Perioperative Echocardiography Research Articles

Perioperative focused cardiac ultrasound: a brief report

The anesthesiologist's emerging role as a perioperative physician has challenged the field to broaden its scope of practice to meet the demands of the patient undergoing surgery today. This brief report aims to identify the indications, clinical impact on management decisions, and perioperative focused cardiac ultrasound accuracy in patients scheduled for non-cardiac surgery. A review from the Department of Anesthesia Perioperative Echocardiography database on transthoracic echocardiography was performed, including clinical, demographic, indications, therapeutic impact, and accuracy from February 1, 2017 to October 10, 2019. A total of 220 FoCUS exams were identified. FoCUS was performed in 55% males and 45% females. The average age was 66.5 years, and 68% of patients were designated ASA 3 classification. The majority underwent thoracic procedures with a history of cardiovascular disease for hemodynamic instability in the post-anesthesia care unit (PACU). In this group, 94% had a change in management. New findings in 9 patients resulted in pre-induction management change. FoCUS was also performed intraoperatively to differentiated hemodynamic instability, significantly altering care. Postoperatively, new wall motion abnormalities findings escalated care to the cardiology service. Immediate assessment of hemodynamic instability altered care and postoperative recovery location in a significant number of patients. In all cases, FoCUS was used to guide management in the differential diagnosis of the acute event and to assess treatment response. This review demonstrates that FoCUS is an excellent clinical adjunct in the perioperative period. Diagnostic accuracy and efficiency by pattern recognition helped answer clinically significant questions and guide management. The non-invasive approach of POCUS and its rapid adaptation makes it an exciting area of future research.

Pro: Length of Adult Cardiothoracic Anesthesiology Fellowship Training Should Be Extended Beyond One Year

THE ADULT CARDIOTHORACIC ANESTHESIOLOGY (ACTA) fellowship has undergone a revolutionary change over the last two decades. Although it has existed since the 1970s, it was not until 2004 that official board certification in perioperative echocardiography was granted by the National Board of Echocardiography, followed by formal accreditation status by the Accreditation Council for Graduate Medical Education (ACGME) in 2006. 1 Capdeville M Ural KG Patel PA et al. The educational evolution of fellowship training in cardiothoracic anesthesiology – Perspectives from program directors around the United States. J Cardiothorac Vasc Anesth. 2018; 32: 607-620 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The ACTA fellowship entered into the match process in June 2013. 2 Goldhammer JE Herman CR Heitz JW et al. ACGME accreditation guide for adult cardiothoracic anesthesiology fellowship. J Cardiothorac Vasc Anesth. 2018; 32: 2395-2401 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The educational evolution of the ACTA fellowship in the United States was elegantly elucidated by Capdeville et al in their article in the Journal of Cardiothoracic and Vascular Anesthesiology in 2018. 1 Capdeville M Ural KG Patel PA et al. The educational evolution of fellowship training in cardiothoracic anesthesiology – Perspectives from program directors around the United States. J Cardiothorac Vasc Anesth. 2018; 32: 607-620 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Accreditation by the ACGME formalized the length, structure, and educational goals of the fellowship and set minimal clinical case requirements for various cardiac and thoracic surgical procedures to be achieved by the end of fellowship training. 2 Goldhammer JE Herman CR Heitz JW et al. ACGME accreditation guide for adult cardiothoracic anesthesiology fellowship. J Cardiothorac Vasc Anesth. 2018; 32: 2395-2401 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar This oversight enforced consistency and made the training programs more accountable for competency-based fellow education, with the ultimate goal of improving patient care, quality, and safety, thereby improving the overall standards for fellowship learning. 2 Goldhammer JE Herman CR Heitz JW et al. ACGME accreditation guide for adult cardiothoracic anesthesiology fellowship. J Cardiothorac Vasc Anesth. 2018; 32: 2395-2401 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar

Perioperative Echocardiography to Confirm Correct Central Venous Catheter Placement: A Case Report

Central venous catheterization is widely regarded as a safe procedure by anesthesiologists and intensivists, but insertion complications and catheter malposition remain challenges for the clinicians performing central venous catheter (CVC) insertion. We report a case in which a right internal jugular CVC was inserted under ultrasound guidance and was found to be malpositioned after sternotomy into an anomalous posterior thymic vein. Therefore, we recommend confirming the correct position of CVC with transesophageal echocardiography if such is indicated for the perioperative period and emphasize the importance of a correct J-tip of the guidewire when placing a CVC.

Left Atrial Dissection and Rupture Following Excision of Left Atrial Myxoma: Role of Transesophageal Echocardiography

Left atrial mass after excision of a left atrial myxoma may occur due to residual or additional masses, such as biatrial or multicentric myxomas and inverted left atrial appendage. In this E-challenge, the authors present a case where intraoperative transesophageal echocardiography allowed visualization of a left atrial mass after excision of a left atrial myxoma. Detailed examination demonstrated that the mass was due to left atrial dissection that progressed to rupture, allowing its early detection and repair. A high index of suspicion, as well as coordination between the surgeon and the perioperative echocardiographer, played a crucial role in the detection and management of this complication.

The Year in Perioperative Echocardiography: Selected Highlights From 2019

This article is the fourth 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 targetted the use of perioperative echocardiography in general.

Adult cardiac surgery and the COVID-19 pandemic: Aggressive infection mitigation strategies are necessary in the operating room and surgical recovery

The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated.

Specific Considerations for the Protection of Patients and Echocardiography Service Providers When Performing Perioperative or Periprocedural Transesophageal Echocardiography during the 2019 Novel Coronavirus Outbreak: Council on Perioperative Echocardiography Supplement to the Statement of the American Society of Echocardiography Endorsed by the Society of Cardiovascular Anesthesiologists

Protecting health care workers and preventing the transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) should be a top priority during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Transesophageal echocardiography (TEE) carries a heightened risk for SARS-CoV-2 spread in nonintubated patients due to possible direct droplet transmission and/or viral aerosolization during insertion and removal of the probe, as well as coughing. Although performing TEE in an already intubated patient may reduce the risk for viral aerosolization, viral transmission may still occur through direct contact with the patient's secretions, resulting in contaminated hands and surfaces.

Miller’s Anesthesia, 9th ed

Miller’s Anesthesia, 9th ed

Intra-operative trans-esophageal echocardiography in heart valve disease.

Peri-operative echocardiography is widely used because it provides information that significantly influences clinical/surgical management and improves outcome in patients undergoing cardiac surgery. The role of intra-operative trans-esophageal echocardiography (TEE) in valvular heart disease cannot be emphasized enough. Increasing use of newer surgical techniques-valve repairs and minimal invasive cardiac surgery also warrants intra-operative TEE. It gives us better insight into the anatomy and physiology of the valvular lesion by digital imaging. This manuscript provides an illustrative case based overview of intra operative TEE (IOTEE) in heart valve surgery.

P258 Giant coronary arteriovenous fistula with significant left-to-right shunt in symptomatic patient - a multimodal diagnostic approach and successful surgical treatment

Abstract Funding Acknowledgements none OnBehalf none Coronary arteriovenous fistula (CAF) is a rare usually congenital defect that occurs in 0.1-0.2% of patients undergoing coronary angiography. A left-to-right shunt exists in more than 90% cases. In approximately 20% of patients CAF is accompanied with coronary artery aneurysm (CAA). We describe a case of 65-years-old woman with history of murmur from childhood, who presents with symptoms of slowly worsening dyspnea on exertion and strong pericardial pain. A suspicion for CAF was made from echocardiography and finally confirmed by other diagnostic modalities (coronary angiography and computed tomography with 3D reconstructions). We have diagnosed a complex case of a giant CAA involving left main and a periphery of left circumflex artery, accompanied with CAF terminating in the right atrium, responsible for a significant left-to-right shunt and coronary steal phenomenon. Patient was successfully treated by surgical ligation of the distal part of CAF in the right atrium. There were no signs of an acute myocardial ischemia on beating heart (ECG, perioperative echocardiography) when CAF was temporary occluded by tourniquet and so definitive surgical ligation of CAF was performed back on cardiopulmonary bypass. The postoperative course was uneventful without complications and the patient was discharged 6 days after surgery. One year after surgery patient is doing well with no complaints. Control echocardiography showed a regression of left and right ventricle volume overload. Coronary angiography showed normal perfusion in the left coronary artery territory, and no more visible collaterals flow right coronary artery. Abstract P258 Figure. complex coronary artery aneurysm

Penetration cardiac wound associated with anterior mitral leaflet perforation: a case report and review of the literature

The paper presents a rare case of successful correction of an anterior mitral leaflet perforation. A 28-years old patient was referred with progressive heart failure symptoms at 18 weeks after he had a penetrating stab wound of the right ventricle. Massive pericardial effusion with cardiac tamponade risk and severe mitral valve insufficiency were found at examination. By the time of referral, spontaneous closure of the ventricular septal defect, which is an inevitable component of the “unhappy triad”, had happened. Accurate topical ultrasound diagnosis of the intracardial lesion that resulted from the penetrating wound of the left ventricular outflow allowed for a successful urgent mitral valve reconstruction with a xenopericardial patch and the insertion of a 28 mm MedEng annuloplasty band. To prevent any future pericardial constriction, subtotal pericardectomy by Cooley was performed.Conclusion: Perioperative echocardiography and subsequent follow up by cardiologist are obligatory in all cases of precordial wounds after discharge from hospital. Timely surgery for traumatic mitral leaflet perforation allows for a successful valvuloplasty.

TEE for Lung Transplantation: A Case Series and Discussion of Vascular Complications

Summary Stenosis at either the pulmonary artery (PA) or pulmonary vein (PV) anastomosis during lung transplantation (LTx) is a serious complication that requires an accurate and timely diagnosis for optimal clinical management. Transesophageal echocardiography (TEE) can play an essential role in making these diagnoses, both intraoperatively and postoperatively. However, it is important to recognize the limitations of TEE in this setting, including the lack of official guidelines to diagnose PA or PV stenosis. In this series, we describe four cases of vascular complications associated with LTx. We highlight the utility of TEE in the perioperative management of these patients, and discuss the diagnostic considerations when using this tool to assess the PA and PV anastomoses. As experts in perioperative echocardiography, anesthesiologists can employ TEE to enhance surgical success and improve patient outcomes after LTx. We therefore advocate the use of TEE during all cases of LTx, and encourage further efforts into the development of official echocardiographic guidelines specific to this patient population.

The Year in Perioperative Echocardiography: Selected Highlights from 2018

This article is the third 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 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.

Perioperative echocardiography in Ozaki’s procedure: An observational study - Single centre experience

Perioperative echocardiography in Ozaki’s procedure: An observational study - Single centre experience

Preparing for a Fellowship in Adult Cardiothoracic Anesthesiology: Resources and Approaches for the Anesthesiology Trainee

Adult cardiothoracic anesthesiology (ACTA) is a competitive fellowship. Despite increases in both the number of programs offering cardiothoracic fellowships and the number of residents applying each year, there is little direction or advice for prospective candidates. This review aims to educate anesthesiology residents who are hoping to pursue cardiothoracic anesthesiology, by examining a brief history of the advanced perioperative echocardiography qualification, the credentialing goals of ACTA fellowships, and the current status of ACTA fellowships. The second part of the review covers the ACTA fellowship application and aims to assist the candidate in navigating this process. The review examines the qualifications that fellowship programs look for in a candidate, including a discussion on professional behavior, and what an applicant can look for in a program. Finally, there is a brief discussion on post-match preparation.

The Year in Perioperative Echocardiography: Selected Highlights from 2017

This article is the second 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 start 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; however, in some cases, these articles will target the use of perioperative echocardiography in general.

Noteworthy Literature published in 2017 for Perioperative Echocardiography.

In this inaugural review, we present noteworthy advances in perioperative echocardiography relevant to the cardiac anesthesiologist. These studies come from different clinical realms including advances in mitral valve imaging, perioperative echocardiographic evaluation, and critical care echocardiography. The importance of perioperative echocardiography continues to grow with cardiac anesthesiologists positioned in a critical role throughout the perioperative care continuum.

Awareness of 'Systolic Anterior Motion' in Different Conditions.

Perioperative echocardiography, especially transesophageal echocardiography, is of paramount importance in evaluating and managing refractory hypotension, a potential cause of which is systolic anterior motion (SAM) of anterior mitral leaflet. Dynamically moving anterior mitral valve leaflet towards the left ventricular outflow tract (LVOT) is described as SAM. Although SAM was initially observed in patients with hypertrophic cardiomyopathy, it can also be seen in patients with complex dynamic anatomy of the left ventricle. Interestingly, SAM may or may not give rise to clinically significant LVOT obstruction. Hence, it is of paramount importance for perioperative physician to know such ‘dynamic SAM’ which can potentially and significantly affect and alter perioperative management.

Perioperative echocardiography for mitral valve repair surgery: Sharing views with cardiac surgeons

Perioperative echocardiography for mitral valve repair surgery: Sharing views with cardiac surgeons

Perioperative echocardiography for invasive thymoma with intracardiac invasion in a child: a case report

In the paediatric population, thymomas are rare mediastinal tumours. Surgical management is the main treatment for these tumours. A case of an aggressive thymoma with intracardiac invasion in a chi...