Perioperative Echocardiography Research Articles

Perioperative echocardiography in a newborn with severe tricuspid dysplasia operated on with CorMatrix tube reconstruction.

Perioperative echocardiography in a newborn with severe tricuspid dysplasia operated on with CorMatrix tube reconstruction.

Con: Perioperative Echocardiography Accreditation Is Costly, Time Consuming, and Unnecessary

Con: Perioperative Echocardiography Accreditation Is Costly, Time Consuming, and Unnecessary

Perioperative echocardiography in minimally invasive surgery for hypertrophic obstructive cardiomyopathy.

Hypertrophic obstructive cardiomyopathy (HOCM) is clinically symptomatic and prone to malignant arrhythmias and sudden cardiac death (SCD). Currently, an effective treatment is surgical resection of the hypertrophic ventricular septum to relieve the left ventricular outflow tract (LVOT) obstruction and mitral insufficiency. Our center performs an innovative, minimally invasive right infra-axillary thoracotomy for transaortic septal myectomy. Minimally invasive procedures rely more on perioperative transesophageal echocardiography (TEE). This study aimed to explore the use of echocardiography during the perioperative period of surgical intervention for HOCM. Between August 2021 and April 2022, 27 patients with HOCM underwent cardiac surgery at our hospital. Minimally invasive transaortic septal resection (Morrow myectomy) was performed from the right axilla. The extent of myectomy and need for mitral valve repair were based on perioperative TEE assessment and surgical findings. The demographic parameters and clinical data of patients were recorded. The cardiopulmonary bypass time, aortic cross-clamp, and mechanical ventilation times were calculated. TEE was used to assess ventricular wall thickening and anatomical abnormalities of mitral regurgitation, assist in intravenous catheterization, and assess the postoperative gradients of the LVOT. Among the 27 patients with HOCM who underwent transaortic septal myectomy by minimally invasive right infra-axillary thoracotomy, 16 had LVOT obstruction, 2 had mid-LV obstruction, and 9 had both LVOT and mid-LV involvement. TEE provides information about the fine structure of the LV cavity and the etiology of the obstruction. In all cases, LVOT obstruction and mitral valve systolic anterior motion were resolved postoperatively, and the degree of mitral regurgitation was significantly reduced. Perioperative echocardiography provides valuable information regarding the complex etiology of LVOT obstruction during minimally invasive right infra-axillary thoracotomy for transaortic septal myectomy. It helps determine the extent of septal resection and assess the need for concomitant mitral valve repair.

Improvement in Left Ventricular Function of the Resected Myocardium after Septal Myectomy in Patients with Aortic Valve Replacement

Background: Some surgeons have previously advocated for a more aggressive concomitant septal myectomy to address left ventricular outflow tract obstruction; however, concerns about the surgical complications of post-septal myectomy remain. Here, we aimed to assess the clinical, echocardiographic, and pathological findings following concomitant septal myectomy with surgical aortic valve replacement. Methods: We reviewed 21 patients who underwent surgical aortic valve replacement and concomitant septal myectomy from April 2014 to September 2019. The global and regional left ventricular ejection fraction changes between the perioperative periods were analyzed using two-dimensional speckle-tracking echocardiography. The resected myocardium was pathologically assessed. Results: No operative mortality was observed during the study period. Transthoracic echocardiography showed no significant differences in preoperative and postoperative left ventricular ejection fraction (68.1 ± 9.9% vs. 68.6 ± 6.0%, p = 0.82) or interventricular septum thickness (11.9 ± 1.4 mm vs. 11.5 ± 1.5 mm, p = 0.23). Interventricular septum thickness at the end-systolic phase, which is the maximum septal wall thickness, was significantly reduced postoperatively (27.7 ± 9.3 mm vs. 22.6 ± 5.5 mm, p < 0.05). The basal, mid, and apical septal areas improved with septal myectomy by 80%, 230%, and 27%, respectively, compared to perioperative echocardiography (basal septal, 80 ± 23%; mid septal, 230 ± 830%; apical septal, 27 ± 350%). Pathological examination of the resected myocardium revealed marked endocardial thickness (mean, 914 µm) with focal fibrosis. Conclusions: In aortic valve stenosis patients with septal hypertrophy, concomitant septal myectomy with surgical aortic valve replacement improved regional myocardial function and eliminated left ventricular outflow tract obstruction by removing thickened endocardium and prominent fibrosis.

Pro: Perioperative Echocardiography Accreditation Will Improve Quality and Should Be Pursued by Cardiac Anesthesia Programs

Pro: Perioperative Echocardiography Accreditation Will Improve Quality and Should Be Pursued by Cardiac Anesthesia Programs

The Year in Perioperative Echocardiography: Selected Highlights from 2023

This article is the eighth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

A systematic methodology for epicardial and epiaortic echocardiography in swine research models.

Perioperative echocardiography is of paramount importance during cardiac surgery. Nonetheless, in the experimental large-animal setting, it might be challenging obtaining optimal imaging when using conventional imaging acquisition techniques, such as transthoracic and transesophageal screenings. Open-chest surgery allows epicardial echocardiographic assessment with direct contact between probe and heart, thus providing superior quality. Standard protocols regarding the use of epicardial ultrasound in swine for research purposes are lacking. Epicardial echocardiography was performed in 10 female German Landrace pigs undergoing cardiac surgery. A structured and comprehensive protocol for epicardial echocardiography was elaborated including apical, ventricular long and short axis, as well as epiaortic planes. All experiments were approved by the local board for animal welfare and conducted in accordance with the German animal protection law (TierSchG) and the ARRIVE guidelines. Systematic protocols using epicardial echocardiography may serve as an additional tool to assess cardiac dimensions and function in experimental scenarios with swine models.

Practical Considerations for Obtaining Perioperative Transesophageal Echocardiography Accreditation: Collective Experiences at Early-Adopting Centers

The Intersocietal Accreditation Commission (IAC) is a non-profit accrediting organization committed to ensuring the quality of diagnostic imaging and related procedures. It is comprised of a collaboration of stakeholders, spanning numerous medical professionals and specialties. In a recent initiative, IAC Echocardiography introduced a new accreditation specifically for Perioperative Transesophageal Echocardiography (PTE). This accreditation process is anchored in rigorous clinical peer review to ensure diagnostic quality and report accuracy, thus maintaining high standards of medical care.The authors represent the inaugural four sites to achieve IAC accreditation for PTE who have collaborated to share their experiences in achieving this accreditation. This review endeavors to offer actionable insights and proven solutions to navigate the accreditation journey for others. Mirroring the IAC Standards and Guidelines for PTE accreditation, this review is divided into three pivotal sections: 1) organization of a perioperative echocardiography service, including stakeholder engagement to facilitate the application for accreditation; 2) performance of examinations and reporting; and 3) instituting quality improvement strategies and establishing a robust program.The pursuit of accreditation in PTE is to transcend a mere compliance exercise. It signifies a dedication to excellence, continual growth, and above all to the well-being of patients.

Intra-aortic band impairs transapical device implantation in a pig: a case report

BackgroundAnatomic anomalies in the ascending aorta may impair the implantation and testing of cardiovascular devices in humans and animal models.Case presentationWe present the rare case of an intra-aortic band in a German Landrace pig. During terminal animal testing, the band hindered the implantation of a left ventricular assist device (LVAD) with transventricular outflow graft across the aortic valve. After lower partial sternotomy, epicardial echocardiography displayed an intraluminal echogenic structure at the sinotubular junction causing unspecific flow turbulences. Under cardiopulmonary bypass, coring of the left ventricular apex was performed. Due to strong resistance in the proximal aorta, accurate positioning of the transventricular LVAD outflow graft was impossible. After euthanasia, necropsy revealed a fibrous band located at the sinotubular junction, dividing the lumen of the ascending aorta.ConclusionsThe occurrence of an intra-aortic band represents an extremely rare case of a most likely congenital anomaly. Awareness of such anomalies is important for planning and performing animal testing. Perioperative echocardiography may help to either remove such anomalies or allow discontinuing the procedure prior to device implantation.

Advanced Perioperative Echocardiography in Venoarterial Extracorporeal Membrane Oxygenation Weaning Trial-Off.

Advanced Perioperative Echocardiography in Venoarterial Extracorporeal Membrane Oxygenation Weaning Trial-Off.

A role for ultra-high resolution three-dimensional printed human heart models.

Echocardiography is essential for diagnosing and assessing the severity of perioperative structural and functional heart disease. Yet, educational opportunities to better understand echocardiography-based cardiac anatomy remain limited by the two-dimensional display, lack of anatomic details, variability of heart models, and costs and global access of training. We performed micro computed tomography of human heart specimens not suitable for orthotopic transplantation. We created high-resolution computational 3D models of different human hearts, sliced them in the different recommended American Society of Echocardiography views, and 3D printed them using different materials. We scanned, 3D modeled, and 3D printed a variety of human hearts both healthy and diseased. We have made the models available in the cardiac operating rooms and routinely use them for teaching anesthesia residents and cardiothoracic anesthesia fellows about basic and advanced echocardiographic views, cardiopulmonary bypass cannulation strategies, and valvular pathology and planned interventions. We have generated a library of 3D printed hearts to display the recommended echocardiographic views as a unique educational tool designed to safely accelerate the understanding of absolute and relative human cardiac anatomy and pathology, especially related to gaining advanced appreciation of clinically employed perioperative echocardiography.

The Year in Perioperative Echocardiography: Selected Highlights From 2022

THIS SPECIAL article is part of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the Editorial Board for the opportunity to continue this series, which focuses on the past year's research highlights that pertain to perioperative echocardiography in relation to cardiothoracic and vascular anesthesia. The major selected themes for 2022 include (1) updates on mitral valve assessments and interventions, (2) training and simulation updates, (3) outcomes and complications of transesophageal echocardiography, and (4) point-of-care cardiac ultrasound. The themes selected for this special article are just a sample of the advances in perioperative echocardiography during 2022. An appreciation and understanding of these highlights will help to ensure and improve the perioperative outcomes for patients with cardiovascular disease undergoing cardiac surgery.

Comparison of visual estimation and quantitative measurement of left ventricular ejection fraction in untrained perioperative echocardiographers

BackgroundPerioperative evaluation of the left ventricular systolic function is essential information to help diagnose and manage life-threatening perioperative emergencies. Although quantifying the left ventricular ejection fraction (LVEF) is recommended to determine the left ventricular function, it may not always be feasible in emergency perioperative settings. This study compared the visual estimation of LVEF (eyeballing) by noncardiac anesthesiologists with the quantitative LVEF measured using a modified Simpson’s biplane method.MethodsTransesophageal echocardiographic (TEE) studies of 35 patients were selected and 3 different echocardiographic views (the mid-esophageal four chamber view, the mid-esophageal two chamber view, and the transgastric mid-papillary short axis view) were recovered from each study and displayed in random order. Two cardiac anesthesiologists certified in perioperative echocardiography independently measured LVEF using the modified Simpson method and categorized LVEF into five grades: hyperdynamic LVEF, normal, mildly reduced LVEF, moderately reduced LVEF and severely reduced LVEF. Seven noncardiac anesthesiologists with limited experience in echocardiography also reviewed the same TEE studies and estimated the LVEF and graded LV function. The precision of the LV function classification and the correlation between visual estimation of LVEF and quantitative LVEF were calculated. The agreement of measurements between the two methods was also assessed.ResultsPearson’s correlation between the LVEF estimated by the participants and the quantitative LVEF using the modified Simpson method was 0.818 (p < 0.001). Of a total of 245 responses, 120 (49.0%) responses were correct grading of the LV function. Participants were able to classify the LV function more accurately in the LV function grades 1 and 5 (65.3%). The 95% level of agreement of the Bland-Altman method was − 11.3-24.5. -21.9-22.6, − 23.1-26.5, − 20.5-22.0 and − 26.6-11.1 for LV grade 1 to 5, respectively.ConclusionVisual estimation of LVEF in perioperative TEE has acceptable accuracy in untrained echocardiographers and can be used for rescue TEE.

Ruptured sinus of Valsalva aneurysm with dynamic aortic regurgitation.

The ruptured sinus of Valsalva aneurysm (SVA) can present with dynamic aortic regurgitation (AR). Hemodynamic changes elicited by induction of general anesthesia can lead to dynamic AR in setting of ruptured SVA. Perioperative echocardiography is critical in understanding the etiology of AR and in guiding surgical decision-making. If the aortic valve is structurally normal, AR may resolve following patch repair of the SVA rupture defect. Conventional measures of assessing AR severity are not accurate with continuous left-to-right flow across a ruptured SVA.

Perioperative Role of Echocardiography and its Influence on Surgical Management

Perioperative echocardiography is an important puzzle piece for surgical management especially in the area of cardiovascular surgery. This imaging technique is not only used to confirm preoperatively made diagnoses but also for morphological and functional assessment of cardiac structures and verification of surgical or interventional results. Moreover, echocardiography is used for hemodynamic monitoring and guidance of pharmacological therapy. This article gives an overview of the impact of echocardiography on surgical management from a clinical point of view. Indications and contraindications are discussed as well as the use of echocardiography during the different phases of surgery and intensive care. The possible influence of the echocardiographic finding on modification of the surgical approach is presented based on a case example and underlined by clinical tips and tricks.

Cardiovascular manifestation of end-stage liver disease and perioperative echocardiography for liver transplantation: anesthesiologist's view.

Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.

The Year in Perioperative Echocardiography: Selected Highlights From 2021

This article is the sixth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but, in some cases, these articles targeted the use of perioperative echocardiography in general.

Peri-operative echocardiography for lung transplantation in a critical patient with COVID-19.

Critical patients with coronavirus disease 2019 (COVID-19) suffer from severe illness and have a high mortality rate. Lung transplantation may be the final option for a subset of these patients. Herein we report the important role of peri-operative echocardiography in a COVID-19 patient who underwent bilateral lung transplantation because of severe respiratory failure. The precise evaluation provided by echocardiography enabled the prevention of anastomotic complications and the successful management of haemodynamic instability. Echocardiographers should be familiar with the complications of lung transplantation and the haemodynamics under extracorporeal membrane oxygenation support to achieve a more accurate interpretation of cardiac parameters.

522 Perioperative Echocardiographic Assessment of Malnutrition-Related Cardiomyopathy: A Case Series

Abstract Introduction It is known that systolic dysfunction (dilated cardiomyopathy) may occur in a high percentage of patients with large TBSA burns. The reversible myocardial depression may be due to many factors: thermal injury, sepsis, severe malnutrition. Monitoring nutritional status is an integral part of improving post-burn cardiomyopathy. Perioperative echocardiography can be used to assess the degree of cardiac dysfunction and alter treatment in these patients. Methods Serial echocardiographic parameters were measured (ejection fraction, fractional shortening, pericardial fluid) in 4 patients with evidence of malnutrition (low BMI, low albumin and prealbumin, muscle wasting), delayed wound healing, and a late presentation to the hospital. Initial echocardiography was performed post-injury day 30 -142; follow-up exams were performed in some patients up to 2 years post-injury. Acutely injured or septic patients were excluded. Results Echocardiographic measurements were obtained in 4 patients, ages 7–21. The TBSA ranged from 33–95% and included flame injury and electrical burns. The initial ejection fraction ranged from 12–38% in patients with a BMI range of 10–16. The mean initial albumin was 1.65g/dL; the mean prealbumin was 10.8mg/dL. Selenium deficiency was noted in 1 patient. Dobutamine was required intraoperatively in several patients. Conclusions Patients presenting with malnutrition and impaired wound healing all had evidence of cardiomyopathy of varying degrees. However, the degree of systolic dysfunction varied significantly. Chronic surgical grafting was used to manage burn wounds, while slow nutritional rehabilitation normalized the patient’s BMI with careful avoidance of refeeding syndrome. As exemplified by serial echocardiography, one patient’s EF improved over 1 year from 12% to 50–55% as the nutritional status also improved, demonstrated by the normalization of his BMI. Despite the lower ejection fractions, many patients maintained an adequate cardiac index and required only short-term inotropic agents. Intraoperative and serial echocardiography allowed for continued monitoring and alteration of the heart failure medication regimens if required. With time and adequate nutrition, cardiac function improved, although many remained with mild dysfunction in the first year.

The Year in Perioperative Echocardiography: Selected Highlights from 2020

This article is the fifth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank Editor-in-Chief Dr. Kaplan and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.