaluation. Due to social barriers, the patient was declined from transplant and ultimately proceeded with patch repair. Intraoperative echocardiography revealed a post-operative EF of 25%. Discussion: This case highlights the need for further data on pseudoaneurysms that are confounded with concurrent heart failure. For this patient, the concerns were for adequate stroke volume given the extent of the pseudoaneurysm and whether improvement in systolic function could be seen with repair or result in further decline. It was postulated that surgical repair would raise his effective stroke volume, and thus improve cardiac function. Postoperative EF changes could have been further explained by myocardial stunning during anesthesia or rapid changes in end-diastolic volume with aneurysmectomy altering Frank-Starling hemodynamics. With isolated case report data, further aneurysmectomy outcome characterization is thus imperative to guide advanced heart failure treatment and improve patient mortality.

CPT 2024: Start Preparing for Accurate Reporting

With 2024 quickly approaching, now is the time for practices to prepare to adopt procedure code changes that will be implemented on the first day of the new year. The 2024 changes to Current Procedural Terminology (CPT®) most applicable to services provided to children are discussed in this and upcoming issues of AAP Pediatric Coding Newsletter™. In this issue, articles include discussion of the following topics related to CPT coding changes that go into effect on January 1, 2024: Changes to time descriptors for office and other outpatient services Revisions to guidelines for split or shared visits New guidelines for brief hospital inpatient or observation stays New codes for cardiac imaging procedures (intraoperative echocardiography and venography)

The importance of intraoperative echocardiography in the early detection of mitral regurgitation as a postsurgical sequel of aortic valve replacement: a case report

BackgroundMitral leaflet perforation (MLP) can rarely be a consequence of aortic valve replacement (AVR), resulting in mitral regurgitation (MR). Determining the cause and severity of MLP following AVR is crucial in preventing hemodynamic consequences, such as pulmonary hypertension and biventricular remodeling. However, the diagnosis of this rare complication requires detailed echocardiographic evaluations.Case presentationIn this paper, we report a 37-year-old Persian male with progressive dyspnea on exertion diagnosed with severe MR caused by anterior MLP following AVR and discuss the importance of intraoperative transesophageal echocardiography (TEE) in the proper and on-time diagnosis of this rare complication.ConclusionDuring AVR procedure, an evaluation with TEE could be beneficial for identifying and treating such condition. Echocardiography is beneficial in providing real-time guidance during surgery, early detection of potential complications, treatment of such complications if present, and prevention of adverse outcomes.

Сhanges in the deformation of the pulmonary vein ostia after radiofrequency and cryoballoon ablation in patients with paroxysmal atrial fibrillation

Aim. To study changes in pulmonary vein ostia strain after radiofrequency (RFA) and cryoballoon ablation (CBA) in patients with paroxysmal atrial fibrillation (AF) by intracardiac echocardiography.Methods. Patients with paroxysmal AF (n=41) aged 60.1±7.1 years and duration of the disease 7.7±4.8 years were included in the study. Pulmonary vein (PV) isolation was performed with RFA (n=23) and CBA (n=18). All patients underwent transthoracic and intraoperative intracardiac echocardiography. Longitudinal strain of PV ostia was assessed before and after isolation.Results. Groups were comparable in main clinical parameters. Regress of PV ostia strain after RFA and CBA was achieved in all of PV, which corresponded to complete PV isolation. Remarked trend toward a more pronounced regression of PV ostia longitudinal strain after CBA compared with RFA for left superior (10±0.7% and 6.1±0.8% respectively, p&lt;0.001) and right inferior PV (9.3±0.7% vs 7.3±0.6%, p&lt;0.001) requires continued observation and analysis of data in a larger group. There were no complications.Conclusion. PV isolation is accompanied by a significant change in their longitudinal strain using intracardiac echocardiography both after CBA and after RFA.

Predictors of Intraoperative Echocardiography: Analysis of The Society of Thoracic Surgeons Database

BackgroundIntraoperative transesophageal echocardiography (TEE) is associated with improved outcomes after cardiac surgery, but unexplained practice pattern variation exists. This study aimed to identify and quantify the predictors of intraoperative TEE use among patients undergoing isolated coronary artery bypass graft surgery (CABG) or cardiac valve surgery. MethodsThis observational cohort study used The Society of Thoracic Surgeon (STS) Adult Cardiac Surgery Database data to identify and quantify the predictors of intraoperative TEE use among adult patients aged 18 years or more undergoing either isolated CABG or open cardiac valve repair or replacement surgery between January 1, 2011, and December 31, 2019. Generalized linear mixed models were used to measure the relationship between intraoperative TEE and patient characteristics, surgical volume, and geographic location, while accounting for clustering within hospitals (primary analysis) or surgeons (secondary analysis). ResultsOf 1,973,655 patients, 1,365,708 underwent isolated CABG and 607,947 underwent cardiac valve surgery. Overall, intraoperative TEE was used in 62% of surgeries. The primary hospital-level generalized linear mixed models analysis demonstrated that the strongest predictor of intraoperative TEE use was the hospital where the surgery occurred—with a median odds ratio for TEE of 10.13 in isolated CABG and 5.30 in cardiac valve surgery. The secondary surgeon-level generalized linear mixed models analysis demonstrated similar findings. ConclusionsIntraoperative TEE use (vs lack of use) during surgery was more strongly associated with hospital and surgeon practice patterns than with any patient-level factor, surgical volume, or geographic location.

CLINICAL APPLICATION OF THE SECOND GENERATION OF AMPLATZER PATENT DUCTUS ARTERIOSUS OCCLUDER IN THE INTERVENTIONAL CLOSURE OF CONGENITAL HEART DISEASE AND CASE SERIES

Background: Some patients with structural heart disease are typically treated or improved by minimally invasive surgeries. Aim: To summarize the efficacy and experience in the treatment of congenital heart disease (CHD) using the second generation of Amplatzer patent ductus arteriosus (ADO- II) occluder. Methods: A total of 37 patients who were admitted to the cardiac surgery department of our hospital from June 2014 to April 2019 were included. After preoperative echocardiography and clinical screening, intraoperative transthoracic echocardiography, and cardiovascular angiography, postoperative echocardiography was carried out to evaluate the incidence of residual shunt and the location and morphology of the ADO-II occluder, as well as postoperative complications. Results: All patients were successfully treated using the ADO-II occluder. There were 27 (73%) cases with patent ductus arteriosus (PDA), as well as 5 (13.5%) cases with ventricular septal defect (VSD), 1 case (2.7%) with VSD combined with PDA, 1 case (2.7%) with aortopulmonary collateral arteries combined with PDA, 1 case (2.7%) with right coronary artery-right atrial fistula, and 2 (5.4%) cases were recanalized after ligation of the main pulmonary artery. All patients had no obvious abnormality in ECG reexamination one month after surgery; The x-ray showed no displacement and shedding, and no long-term significant residual shunt was found in transthoracic echocardiography. No death was reported. Conclusions: The ADO-II occluder is relatively simple to operate, with a high success rate and few complications, and it can be applied to not only PDA occlusion but also to other CHDs, making it worthy of further clinical promotion under the premise of grasping the indicators of interventional therapy.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Intraoperative epicardial echocardiography or transoesophageal echocardiography in CHD: how much does it matter?

Intraoperative imaging determines the integrity of surgical repairs. Transoesophageal echocardiography represents standard care for intraoperative imaging in CHD. However, some conditions preclude its use, and epicardial echocardiography is used alternatively. Minimal literature exists on the impact of epicardial echocardiography versus transoesophageal echocardiography. We aimed to evaluate accuracy between the two modalities and hypothesised higher imaging error rates for epicardial echocardiography. We retrospectively reviewed all epicardial echocardiograms performed over 16 years and compared them to an age- and procedure-matched, randomly selected transoesophageal echocardiography cohort. We detected un- or misidentified cardiac lesions during the intraoperative imaging and evaluated patient outcomes. Data are presented as a median with a range, or a number with percentages, with comparisons by Wilcoxon two-sample test and Fisher's exact test. Totally, 413 patients comprised the epicardial echocardiography group with 295 transoesophageal echocardiography matches. Rates of imaging discrepancies, re-operation, and incision infection were similar. About 13% of epicardial echocardiography patients had imaging discrepancies versus 16% for transoesophageal (p = 0.2352), the former also had smaller body sizes (p < 0.0001) and more genetic abnormalities (33% versus 19%, p < 0.0001). Death/mechanical support occurred more frequently in epicardial echocardiography patients (16% versus 6%, p < 0.0001), while hospitalisations were longer (25 versus 19 days, p = 0.0003). Diagnostic accuracy was similar between patients undergoing epicardial echocardiography and transoesophageal echocardiography, while rates of death and mechanical support were increased in this inherently higher risk patient population. Epicardial echocardiography provides a reasonable alternative when transoesophageal echocardiography is not feasible.

The role of ultrasonography in anesthesia for bariatric surgery.

ABSTRACTBariatric surgeries are effective long-term management for morbid obesity with its adverse sequelae. Anesthesia of bariatric surgeries poses unique challenges for the anesthesiologist in every step starting with vascular access till tracheal extubation. The usage of ultrasound in anesthesia is becoming more prevalent with a variety of benefits, especially in the obese population. Ultrasound is successfully used for obtaining vascular access, with more than 15 million catheters placed in the United States alone. Ultrasound can also be used to predict difficult intubation, as it can confirm the tracheal intubation and assess the gastric content to prevent pulmonary aspiration. Ultrasound is also used in the management of mechanically ventilated patients to monitor lung aeration and to identify respiratory complications during positive pressure ventilation. Moreover, intraoperative echocardiography helps to discover the pulmonary embolism and guides the fluid therapy. Finally, ultrasound can be used to perform neuraxial and fascial plane block with a less overall time of the procedures and minimal complications. The wide use of ultrasound in bariatric anesthesia reflects the learning curve of the anesthesiologists and their mounting efforts to provide safe anesthesia utilizing the updated technology. In this review, we highlight the role of ultrasonography in anesthesia of bariatric surgery and discuss the recent guidelines.

Regional Right Ventricular Function Assessed by Intraoperative Three-Dimensional Echocardiography Is Associated With Short-Term Outcomes of Patients Undergoing Cardiac Surgery.

BackgroundThe assessment of right ventricular (RV) function in patients undergoing elective cardiac surgery is paramount for providing optimal perioperative care. The role of regional RV function assessment employing sophisticated state-of-the-art cardiac imaging modalities has not been investigated in this cohort. Hence, this study investigated the association of 3D echocardiography-based regional RV volumetry with short-term outcomes.Materials and MethodsIn a retrospective single-center study, patients undergoing elective cardiac surgery were included if they underwent 3D transesophageal echocardiography prior to thoracotomy. A dedicated software quantified regional RV volumes of the inflow tract, apical body and RV outflow tract employing meshes derived from 3D speckle-tracking. Echocardiographic, clinical and laboratory data were entered into univariable and multivariable logistic regression analyses to determine association with the endpoint (in-hospital mortality or the need for extracorporeal circulatory support).ResultsOut of 357 included patients, 25 (7%) reached the endpoint. Inflow RV ejection fraction (RVEF, 32 ± 8% vs. 37 ± 11%, p = 0.01) and relative stroke volume (rel. SV) were significantly lower in patients who reached the endpoint (44 ± 8 vs. 48 ± 9%, p = 0.02), while the rel. SV of the apex was higher (38 ± 10% vs. 33 ± 8%, p = 0.01). Global left and right ventricular function including RVEF and left ventricular global longitudinal strain did not differ. In univariable logistic regression, tricuspid regurgitation grade ≥ 2 [odds ratio (OR) 4.24 (1.66–10.84), p < 0.01], inflow RVEF [OR 0.95 (0.92–0.99), p = 0.01], inflow rel. SV [OR 0.94 (0.90–0.99), p = 0.02], apex rel. SV [OR 1.07 (1.02–1.13), p < 0.01] and apex to inflow rel. SV ratio [OR 5.81 (1.90–17.77), p < 0.01] were significantly associated with the endpoint. In a multivariable model, only the presence of tricuspid regurgitation [OR 4.24 (1.66–10.84), p < 0.01] and apex to inflow rel. SV ratio [OR 6.55 (2.09–20.60), p < 0.001] were independently associated with the endpoint.ConclusionsRegional RV function is associated with short-term outcomes in patients undergoing elective cardiac surgery and might be helpful for optimizing risk stratification.