Transesophageal Echocardiography Monitoring Research Articles

Anesthetic and Perioperative Considerations for Convergent Procedure for Atrial Fibrillation, A Retrospective Observational Cohort Study

ObjectivesTo summarize anesthetic and perioperative considerations in patients undergoing the convergent procedure for atrial fibrillation (AF). DesignRetrospective observational study. SettingSingle center quaternary teaching hospital. ParticipantsAdult patients with atrial fibrillation undergoing the convergent procedure before January, 2024. InterventionsRetrospective chart review. Measurements/main resultsA total of 40 patients were included; of them 35 patients had persistent longstanding AF. The mean age (SD) was 64 (6) years and 33 patients (83%) were male. Common comorbidities included obesity 27 (68%), obstructive sleep apnea 29 (73%), history of tachycardia-mediated cardiomyopathy 10 (25%), and significant alcohol use 10 (25%). Sixteen of 40 patients (40%) had a history of prior endocardial ablation, and 37 patients (93%) required a cardioversion in the past. In all, 39 patients (98%) were anticoagulated and 38 (95%) were on at least 1 anti-arrhythmic medication prior to the procedure. All patients received general anesthesia; 39 patients (98%) inhalational and 1 patient (3%) total intravenous, with regional analgesia adjuncts in 36 patients (88%). All patients required lung isolation, arterial line, central venous access, and transesophageal echocardiographic monitoring. While cardiopulmonary bypass (CPB) was on standby and ready to be initiated for every patient, only 3 patients (8%) required CPB (1 planned, 2 emergent). Thirty seven of 40 patients (93%) were extubated in the operating room, and 11 (28%) of patients required intensive care unit (ICU) admission (planned or unplanned). The median ICU and hospital length of stay were 1 and 4 days, respectively. ConclusionsThis retrospective analysis of medical records showed that many patients with recurrent atrial fibrillation presenting for convergent procedure carry a burden of multiple comorbidities (obesity, obstructive sleep apnea), and history of unsuccessful ablations. Multistage multidisciplinary convergent procedure might be lengthy, potentially complicated and requires meticulous preparation (endotracheal intubation, lung isolation, advanced cardiac monitoring, central venous access) to ensure optimal outcomes. Anesthesiologists and perioperative physicians should tailor their approach to this multimorbid population, while anticipating perioperative respiratory events, rapid hemodynamic shifts, blood loss, and a possibility of cardiopulmonary bypass.

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.

The effects of an IV fluid bolus on mitral annular velocity and the assessment of diastolic function: a prospective non-randomized study

BackgroundAbnormal diastolic function is an independent predictor of adverse postoperative outcomes. Mitral annular tissue Doppler velocity (e’) is a key parameter for assessing diastolic function. The purpose of this study was to confirm that an acute increase in preload did not significantly impact the intraoperative measurement of e’ and secondarily evaluate the impact of this acute intravascular volume increase on the clinical assessment of diastolic function using a previously described simplified algorithm.MethodsThis was a prospective, non-randomized study in adult patients undergoing elective cardiac surgeries requiring transesophageal echocardiographic monitoring, arterial pressure and Swan-Ganz catheter placements as part of the surgical procedure. Following baseline echocardiographic and hemodynamic measurements, 500 ml of crystalloid solution was infused over 10 min. Hemodynamic and echocardiographic measurements were repeated 5 min after fluid administration.ResultsComplete data sets were available from 84 of the 100 patients who were enrolled in this study. There was no significant change in the values of e’. The average baseline was 7.8 ± 2.0 cm/s (95%CI: 7.4, 8.2) and 8.1 ± 2.4 (95%CI: 7.6, 8.6) following the fluid bolus (p = 0.10). All hemodynamic variables associated with increased intravascular volume (central venous pressure, pulmonary arterial pressures and stroke volume variation) changed significantly. The overall distribution of diastolic function grades did not change following fluid administration (p = 0.69). However, there were many individual patient differences. When using this simplified algorithm, functional grading changed in 35 patients. Thirty of these 35 changes were only a single grade shift. 22 patients had worse functional grading after fluid administration while 13 had improved grading. Nine patients with normal diastolic function at baseline demonstrated diastolic dysfunction after fluid administration while 6 patients with baseline dysfunction normalized following the fluid bolus.ConclusionWe confirmed that e’ is a robust measurement that is reproducible in the intraoperative setting despite variable vascular volume loading conditions, however, the clinical assessment of diastolic function was still altered in 42% of the patients following an intravenous fluid bolus.

Renal cell carcinoma with an “uncoiling” tumor thrombus: intraoperative shift from level III to level IV

BackgroundThe gold standard treatment for renal cell carcinoma (RCC) with tumor thrombus (TT) is complete surgical excision. The surgery is complex and challenging to the surgeon, especially with large tumor thrombus extending into the inferior vena cava (IVC) and right atrium. Traditionally, these difficult cases required the use of cardiopulmonary bypass (CPB) with or without deep hypothermic cardiac arrest, but in recent years, different surgical techniques derived from the field of liver transplantation have been used in efforts to avoid CPB.Case presentationWe present a case of RCC with TT level IIIc (extending above major hepatic veins) that “uncoiled” intraoperatively into the right atrium after division of the IVC ligament, transforming into a level IV TT. Despite the new TT extension, the surgery was successfully completed exclusively through an abdominal approach without CPB and while using intraoperative transesophageal echocardiography (TEE) monitoring and a cardiothoracic team standby.ConclusionsThis case highlights the need for a multidisciplinary approach and the utility of intraoperative continous TEE monitoring which helped to visualize the change of the TT venous extension, allowing the surgical teamto modify their surgical approach as needed avoiding a catastrophic event.

Temporal Trends in Transcatheter Aortic Valve Implantation: 10-Year Analysis of the TAVIDOR Registry.

Transcatheter aortic valve implantation (TAVI) has established itself as the preferential strategy to approach severe aortic stenosis. Information on procedural improvements and nationwide results obtained with the technique throughout the past decade are unknown. To assess the temporal variation of the demographic profile, procedural characteristics, and in-hospital outcomes of patients undergoing TAVI procedures at the Rede D'Or São Luiz. Observational registry comprising 29 national institutions, comparing the characteristics of the TAVI procedures performed from 2012 to 2017 (Group 1) to those performed from 2018 to 2023 (Group 2). The statistical significance level adopted was p < 0.05. This study assessed 661 patients, 95 in Group 1 and 566 in Group 2, with a mean age of 81.1 years. Group 1 patients had a higher prevalence of New York Heart Association functional class III or IV and STS risk score > 8%. In addition, they more often underwent general anesthesia, transesophageal echocardiographic monitoring, and access through femoral dissection. Group 2 patients had a higher success rate of the TAVI procedure (95.4% versus 89.5%; p = 0.018), lower mortality (3.9% versus 11.6%; p = 0.004), and less often needed permanent pacemaker implantation (8.5% versus 17.9%; p = 0.008). The 10-year temporal trends analysis of the TAVIDOR Registry shows a reduction in patients' clinical complexity over time. Furthermore, the advance to minimalistic implantation techniques, added to the technological evolution of the devices, may have contributed to the favorable outcomes observed among those whose implantation occurred in the last 5 years studied.

Transesophageal Echocardiography Probe-induced Esophageal Perforation

Transesophageal echocardiography (TEE) probe-induced esophageal perforation is rare. A 67-year-old man underwent a Bentall procedure with mitral valve replacement under TEE monitoring. Two hours later, the patient had a blood-stained aspirate from the nasogastric tube. Contrast-enhanced computed tomography of the chest showed esophageal perforation, which was treated with the fluoroscopic deployment of covered metal stents. The patient had an uneventful recovery.

Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum.

Background: Minimally invasive repair of pectus excavatum involves placement of retrosternal support (Nuss) bars. Hardware removal has been rarely associated with life-threatening hemorrhage from the heart, aorta, internal mammary arteries, and/or lung. There is no accepted standard intraoperative monitoring technique used during removal. We hypothesized that the use of transesophageal echocardiography (TEE) during Nuss bar removal would enhance safety of the procedure and be cost-effective. Methods: IRB-approved retrospective review of patients who underwent Nuss bar removal with intraoperative TEE monitoring over a 4-year period, from March 2013 to May 2017, was completed. Bar removal procedures were performed supine, under general anesthesia. TEE images were monitored and any distortion of the cardiac silhouette, new pericardial effusion, and/or cardiac arrhythmias would be considered evidence of possible bar adherence, triggering possible conversion to sternotomy or thoracotomy. Results: In total, 87 consecutive patients, mean age of 20 years, were identified. Bars had been in place for a mean of 30 months. Average procedure time was 67 minutes. No patients experienced arrhythmias, cardiac injury, or significant hemorrhage during removal. TEE gave excellent visualization of the cardiac silhouette and pericardium in all cases. No patient required insertion of an arterial line, a postoperative chest X-ray, or overnight hospitalization. Patients were discharged from the recovery room an average of 89 minutes postprocedure. Conclusion: TEE offers a minimally invasive safe way to visualize the pericardium and its contents during Nuss bar removal. Significant cardiac/mediastinal injuries should be immediately visible. The use of TEE is cost-effective and allows safe discharge the day of surgery.

Abstract P3012: Routine Monitoring For Intracardiac Thrombosis And Pulmonary Embolism With Intraoperative Transesophageal Echocardiography In Orthotopic Liver Transplantation

Background: Intracardiac thrombosis (ICT) and pulmonary embolism (PE) are significant intraoperative complications during orthotopic liver transplantation (OLT). Despite the high mortality associated with these events, current monitoring practices are inadequate at detecting these complications during OLT. Transesophageal echocardiography (TEE) allows continuous monitoring of myocardial function and detection of ICT/PE. In this study, we aim to report the incidence of ICT/PE during OLT at our center and to advocate for the use of intraoperative TEE as a standard monitoring tool. We also propose a medical management algorithm stratified by the severity of RV dysfunction and pulmonary artery pressure (PAP) in cases of ICT with/without PE. Methods: We conducted a single-center retrospective chart review of OLT patients with intraoperative TEE monitoring from March 13, 2019 - March 13, 2023. Intraoperative data of interest included hemodynamics, RV dysfunction, PAP, presence of ICT and/or PE as identified on TEE and associated medical management. RV dysfunction was graded as mild, moderate, or severe reduction in cardiac contractility. Secondary outcome was mortality during index hospitalization. Results: We identified 99 patients at our center who had intraoperative TEE monitoring during OLT. Prevalence of ICT in this population was 9.09% (n=9), of which 44.4% (n=4) developed hemodynamically significant PE. ICT patients who remained hemodynamically stable were observed without intervention (33%, n=3). Heparin was administered to prevent thrombus enlargement in patients with an increase in PAP but no significant RV dysfunction detected on TEE (22%, n=2). Those showing signs of hemodynamically significant PE with moderate or severe RV failure were given tissue plasminogen activator (tPA) for thrombolysis (44%, n=4). Perioperative mortality among all ICT patients was 44.4% (n=4) due to hemorrhagic shock secondary to coagulopathy and heart failure. Conclusion: The results of this study show the utility of routine TEE use in intraoperative monitoring for identifying ICT and PE in OLT patients, given the high mortality associated with these complications. TEE also allows for a stepwise approach to medical management based on RV function and PAP.

Malposition of a pulmonary artery catheter in the left ventricle: a case report

BackgroundPlacement of pulmonary artery catheters may be associated with a variety of complications. We present a case where a pulmonary artery catheter was accidentally advanced into the left ventricle by perforating the intraventricular septum.Case presentationA 73-year-old woman underwent mitral valve dysfunction. A pulmonary artery catheter could not pass the tricuspid valve under general anesthesia, which was manually advanced via the right ventricle during surgery. After valve replacement, systolic pulmonary artery pressure was higher than radial arterial blood pressure. Transesophageal echocardiography (TEE) revealed the tip of the catheter in the left ventricle. The catheter was withdrawn and then advanced to the pulmonary artery under monitoring of TEE. Transseptal shunt flow gradually decreased and finally disappeared. The surgery was completed without additional procedures.ConclusionsAlthough ventricular septal perforation is rare, it should be recognized as a potential complication of pulmonary artery catheter insertion.

Coronary Obstruction during Valve-in-Valve Transcatheter Aortic Valve Replacement: Pre-Procedural Risk Evaluation, Intra-Procedural Monitoring, and Follow-Up.

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is emerging as an effective treatment for patients with symptomatically failing bioprosthetic valves and a high prohibitive surgical risk; a longer life expectancy has led to a higher demand for these valve reinterventions due to the increased possibilities of outliving the bioprosthetic valve's durability. Coronary obstruction is the most feared complication of valve-in-valve (ViV) TAVR; it is a rare but life-threatening complication and occurs most frequently at the left coronary artery ostium. Accurate pre-procedural planning, mainly based on cardiac computed tomography, is crucial to determining the feasibility of a ViV TAVR and to assessing the anticipated risk of a coronary obstruction and the eventual need for coronary protection measures. Intraprocedurally, the aortic root and a selective coronary angiography are useful for evaluating the anatomic relationship between the aortic valve and coronary ostia; transesophageal echocardiographic real-time monitoring of the coronary flow with a color Doppler and pulsed-wave Doppler is a valuable tool that allows for a determination of real-time coronary patency and the detection of asymptomatic coronary obstructions. Because of the risk of developing a delayed coronary obstruction, the close postprocedural monitoring of patients at a high risk of developing coronary obstructions is advisable. CT simulations of ViV TAVR, 3D printing models, and fusion imaging represent the future directions that may help provide a personalized lifetime strategy and tailored approach for each patient, potentially minimizing complications and improving outcomes.

A Patient with Extremely Severe Constrictive Pericarditis Underwent Emergency Pericardiectomy Without Cardiopulmonary Bypass

We report a case of a 58-year-old man admitted to hospital with severe constrictive pericarditis. An emergency pericardiectomy was planned due to the patient's orthopnea associated with hemodynamic instability. The patient performed pericardiectomy without cardiopulmonary bypass. The patient was found to be orthopnea and began to experience disturbance of consciousness after entering the operating room. Non-invasive blood pressure was 100/54 mmHg, accompanied by atrial fibrillation, the ventricular rate was 158 beats/min, and arterial oxygen saturation was 90% with air inhalation. After intubation, the ventricular rate rose to 187 beats/min, the blood pressure dropped to 65/45 mmHg, and vasopressors were urgently administered to maintain circulatory stability. At the same time, the internal jugular vein cannula was placed ultrasound-guided. During the operation, the central venous pressure (CVP) increased to 41.2 cmH₂O, and cerebral oxygen saturation dropped to 47.6%. Although the patient with severe constrictive pericarditis, we still performed pericardiectomy without cardiopulmonary bypass. The operation time was about 3 hours, and the patient was successfully transferred to the Intensive Care Unit (ICU) to continue monitoring and treatment, and the tracheal intubation was removed 48 hours after the operation and he was discharged 19 days after the operation. Real-time transesophageal echocardiography (TEE) monitoring played a crucial role in intraoperative management.

To grade or not to grade safety requirements for transvenous lead extraction: Experience with 2216 procedures.

Transvenous lead extraction (TLE) procedures are now increasingly safe, but there is still a risk of major complications (MC). We aimed to assess the impact of TLE organization on the safety of procedures. We analyzed 2216 TLE procedures performed in two centers in the years 2006-2021 and compared three organizational procedural models: (1) TLE in an electrophysiology laboratory (EP-LAB) with intravenous analgesia/sedation; (2) TLE with grading of safety requirements (high-risk patients in the cardiac surgery operating theatre, others in EP-LAB); (3) TLE in the hybrid room in all patients under general anesthesia with transesophageal echocardiographic (TEE) monitoring. The safety of procedures and mortality after TLE in three-year follow-up were assessed. The rate of MC in the EP-LAB group was 1.55%, and the rate of procedure-related deaths (PRD) was 0.33%. While using the graded approach to safety requirements, the percentage of MC was 2.61% and PRD 0.29%. When performing TLE procedures in the hybrid room, the MC percentage was 1.33% and PRD 0.00%. Long-term survival after TLE was comparable in all study groups. A key factor in preventing TLE-related deaths is procedure organization that enables emergency cardiac surgery. TLE performed in a hybrid room with a collaborating cardiac surgeon and vital signs monitoring appears to be the safest possible option for the patient. A graded safety approach is associated with the risk of unexpected MC and PRD. Any newly established TLE center can achieve satisfactory results if the optimal organizational model of the procedure is used.

Statistical matching and subclassification with a continuous dose: Characterization, algorithm, and application to a health outcomes study

Subclassification and matching are often used in empirical studies to adjust for observed covariates; however, they are largely restricted to relatively simple study designs with a binary treatment and less developed for designs with a continuous exposure. Matching with exposure doses is particularly useful in instrumental variable designs and in understanding the dose-response relationships. In this article we propose two criteria for optimal subclassification based on subclass homogeneity, in the context of having a continuous exposure dose, and propose an efficient polynomial-time algorithm that is guaranteed to find an optimal subclassification with respect to one criterion and serves as a 2-approximation algorithm for the other criterion. We discuss how to incorporate dose and use appropriate penalties to control the number of subclasses in the design. Via extensive simulations, we systematically compare our proposed design to optimal nonbipartite pair matching and demonstrate that combining our proposed subclassification scheme with regression adjustment helps to reduce model dependence for parametric causal inference with a continuous dose. We apply the new design and associated randomization-based inferential procedure to study the effect of transesophageal echocardiography (TEE) monitoring during coronary artery bypass graft (CABG) surgery on patients’ postsurgery clinical outcomes, using Medicare and Medicaid claims data, and find evidence that TEE monitoring lowers patients’ all-cause 30-day mortality rate.

Transesophageal Echocardiography Use for Orthotopic Liver Transplant

Impact Statement: Transesophageal echocardiography (TEE) is an invaluable tool used in cardiac surgery. So why is it not consistently used in other high-risk surgeries, such as orthotopic liver transplantation (OLT)? Key Words: Transesophageal echocardiography, Liver graft, Liver transplantation Introduction: This scholarly project observes a high-risk patient undergoing an OLT. Hemorrhage, acute cardiac dysfunction, fluid shifts, and other intraoperative pathologies associated with OLT present many challenges for the anesthesia provider. Therefore, timely identification, evaluation, and intervention of intraoperative pathology are necessary to maintain hemodynamic stability. Traditionally, intra-arterial and pulmonary artery catheters (PACs) were used as hemodynamic monitors. Recently, however, transesophageal echocardiography (TEE) has been used for noncardiac surgery to assess hemodynamic status. The objective of this project is to identify the benefits gained from using TEE during OLT in addition to traditional hemodynamic monitoring techniques (CVP/PAOP) and how these findings affect fluid and medication management. Case Presentation: A 50-year-old female underwent general anesthesia for OLT. The patient’s medical history included cirrhosis, ascites, portal hypertension, portal vein thrombosis, thrombocytopenia, anemia, obesity, and coronary artery disease. Surgical history included splenic embolization and coronary artery bypass graft. The patient was transported to the OR, and standard monitors were applied. Initial VS were as follows: BP 148/75, HR 89, SpO2 92%, RR 24. The patient underwent an uneventful anesthetic induction and intubation. Sevoflurane was used to maintain anesthesia. A radial arterial line and an internal jugular introducer with a PAC were placed. Epinephrine and norepinephrine infusions were used to treat intraoperative hypotension. 1.5 L of 5% albumin, 6 U of packed red blood cells (PRBCs), 5 U of fresh frozen plasma (FFP), and 1 U of platelets were administered. Along with intraarterial blood pressure monitoring, CVP and PA pressure monitoring was used to estimate volume status and treat hypotension. Profound hypotension was treated frequently with vasopressors, fluids, and blood products throughout the case. The patient remained intubated and was transported to the intensive care unit (ICU) postoperatively. Forty-eight hours postoperatively, the patient remained intubated. Due to acute kidney injury, a continuous furosemide infusion and subsequent dialysis were required. Discussion: The reviewed literature provided ample evidence that TEE for OLT can be used to make new intraoperative diagnoses, many of these being difficult to identify by other means. Common findings included intracardiac thrombus (ICT), ventricular dysfunction, and multiple embolic pathologies. Shillcutt et al found that 88% of participants in their study had some form of abnormal TEE finding during OLT. TEE findings were also found to impact fluid and medication administration. Hofer et al found that vasopressor (56%), vasodilator (63%), and fluid management (50%) were all impacted by TEE findings in OLT patients. While evidence was provided to exhibit the efficacy of TEE as an intraoperative monitor, sufficient evidence was not provided to support better patient outcomes based on TEE assessments. This is largely due to a lack of quality observations and controlled research during OLT. The most significant evidence supporting better outcomes was from a retrospective observational cohort study that compared TEE, PAC, and a combined therapy group. The authors found that the patients undergoing OLT with both TEE and PAC had the lowest hospital length of stay (LOS), 30-day mortality, and infusion of fluids. This suggests that the addition of TEE with traditional monitors may be the safest method of hemodynamic monitoring. In the presented case study, the addition of TEE monitoring may have helped diagnose the causes of hemodynamic instability more rapidly and potentially altered medication and fluid administration. While the assumption that timely diagnosis of intraoperative findings leads to better outcomes may be reasonable, higher-powered studies are necessary to verify this assumption. Until beneficial outcomes have been validated, the use of TEE cannot be recommended as a comprehensive intervention for every OLT. However, it should be used based on the anesthesia provider’s judgment along with other monitoring tools. Conflict of Interest: I have no conflict of interest to disclose.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Assessment of the impact of organisational model of transvenous lead extraction on the effectiveness and safety of procedure: an observational study

ObjectivesTo estimate the impact of the organisational model of transvenous lead extraction (TLE) on effectiveness and safety of procedures.DesignPost hoc analysis of patient data entered prospectively into a computer database.SettingData...

Cardiac tamponade as an inherent but potentially nonfatal complication of transvenous lead extraction: Experience with 1126 procedures performed using mechanical tools.

Cardiac tamponade (CT) is one of the most common and dangerous complications of transvenous lead extraction (TLE). So far, however, there has been little discussion about the problem. We analyzed the occurrence of CT in a group of 1226 patients undergoing TLE at a single reference center between June, 2015 and February, 2021. Using standard mechanical devices as first-line tools, a total of 2092 leads had been extracted. CT occurred in 18 patients (1.47%): due to injury to the wall of the right atrium in 14 patients (1.14%) and other cardiac walls in four patients (0.33%). Younger patient age at first implantation, female gender, high left ventricular ejection fraction (LVEF), lowerNew York Heart Association class, low Charlson comorbidity index, longer implant duration, and the number of previous procedures related to cardiac implantable electronic devices (CIED) are important patient-related risk factors for CT. Significant procedure-related risk factors include the number of extracted leads, extraction of atrial leads and longer dwell time of extracted leads. Intraoperative transoesophageal echocardiography (TEE) provides a lot of information about pulling on various cardiac structures and is able to detect a very early phase of bleeding to the pericardial sac. As a result of implementing best practices guidance in performing extraction procedures and close collaboration with cardiac surgeons that allowed immediate rescue intervention in our series of 18 CT cases, there were no procedure-related deaths (mortality 0%). The need for rescue surgery due to CT has no influence on clinical and procedural success. Early diagnosed (TEE monitoring) and properly managed CT does not generate any additional risk in short- and long-term follow-up after TLE.

Complications of the Percutaneous Mitral Valve Edge-To-Edge Repair: Role of Transesophageal Echocardiography

The use of transcatheter edge-to-edge repair for the treatment of mitral regurgitation has markedly increased in the last few years. The rate of adverse events related to the procedure is low; however, some of the complications that may occur are potentially dangerous. Due to the growing popularity of the technique, which is no longer limited to high-volume centers, knowledge of the complications related to the procedure is fundamental. Transesophageal echocardiography has a key role in the guidance of the intervention while allowing for the avoidance of most of these adverse events, as well as enabling us to diagnose them early. In this article, we review the main complications that might present during a transcatheter mitral edge-to-edge repair procedure (tamponade, thromboembolic events, single leaflet device attachment, device embolization, vascular injury…) while highlighting key aspects of transesophageal echocardiographic monitoring in the prevention and prompt diagnosis of these complications.

Association between transoesophageal echocardiography monitoring indicators and the incidence of postoperative acute kidney injury in coronary artery bypass grafting: a study protocol for a prospective multicenter cohort study.

IntroductionPrevious studies on transoesophageal echocardiography in coronary artery bypass grafting mainly focused on whether to change the surgical plan rather than improve the clinical prognosis. Currently, there are sparse studies on the relationship between transoesophageal echocardiography indicators and the prognosis of patients undergoing coronary artery bypass grafting. The primary aim of this study is to explore the association between transoesophageal echocardiography monitoring indicators the respiratory variability of inferior vena cava diameter, tricuspid annular plane systolic excursion and the incidence of acute kidney injury in coronary artery bypass grafting patients.Methods and analysisWe designed this prospective multicenter cohort study, which included approximately 150 adult patients (≥18 years) undergoing elective coronary artery bypass surgery. Different hospitals will be assessed to obtain information on the prevalence, risk factors, management strategies and outcomes in coronary artery bypass surgery. The cohort will be followed after the coronary artery bypass surgery period, up to 30 days after enrolment. The incidence of postoperative acute kidney injury and baseline data will be presented by descriptive statistics. We will use Freidman inspection and multivariable logistic regression to assess the association between transoesophageal echocardiography monitoring indicators and the incidence of acute kidney injury in coronary artery bypass grafting patients.Ethics and disseminationThe study has been approved by the ethics committee of Shandong Provincial Qianfoshan Hospital, China (approval number: YXLL-KY-2021(067)). This is an observational study that poses no risk to the patients. All participants will obtain informed consent according to the ethics committee before patient enrolment. Funding sources will have no influence on data handling, analyses or writing of the manuscript. The article is planned for submission in an international peer-reviewed journal.Trial registration numberNCT05139108.

Is There a Correlation Between Left Ventricular Outflow Tract Velocity Time Integral and Stroke Volume Index in Patients Undergoing Cardiac Surgery?

IntroductionLeft ventricular outflow tract velocity time integral (LVOT VTI) is a promising surrogate for stroke volume (SV). However, there is controversy in the literature regarding its correlation with thermodilution or newer cardiac output measurement techniques. This study was conducted to determine the correlation between LVOT VTI determined by transesophageal echocardiography (TEE) with stroke volume index (SVI) calculated by thermodilution.MethodsConsecutive patients older than 17 years undergoing elective cardiac surgery with pulmonary artery catheter (PAC) and TEE monitoring between September 2021 and February 2022 were included in this prospective, descriptive, single-center study. LVOT VTI was measured using TEE after induction of anesthesia but before skin incision and at least four hours after initial LVOT VTI measurement. SVI was simultaneously measured using the continuous thermodilution technique with a PAC. The correlation between LVOT VTI and SVI was determined with Pearson’s correlation index.ResultsTwelve patients were included and 21 paired measurements were compared. Mean SVI was 31.62 ± 10.71 mL/m2 and mean LVOT VTI was 14.74 ± 4.79 cm. The Pearson's correlation index for the two measurements was r = 0.257, p = 0.262.ConclusionThis prospective study demonstrated a weak correlation between LVOT VTI and SVI in patients undergoing cardiac surgery.