Routine Use Of Transesophageal Echocardiography Research Articles

A gray zone: Role of transesophageal echocardiography before atrial tachycardia catheter ablation.

There is a lack of studies in the literature directly investigating the relationship between atrial tachycardia (AT) and left atrial (LA)/left atrial appendage (LAA) thrombus, and current guidelines do not provide strong recommendations regarding the use of transesophageal echocardiography (TEE) before AT catheter ablation. This study aims to elucidate the relationship between AT and the presence of LA/LAA thrombus and contribute to the literature on the use of TEE before AT catheter ablation. This single-center retrospective observational study screened patients who underwent TEE between February 10, 2019, and February 10, 2023. Patients were assigned to the AT patient and control groups. TEE was conducted to exclude thrombus in the AT ablation group. The control group included patients who underwent TEE for interatrial septum evaluation and had LA imaging during TEE but did not have atrial arrhythmia. To mitigate bias between the AT patient group and the control group, they were randomized 1:1 using propensity-score matching (PSM). Following randomization, each group consisted of 49 patients. All analyses were conducted after PSM. There were no statistically significant differences between the AT patient and control groups in terms of baseline clinical characteristics and echocardiographic features. Additionally, no significant differences were found between the blood viscosities calculated at low and high shear rates in both groups. The study revealed a significant difference between the two groups in the presence of LA spontaneous echo contrast (SEC) (24.5% in AT group vs 0% in Control group, p = .001), but not in the presence of thrombi (8.2% in AT group vs 0% in Control group, p = .117). Compared to the control group, the presence of SEC was significantly higher in the AT patient group. The increased frequency of SEC in AT patients suggests the hypothesis that AT may contribute to LA stasis. The routine use of TEE before AT catheter ablation remains controversial, despite the presence of LA thrombus and SEC in the AT patient group. The clinical assessment of thrombus presence before the procedure must be conducted on a patient-specific basis.

Use of Transesophageal Echocardiography for Liver Transplantation: A Global Comparison of Practice From the ILTS, SATA, and LICAGE.

Anesthesiologists frequently use intraoperative transesophageal echocardiography (TEE) to aid in the diagnosis and management of hemodynamic problems during liver transplantation (LT). Although the use of TEE in US centers continues to increase, data regarding international use are lacking. This prospective, global, survey-based study evaluates international experience with TEE for LT. Responses from 252 LT (105 US and 147 non-US) centers representing 1789 anesthesiologists were analyzed. Routine use of TEE in the United States has increased in the last 5 y (from 37% to 47%), but only 21% of non-US LT anesthesiologists use TEE routinely. Lack of training (44% US versus 70% non-US) and equipment (9% non-US versus 34% US) were cited as obstacles. Most survey participants preferred not to perform a complete cardiac examination but rather use only 6 of 11 basic views. Although non-US LT anesthesiologists more frequently had additional clinical training than their US counterparts, they had less TEE experience (13% versus 44%) and less frequently, TEE certification (22% versus 35%). Most LT anesthesiologists agreed that TEE certification is essential for proficiency. Of all respondents, 89% agreed or strongly agreed that TEE provides valuable information needed for immediate clinical decision-making, and >86% agreed or strongly agreed that that information could not be derived from other sources. The use of TEE for LT surgery in the US LT centers is currently higher compared with non-US LT centers. This may become a standard monitoring modality during LT in the near future.

Assessment of regional wall motion abnormality using transesophageal echocardiography in patient undergoing off pump coronary artery bypass grafting – An observational study

Context: Transesophageal echocardiography (TOE) has been widely used intraoperatively in cardiovascular surgeries. Its influence on perioperative decision-making in both surgical and pharmacological planning has been well recognized. A study was undertaken to establish the fact that the routine use of TOE not only reduces the complications of Coronary artery bypass grafting procedures, but also helps in better surgical decision-making. Aims: To compare the regional wall motion abnormality (RWMA) using TOE at pre and postgrafting Off-pump coronary artery bypass (OPCAB) procedure. Settings and Design: The study design involves institutional setting and observational study. Subjects and Methods: Seventy-two adult patients undergoing elective OPCAB procedures were included between January 2019 and June 2020. RWMA and ejection fraction (EF) were assessed before grafting and postgrafting using intraoperative TOE (IOTOE) to quantify the improvement of wall motion, if no improvement then the need for graft revision or additional grafting was suggested. Statistical Analysis Used: Quantitative outcomes were compared using paired t-tests. SPSS 20.0 was used to analyze the data collected. P < 0.05 was considered to be statistically significant. Results: Sixty-five (90%) patients had RWMA and EF improvement after the grafting and 3 (4%) patients had improvement after graft revision as suggested by IOTOE. So, 68 (94%) patients out of 72 had good surgical outcomes. The comparison between pre and postgrafting EF showed a statistically significant difference i.e., P < 0.05. Conclusions: IOTOE can be used routinely as a definitive mandatory monitoring tool to help in appropriate intra-operative surgical decision-making in patients undergoing OPCAB to enable better surgical outcomes and thereby reduce the morbidity and mortality associated with the procedure.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Transoesophageal echocardiography findings in young patients with cryptogenic ischemic stroke

Abstract Background and purpose The cause of ischemic stroke (IS) remains often unclear in young patients. Relevant structural heart abnormities with known embolic potential may represent cause of IS also in young population. The use of transoesophageal echocardiography (TEE) allows reliable detection of most relevant structural pathologies. The aim was to assess frequency and spectrum of relevant cardiac abnormities in young IS patients. Subjects and methods The study set consisted of young acute IS patients &amp;lt;50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study, registered on ClinicalTrials.gov NCT01541163). In all patients, the brain ischemia was confirmed on CT or MRI. Admission ECG, serum specific cardiac markers, TEE, 24-hour and 3-week ECG-Holter were performed in all patients. Results Out of 1284 patients enrolled in the HISTORY study, 135 (73 males, mean age 40.2±8.1 years) were &amp;lt;40 years. In total, the relevant TEE abnormities were present in 47 (35%) of these patients. Patent foramen ovale (PFO) with evident left to right shunt was detected in 38 (28%) patients, with significant right to left shunt in 25 (19%) patients, and other atrial septal defect with clinically significant bidirectional flow in 4 (3%) patients. Significant valvular heart disease was present in 2 (1%) patients (1 bicuspid aortic valve with moderate aortic regurgitation, 1 chronic severe mitral regurgitation), and 4 (3%) patients severe left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%) due to idiopathic dilated cardiomyopathy. Left atrial myxoma was detected in one patient. Conclusion The relevant structural abnormities with embolic potential were detected using TEE in 35% of young IS patients. Routine use of TEE to elucidate the causes of stroke, has a role especially in young patients who present with cryptogenic stroke and no cardiovascular risk factors, as well as in the setting of a PFO associated with a deep venous thrombosis. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): IGA LF UP, MH CZ - DRO

Left Ventricular Ejection Fraction Can Predict Atrial Thrombosis Even in Non-High-Risk Individuals with Atrial Fibrillation.

Background—Current guidelines do not recommend routine use of transesophageal echocardiography (TOE) in anticoagulated patients with atrial fibrillation (AF). The aim of our study was to identify predictors for left atrial thrombosis (LAT) in patients with AF that would require TOE despite anticoagulation therapy, using clinical, laboratory and echocardiographic data which are usually obtained in those patients in a real-world setting. Methods—We analyzed data from electronic medical records (EMR) of consecutive AF patients referred to two university hospitals between January 2014 and December 2017 for pulmonary vein isolation (PVI) or direct current cardioversion. The primary endpoint was the presence of left atrial thrombus on TOE. Multivariable and univariable logistic regression models were computed using variables that were significantly different between the LAT and the control groups. Results—A total of 838 patients were included, of whom 132 (15.8%) had LAT. After controlling for other variables, only the left ventricle ejection fraction (LVEF) remained statistically significant with an OR of 0.956 (95% CI 0.934–0.979), p < 0.01. Regression models including LVEF had significantly higher areas under the receiver operating characteristic (ROC) curves, including in subgroups with non-high thromboembolic risk (CHA2DS2-Vasc = 0 or 1), with an area under the curve (AUC) of 0.76 (95% CI 0.71–0.81), p < 0.0001. Conclusions—The LVEF is an independent predictor of LAT, and it might improve thromboembolic risk stratification in future models. LVEF significantly increased the predictive value of the CHA2DS2-Vasc model and was able to identify LAT in non-high-risk patients.

Intraoperative intracardiac thrombus in liver transplantation: A 9-year retrospective review focusing on treatment and outcomes.

This study characterizes incidence and outcomes surrounding intracardiac thrombosis (ICT) during liver transplantation over 9 years at a single center before and after the routine use of transesophageal echocardiography (TEE). Adult liver transplantation patients from 2011 to 2020 were divided into eras based on routine TEE use. ICTs were identified by querying anesthetic records for search terms. Descriptive statistics included counts and proportions for baseline recipient, donor, intraoperative, and postoperative characteristics. Outcome data were based on date of hospital discharge and date of death. The incidence of ICT increased in the TEE era (2016-2020) compared with the pre-TEE era (2011-2015; 3.7% [25/685] vs. 1.9% [9/491]; p < 0.001). Patients with ICT had significantly higher Model for End-Stage Liver Disease-sodium (MELD-Na) scores, pretransplant hospitalization, malignancy, drug-induced liver injury, hypertension, deep vein thrombosis, reperfusion syndrome, transfused platelets and cryoprecipitate, and use of hemostatic medications. A higher proportion of patients in the ICT group underwent simultaneous liver-kidney transplantation. The patients with ICT were similar, except patients in the pre-TEE era had higher MELD-Na scores and incidences of hepatitis C virus and lower incidences of encephalopathy. In the pre-TEE era, all ICTs presented as intraoperative cardiac arrest, and the 30-day mortality in the setting of ICT was 66.7% (6/9). During the TEE era, 80% of ICTs were diagnosed incidentally or attributed to hemodynamic instability (p=0.002). The 30-day mortality rate was 36% (9/25) in the TEE era (p=0.25). ICT incidence increased in the TEE era, yet the mortality rate was lower, suggesting that routine intraoperative TEE may lead to the early detection of ICT prior to hemodynamic collapse.

Association of Intraoperative Transesophageal Echocardiography and Clinical Outcomes After Open Cardiac Valve or Proximal Aortic Surgery

Intraoperative transesophageal echocardiography (TEE) is used frequently in cardiac valve and proximal aortic surgical procedures, but there is a lack of evidence associating TEE use with improved clinical outcomes. To test the association between intraoperative TEE use and clinical outcomes following cardiac valve or proximal aortic surgery. This matched, retrospective cohort study used national registry data from the Society of Thoracic Surgeon (STS) Adult Cardiac Surgery Database (ACSD) to compare clinical outcomes among patients undergoing cardiac valve or proximal aortic surgery with vs without intraoperative TEE. Statistical analyses used optimal matching within propensity score calipers to conduct multiple matched comparisons including within-hospital and within-surgeon matches, a negative control outcome analysis, and sensitivity analyses. STS ACSD data encompasses more than 90% of all hospitals that perform cardiac surgery in the US. The study cohort consisted of all patients aged at least 18 years undergoing open cardiac valve repair or replacement surgery and/or proximal aortic surgery between 2011 and 2019. Statistical analysis was performed from October 2020 to April 2021. The exposure was receipt of intraoperative TEE during the cardiac valve or proximal aortic surgery. The primary outcome was death within 30 days of surgery. The secondary outcomes were (1) a composite outcome of stroke or 30-day mortality and (2) a composite outcome of reoperation or 30-day mortality. Of the 872 936 patients undergoing valve or aortic surgery, 540 229 (61.89%) were male; 63 565 (7.28%) were Black and 742 384 (85.04%) were White; 711 326 (81.5%) received TEE and 161 610 (18.5%) did not receive TEE; the mean (SD) age was 65.61 years (13.17) years. After matching, intraoperative TEE was significantly associated with a lower 30-day mortality rate compared with no TEE: 3.81% vs 5.27% (odds ratio [OR], 0.69 [95% CI, 0.67-0.72]; P < .001), a lower incidence of stroke or 30-day mortality: 5.56% vs 7.01% (OR, 0.77 [95% CI, 0.74-0.79]; P < .001), and a lower incidence of reoperation or 30-day mortality: 7.18% vs 8.87% (OR, 0.78 [95% CI, 0.76-0.80]; P < .001). Results were similar across all matched comparisons (including within-hospital, within-surgeon matched analyses) and were robust to a negative control and sensitivity analyses. Among adults undergoing cardiac valve or proximal aortic surgery, intraoperative TEE use was associated with improved clinical outcomes in this cohort study. These findings support routine use of TEE in these procedures.

Transesophageal echocardiography for perioperative management in thoracic surgery.

Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures. Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion. Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.

Anaesthetic management of a large paraganglioma resection in a woman with isolated L-looped transposition of the great arteries: a case report

BackgroundReports of anaesthetic management of paraganglioma resection in patients with isolated L-transposition of the great arteries (L-TGA) are rare. We focus on the preoperative evaluation, intraoperative management, and postoperative care of a frail patient with “physiologically corrected” L-TGA for paraganglioma resection.Case presentationWe performed general anaesthesia for a 46-year-old patient with “physiologically corrected” L-TGA undergoing open large retroperitoneal paraganglioma resection. Although the preoperative medical therapy had attained its goals, the patient went through three periods of severe episodic hypertension and tachycardia as tumour manipulation released catecholamines. Goal-directed fluid therapy based on pulse pressure variation (PPV) and point-of-care transesophageal echocardiography (TEE) imaging enabled anaesthesiologists to make rapid judgments and to regulate blood pressure in a timely manner, thereby reducing the risk of heart failure caused by massive rapid fluid bolus therapy. The patient was transferred to the intensive care unit because of intraoperative hemodynamic changes and significant blood loss. Despite transient myocardial injury (elevated troponin I), no lethal arrhythmia or complications occurred perioperatively, and the patient recovered well and was discharged 1 week later.ConclusionsGoal-directed fluid therapy combined with the adoption of TEE could effectively guide fluid administration, which is helpful for anaesthesia management during operation. We recommend the routine use of TEE in such cases.

Role of Intraoperative Transesophageal Echocardiography in Cardiac Surgery: an Observational Study.

AIM:This study is based on the hypothesis that the routine use of transesophageal echocardiography in cardiac surgery will influence the surgical decision taken by the surgeon intra-operatively in Kasr-Alainy hospitals.METHODS:Patients were examined with intraoperative transesophageal echocardiography (TEE) before and after cardiopulmonary bypass. Complete and comprehensive intraoperative TEE examinations will be performed by TEE certified cardiac anesthesiologists. Data that will be collected from the intraoperative examination and will be compared with preoperative transthoracic echocardiography, and the surgical decision that was taken preoperatively will be revised again with the cardiothoracic surgeon before the start of surgery. Also, TEE will be used again after weaning from bypass for revision and assessment of our decision.RESULTS:We examined the utility of TEE in 100 patients undergoing different types of cardiac procedures in Kasr Al-Ainy hospital. This prospective clinical investigation found that the pre- and post-CPB TEE examinations influenced surgical decision making in 10% of all evaluated patients.CONCLUSION:Intraoperative TEE has the potential to influence clinical decision making for cardiac surgical patients significantly. It is useful in surgical planning, guiding various hemodynamic interventions, and assessing the immediate results of surgery. Thus, IOTEE should be used routinely in all patients undergoing all types of cardiac surgeries.

Risk Factors for Intracardiac Thrombus During Liver Transplantation.

Intracardiac thrombus (ICT) is an intraoperative complication with high mortality that occurs during orthotopic liver transplantation (OLT). Patients with end-stage liver disease have compromised coagulation pathways, and when combined with stressors of surgery, thrombi can form. However, it is unknown which patients are most likely to develop ICT. We performed a retrospective cohort study of all OLT patients at our hospital from 2010 to 2017 to identify risk factors for ICT. An analysis was performed with conventional bivariate tests and logistic regression. The incidence of ICT during OLT was 4.2% (22/528) with a 45.5% (10/22) mortality. Patients who developed ICT had higher physiologic Model for End-Stage Liver Disease scores at the time of transplant (25.1 versus 32.4; P=0.004), received grafts from donors with a higher body mass index (28.1 versus 32.2kg/m2 ; P=0.007), and had longer intraoperative warm ischemia times (53.1 versus 67.5 minutes; P = 0.001). The odds of developing ICT were significantly lower after administration of intravenous (IV) heparin prior to inferior vena cava (IVC) clamping compared with no administration of heparin (odds ratio, 0.25; 95% confidence interval, 0.08-0.75; P = 0.01). In conclusion, the incidence of ICT at our institution is higher than previously reported, which may be explained by our routine use of transesophageal echocardiography. Although many factors associated with ICT in this study are nonmodifiable, administration of IV heparin prior to IVC cross-clamping is modifiable and was found to be protective. Further studies will be needed to confirm findings and ultimately aid in preventing these lethal events.

Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management.

In this review, we analyze the epidemiology of thromboses related to end-stage liver disease (ESLD), discuss causes of hypercoagulability, describe susceptible populations, and critically evaluate proposed prophylaxis and treatment of thromboses. Classically, ESLD has been regarded as a model for coagulopathy, and patients were deemed to be at high risk for bleeding complications. Patients with ESLD are not auto-anticoagulated, and they do not have a lower risk of portal vein thrombosis, intracardiac thrombus formation, pulmonary embolism or hepatic artery thrombosis. Though the cause of hypercoagulability is multifactorial, endothelial dysfunction likely plays a central role for all patients with ESLD. Some subpopulations, such as patients with nonalcoholic steatohepatitis and autoimmune conditions, are at increased risk of thrombotic events as are patients of Hispanic ethnicity. The science behind prophylaxis of different types of clotting and treatment of thromboses is developing rapidly. A number of medications, including low molecular weight heparin, unfractionated heparin, aspirin, vitamin K antagonists, and direct oral anticoagulants can be used, but clear guidelines are lacking. Acute intraoperative clotting can be associated with high mortality. Routine use of transesophageal echocardiography can be helpful in early recognition and treatment of intraoperative thrombosis. Heparin should be reserved for cases of intracardiac thrombus/pulmonary embolism without hemodynamic instability. In unstable patients, low dose of recombinant tissue plasminogen activator can be used. In this new era of heightened awareness of thrombotic events in ESLD patients, prospective randomized trials are urgently needed to best guide clinical practice.

Outcomes and Safety of Transcatheter Aortic Valve Implantation With and Without Routine Use of Transesophageal Echocardiography

Transesophageal echocardiography (TEE) has been extensively used historically for Transcatheter aortic valve implantation (TAVI) but focus is shifting from routine use of TEE and general anesthesia to "as needed" use. We evaluated patients who had TAVI in our institution from September 2012 to February 2017. Decision for implantation and use of TEE during procedure was made by the structural heart team on a case-to-case basis, based on FDA approved indications. Data including procedural details, length of stay and rehospitalizations were obtained from all patients. TAVI was performed on 178 patients during the study period of which 104 of 178 had TEE during TAVI. Baseline characteristics were fairly comparable in both groups. Similar proportion of self-expanding and balloon expanding valves were deployed. Patients in TEE group had longer overall procedure time (107 minute vs 83 minute, p = 0.0002) and longer length of stay (5.01days vs 2.49days, p < 0.0001). Echocardiographic study postprocedure showed similar incidence of paravalvular leak and similar gradients and velocities across aortic valve. Rates of 30-day readmissions were similar in both groups. In conclusion, in this single-center retrospective analysis-TAVI without the 'routine use' of TEE was comparable with those done with TEE guidance in terms of periprocedural complications and 30-day readmissions. Overall procedure length and length of stay was predictably higher in the TEE group.

Abstract 12921: Role of Transesophageal Echocardiogram in Affecting Treatment in Older Adults Undergoing Evaluation for Transient Ischemic Attack or Stroke

Background: As the United States medical system transitions to value-based reimbursement, interested parties will increase scrutiny in testing that may not alter management or outcomes. We investigated whether transesophageal echocardiography (TEE) provokes treatment alteration across age strata in hospitalized patients undergoing a TIA/stroke work-up. Methods: Consecutive patients admitted to the Mayo Clinic Arizona healthcare system between 1/1/2010 and 2/9/2015 were evaluated. A total of 832 patients were identified of which 314 were excluded primarily due to the fact that the TEE was performed as an outpatient. Therefore, 518 subjects (mean age = 68.2 +/- 14.1 y, 42.5% female) were included. A change in treatment was defined a priori as: anticoagulation (AC) initiated for atrial fibrillation found on TEE only (i.e. not identified on telemetry), complex proximal aortic arch plaque, left atrial or left atrial appendage thrombus, intracardiac mass, intracardiac shunt (atrial septal defect (ASD)/ patent foramen ovale (PFO)) ; PFO closure; cardiac mass removal; valve replacement for endocarditis; antibiotics for endocarditis. Results: See Tables A &amp; B Conclusion: TEE in the evaluation of hospitalized patients with TIA/stroke resulted in a change in treatment in approximately 7% of patients regardless of age. Many of the decisions to change treatment were judgment-based and therefore adoption of the routine use of TEE in all patients with TIA/stroke is dependent on institutional practice standards.

Abstract 17571: Use of Goal Directed Transesophageal Echocardiography in the Arresting Patient

Background: With outcomes from cardiac arrest remaining generally poor, there is an urgency to evaluate interventions that allow physicians to manage cardiac arrest more effectively. Transesophageal echocardiography (TEE) can be used at the point of care in a goal-directed manner and can rapidly provide a flurry of data on cardiac structure and function. TEE in the arrested patient is unobtrusive to resuscitation and can provide vital information regarding the potential etiology of arrest, guidance of certain procedures and prognosis. As such, some centers, including our own, have adopted increasingly routine use of TEE in this context. Given the paucity of data in this area, we sought to examine the influence of point-of-care TEE conducted by emergency physicians or intensivists at our institution for patients in or immediately after cardiac arrest. Methods: Goal-directed TEE in the emergency department (ED) or intensive care units (ICU) and their reports were archived in a dedicated point-of-care ultrasound imaging database. We conducted a search of all TEE examinations archived between December 2012 and April 2015 in the peri-arrest period (in or immediately after cardiac arrest). The details from reports were abstracted. TEE-directed management changes were noted when recommendation(s) regarding initiation/escalation of inotropes, fluid administration, termination of resuscitation or surgical procedure were featured in the TEE report. Results: A total of 57 peri-arrest TEE exams were identified (21 in ICUs and 36 in EDs). Goal-directed TEE changed management in 61.4% of cases. TEE facilitated the escalation/initiation of inotropes (35.3%), decision to terminate resuscitation (32.4%), guided fluid management (23.5%) and surgical procedures (8.8%). TEE studies altered management in 66.7% of cases in the Intensive Care Unit and in 58.3% of cases in the Emergency Department. Conclusions: Goal-directed TEE performed by emergency physicians or intensivists has an impact on management on patients in the peri-arrest setting the majority of the time. Given the lack of reliable diagnostic and therapeutic options in arresting patients, a larger study examining the influence of goal-directed TEE on patient outcomes in cardiac arrest should be carried out.

Intracardiac thrombosis during liver transplant: A 17-year single-institution study.

Intracardiac thrombosis (ICT) during orthotopic liver transplantation (OLT) is an uncommon event. However, it is a devastating complication with high mortality when it occurs. This study aimed to identify possible predisposing factors for ICT during OLT. We retrospectively identified the cases of all patients with ICT during OLT at our institution from 1998 to 2014. Of 2750 OLTs performed, 10 patients had ICT intraoperatively. The patients' immediate prethrombosis intraoperative hemodynamic and coagulation values and thromboelastography (TEG) data were reviewed. Preexisting venous thrombosis, atrial fibrillation, and the prior placement of a transjugular intrahepatic portosystemic shunt for portal hypertension were noted in several patients and may be related to ICT during OLT. A high Model of End-Stage Liver Disease score, low cardiac output, and sepsis did not appear to be associated with ICT. ICT occurred in some patients without the administration of antifibrinolytic agents. TEG and coagulation parameters did not appear to be helpful in predicting the onset of ICT. Four patients had ICT in both right- and left-sided heart chambers; none of these 4 patients survived. All 6 patients with only right-sided thrombus survived. In those who survived, improved hemodynamics and clot disappearance on transesophageal echocardiography (TEE) occurred over time, even without the use of thrombolytics. Whether this is because of endogenous thrombolysis or distal clot propagation into the pulmonary vasculature, or both, is unclear. Tissue plasminogen activator may have a role in the resuscitation procedure. In conclusion, without the routine use of TEE during OLT, the incidence of ICT will remain an under-recognized event.

Clinical utility of routine use of continuous transesophageal echocardiography monitoring during transvenous lead extraction procedure.

Data on the use of transesophageal echocardiography (TEE) during transvenous lead extraction (TLE) procedures are scarce. The purpose of this study was to assess the routine use of TEE during transvenous lead extraction. From January 2009 to January 2014, TLE of 241 leads in 168 patients (mean age 70 ± 13 years, 129 male, left ventricular ejection fraction 37% ± 13%) was performed. Indication for TLE was lead dysfunction (56.5%), upgrade (27.0%), infection (13%), or other (3.1%). TLE techniques combined a mechanical approach amended by laser technique if required. Extraction procedures were performed with patients under general anesthesia with continuous invasive arterial blood pressure and TEE monitoring. TEE was possible in all except 1 patient. TEE images in different projections were acquired and stored before and immediately after extraction of each lead. TLE was complete for 236 of 241 leads (97.9%); 4 distal lead tips (1.7%) remained in situ, and 1 dual-coil implantable cardioverter-defibrillator electrode (0.4%) could not be removed. New TEE findings after TLE were observed in 7 of 161 cases (4.3%): pericardial effusion (mild in 4 [2.5%] and severe in 1 [0.6%]) and worsening of tricuspid valve insufficiency (2 patients [1.2%]). The only case of severe pericardial effusion occurred after laceration of the superior vena cava, which required immediate rescue surgery (0.6%, confidence interval 0.01-3.3). In all other cases, TEE findings did not entail immediate diagnostic or therapeutic measures. New TEE findings produced during TLE necessitating immediate therapeutic measures occurred in only 0.6% of cases, suggesting the limited utility of routine continuous TEE monitoring during TLE.

Transesophageal echocardiography in patients with cryptogenic ischemic stroke: A systematic review

The clinical utility of routine transesophageal echocardiography (TEE) for patients with unexplained ischemic stroke is controversial. We performed a systematic review to determine the frequency of detection of new cardiac findings in patients with cryptogenic ischemic stroke (IS) undergoing transesophageal echocardiography (TEE). Systematic review and meta-analysis of cohort studies of consecutive patients with "cryptogenic" IS undergoing TEE after routine etiologic workup. Patients were categorized into 2 groups: A (< 55 years) and B (≥ 55 years). Outcomes included proportion of patients with new TEE-detected cardiac findings and proportion of patients commenced on oral anticoagulation after TEE. Twenty-seven studies were included (n = 5,653). We identified significant heterogeneity among studies and report a range of prevalence rates and I2 statistic as our primary analysis. Prevalence of individual cardiac findings on TEE varied significantly among studies; patent foramen ovale (A: 12.0%-57.8%, I2 = 89.9%; B: 3.9%-43.5%, I2 = 86.7%), atrial septal aneurysm (A: 0-48.9%, I2 = 91.9%; B: 3.5%-25.0%, I2 = 84.5%), left atrial thrombus (A: 0-10.9%, I2 = 61.1%; B: 0-21.2%, I2 = 91.7%), spontaneous echo contrast (A: 0-11.9%, I2 = 57.2%; B: 0-21.3%, I2 = 89.8%), and aortic atheroma (A: 0-9.6%, I2 = 53.8%; B: 2.8%-44.4%, I2 = 89.7%). Definitions of common findings were not provided for many studies. Five studies (n = 591) reported on the proportion of patients who were commenced on anticoagulant therapy after TEE (range 0-30.7%). Routine TEE in patients with cryptogenic IS identifies cardiac findings in a large proportion. However, there is marked interstudy variation in the definition and prevalence of common findings. Transesophageal echocardiography-detected findings prompted the introduction of anticoagulant therapy in up to one-third of patients. However, these were mostly not for established guideline-based indications based on randomized controlled trial evidence. It is unclear if routine use of TEE in patients with cryptogenic IS is indicated.

Venous air embolism during major liver surgery

Editor, Venous air embolism is a potentially fatal event, but its prevalence during liver resection is unknown. Although major gas embolisms have been reported during liver surgery, liver resection has not been documented as a procedure bearing a serious risk of this complication.1 Lodging of air in the pulmonary vessels results in the elevation of pulmonary arterial pressure and a rapid decrease in end-tidal carbon dioxide concentration (EtCO2).2 The sudden onset of this symptom during an operation usually raises the suspicion of possible venous air embolism. The aim of this study was to assess the incidence of embolic events during liver resection with the use of transoesophageal echocardiography (TOE), the most sensitive method for detection of pulmonary air embolism.3 Ethical approval for this study (Ethical Committee No. RNN/369/12/KB) was provided by the Ethical Committee of the Medical University of Lodz, Poland (Chairperson Prof Przedzisław Polakowski) on 22 May 2012. Intraoperative visualisation of heart chambers was obtained by inserting a TOE probe (model 6T GM Medical System, complementary with VIVID 7 PRO; General Electric, Milwaukee, USA) into the oesophagus. All the TOE examinations were made along the interatrial septum. The data were analysed using software for quantitative analysis of signal intensity (Q-analyse; General Electric, Milwaukee, WI, USA). Using the time intensity curves, data were analysed in two regions of interest: right atrium (RA) and left atrium. All statistical calculations were performed using SigmaPlot version 12.0 (Systat Software Inc., San Jose, CA, USA). To compare the differences in maximum and minimum EtCO2, heart rate and mean arterial pressure in groups with and without gas embolism on TOE, we applied the parametric t-test and nonparametric Mann–Whitney test. All data are given in the text as mean and standard deviation Thirty-eight consecutive patients scheduled for hemihepatectomy (right: 29, left: 9) for metastatic tumours of the liver were enrolled in the study. The average age was 56.3 years (range 22 to 75 years). Combined general and epidural anaesthesia was undertaken in all patients. Minor [defined as several air bubbles in the RA and right ventricle (RV)] and major air embolisms (air bubbles filling at least 50% of the RA and RV) were identified in 23 (60%) and five (13%) patients, respectively. Air embolism was accompanied by cardiorespiratory changes including a decrease in minimum EtCO2 (to 3.2 ± 0.4 versus 3.8 ± 0.4 kPA; P = 0.005) and increase in maximum heart rate (101.1 ± 12.0 versus 87.3 ± 12.1 beats per minute; P = 0.003). The difference in signal intensity (dB) between the RA and the left atrium is shown in Fig. 1.Fig. 1: No captions available.Furthermore, all serious complications, including early postoperative myocardial infarction (one case; 2.6%) and bleeding requiring intraoperative blood transfusion (six cases; 15%) occurred in patients with air embolism. Finally, the mean length of hospital stay tended to be longer in this group than in patients without air embolism (13.1 ± 7.7 versus 8.5 ± 1.7 days; P = 0.123). The prevalence of venous air embolism during liver surgery is underestimated.4 Liver resection requires intraoperative reduction of central venous pressure to minimise bleeding from transected parenchyma. The combination of general and epidural anaesthesia used for this purpose results in arterial hypotension, masking the main signs of pulmonary embolism.5,6 To the best of our knowledge, this is the first study investigating the prevalence of pulmonary air embolism during major liver surgery with the routine use of TOE. The results show that air embolism is common and generally asymptomatic. However, further studies elucidating its influence on the postoperative course of patients after liver resection are needed. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.