Transesophageal Ultrasonography Research Articles

Renal Embolism Associated with the Atrial Myxoma: A Case Report and Literature Review

Renal embolisms due to cardiac myxomas are extremely rare; the clinical course, treatment, and prognosis of this disease are not established. A 69-year-old Japanese woman who underwent a nephrectomy for renal cell carcinoma 3 years earlier was hospitalized with a right occipital lobe cerebral infarction. Her renal function suddenly worsened 3 days post-admission: her serum creatinine rose from 1.46 mg/dL to 6.57 mg/dL and then to 8.03 mg/dL the next day, and hemodialysis therapy was started. Abdominal computed tomography (CT) scans showed patchy non-contrasted low-density areas in the right kidney, and chest CT scans and transesophageal ultrasonography revealed a left atrial tumor. We diagnosed renal infarction due to a left atrial myxoma. Hemodialysis and anticoagulant therapy (heparin) were continued, followed by the cardiac myxoma’s resection. The patient’s renal function gradually improved post-surgery, and the hemodialysis was discontinued. Considering our patient and 19 other case reports of renal infarction associated with cardiac myxoma, the treatment for such a renal infarction and the outcomes differ depending on the embolus site. The poor outcome of abdominal aortic embolism requires a prompt embolectomy, whereas a branch renal artery embolism requires anticoagulation therapy to prevent thrombosis formation around the myxoma.

Assessing venous congestion in cardiac surgery with extracorporeal circulation using point‐of‐care transesophageal ultrasonography

AbstractPurposeIndividualizing fluid resuscitation utilizing indicators that assess fluid tolerance could positively impact optimizing volemia while avoiding venous congestion in cardiac surgery. Our study aims to describe hemodynamic changes based on the assessment of venous congestion using transesophageal ultrasonography (TEUS), both before and after cardiopulmonary bypass (CPB) in patients with preserved right ventricle (RV) function.MethodsA retrospective study was conducted at the Hospital Privado Universitario de Córdoba, involving patients who underwent cardiac surgery with CPB. The study assessed ultrasonographic venous congestion parameters before and after CPB using TEUS. The measured parameters included the diameter of the inferior vena cava (IVC), the pattern of hepatic vein flow (HVF), and the pulsatility index of portal vein flow (PVF).ResultsA total of 43 patients who underwent cardiac surgery between January 2021 and January 2022 were enrolled. A significant difference in the IVC diameter was observed before and after initiation of CPB (p = .0001). Comparative measurements of the HVF pattern before and after CPB revealed a significant difference, indicating modifications in congestion patterns related to CPB initiation (p = .0001). Pre‐CPB, portal flow was normal in all patients, while more than 50% of patient showed altered post‐CPB PVF. A significant difference in the PVF pulsatility index related to CPB initiation was observed, suggesting increased portal venous congestion (p = .0001).ConclusionOur study demonstrates that extracorporeal circulation can induce signs of venous congestion, which are detectable by TEUS, in patients with preserved RV function preoperatively.

En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach.

Renal cell carcinoma (RCC) is the most common primary kidney cancer. In up to 4-10% of patients, the tumor is complicated with a malignant thrombus extending to the inferior vena cava (IVC). Complete surgical excision of the RCC and the neoplastic thrombus can be curative. We aim to present a safe and feasible alternative transabdominal operative technique with the omission of thoracotomy, as applied in six patients diagnosed with RCC and IVC thrombus extending over the diaphragm. This case series study was conducted in a tertiary university hospital in Athens, Greece. All six patients, who were operated on for RCC and a malignant thrombus exceeding in the intrapericardial IVC in our department from January 2009 until March 2020, were screened. Intraoperatively, the infrarenal and intrapericardial IVC were clamped simultaneously with the renal and liver blood inflow. Access to the intrapericardial IVC was obtained via the central tendon of the diaphragm. Intrathoracic extension of the tumor was confirmed by transesophageal or intraoperative ultrasonography. The intrathoracic IVC was exposed to direct vision and two finger palpation was applied to secure the clamping of the IVC above the tip of the thrombus. The tumor was resected through a longitudinal venotomy and the operation was completed on a standard radical nephrectomy. During the study period six patients presented with RCC and intrapericardial IVC thrombus. All patients, five female and one male, underwent radical nephrectomy combined with IVC thrombectomy, without the need for a thoracotomy. The mean age was 66 years old and the mean operative time was 122.5 minutes. Mean blood loss was 338 ml and only four of the patients were transfused with two units of RBC. Operative and hospital mortality was 0%. The hospital stay was seven (six to nine) days. Only one patient required readmission and reoperation 30 days later, due to intrapericardial herniation. The proposed surgical technique may be curative in patients with advanced intracaval thrombus and helps reduce the associated morbidity, mortality, and the overall cost of more extended operations.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

External transcutaneous ultrasound technique in the equine cricoarytenoideus dorsalis muscle: Assessment of muscle size and echogenicity with resting endoscopy.

Recent studies have assessed the cricoarytenoideus dorsalis muscle (CAD) using transoesophageal ultrasonography in equine recurrent laryngeal neuropathy (RLN). We assessed the CAD using the external transcutaneous ultrasound technique, which may constitute an easier method in horses. To evaluate ultrasonographic imaging of the left cricoarytenoideus dorsalis muscle (LCAD) and right cricoarytenoideus dorsalis muscle (RCAD) as a diagnostic tool for RLN using the transcutaneous ultrasound technique. Cross-sectional study. The axial plane thickness, cross-sectional area and echogenicity of the LCAD and RCAD were measured using transcutaneous ultrasonography in 164 horses. Assessments of LCAD were compared with those of RCAD. The LCAD:RCAD ratios in thickness and area were compared between control horses (resting grades 1 and 2) and horses with resting laryngeal grades 3 and 4 using the Havemeyer 4-point grading system with subgrades. The LCAD:RCAD ratios for thickness and area were 0.69 and 0.66 in horses with resting grades 3 and 4 respectively; LCAD was more hyperechogenic than RCAD in resting grades 3 and 4. LCAD:RCAD ratios for thickness and area in grades 3.II, 3.III and 4 were significantly lower than those in control horses. Thickness and area of the LCAD were negatively correlated with resting laryngeal grade MAIN LIMITATIONS: Overground endoscopy was not performed in this study. There were some differences in methodology: measurement of the physical thickness of the LCAD and clipping of hair at the laryngeal region were only performed in horses that underwent laryngoplasty. Results of ultrasonographic assessments of the CAD using transcutaneous ultrasonography were similar to those obtained by transoesophageal ultrasonography. This technique enables a simple, noninvasive, direct and easy examination. Assessment of the CAD using transcutaneous ultrasonography may be a useful technique and a potential option for determining whether to perform nerve graft or laryngoplasty.

Unusual Suspect Causing Myocardial Infarction

An 84-year-old man with New York Heart Association functional class III/IV, due to prolapse of segment 2 of the anterior mitral valve leaflet with severe regurgitation as a result, was admitted for elective percutaneous edge-to-edge mitral valve repair. Significant coronary artery disease was ruled out previously. The left ventricular systolic function was normal with moderate concomitant aortic regurgitation. Mitral valve surgery was not considered a suitable option by the heart team due to frailty and a prohibitive surgical risk profile. The patient had an indication for transcatheter mitral-leaflet approximation, using the MitraClip-NT device (Abbott Vascular, Abbott Park, IL, USA). Implantation of the first clip resulted in insufficient reduction of mitral regurgitation. Therefore, a second device was positioned. Within minutes after release, transesophageal ultrasonography showed single leaflet device attachment of the second device, necessitating the deployment of a third device in order to stabilize the flailing clip (Figure 1a). Although regurgitation was reduced to moderate hereafter, flailing of the second device persisted. Two days later, the patient developed severe chest pain and cardiogenic shock. Electrocardiography showed ST-elevation in the inferior leads, corresponding to acute inferior wall myocardial infarction. Coronary angiography showed a dislodged clip seated in the right coronary ostium (Figure 1b). A 24Fr sheath was placed in the right femoral artery. After several attempts, a 35-mm Amplatz gooseneck snare was successfully positioned around the clip (Figure 1c). Subsequently, the device was retracted across the thoracic and abdominal aorta into the femoral sheath, which was successfully removed thereafter (Figure 1d). After the procedure, the patient was hemodynamically stable with normalization of the electrocardiogram. Transcatheter mitral-leaflet approximation using the MitraClip-NT device is used in high-risk patients with symptomatic mitral valve regurgitation. This unique case demonstrates an extremely rare complication of this procedure with a successful percutaneous solution. No potential conflict of interest was reported by the authors.

Transesophageal ultrasonography during orthotopic liver transplantation: Show me more.

The first perioperative transesophageal echocardiography (TEE) guidelines published 21years ago were mainly addressed to cardiac anesthesiologists. TEE has since expanded its role outside this setting and currently represents an invaluable tool to assess chamber sizes, ventricular hypertrophy, and systolic, diastolic, and valvular function in patients undergoing orthotopic liver transplantation (OLT). Right-sided microemboli, right ventricular dysfunction, and patent foramen ovale (PFO) are the most common intra-operative findings described during OLT. However, left ventricular outflow tract obstruction and left ventricular ballooning syndrome are more difficult to recognize and less frequent. Transesophageal ultrasonography (TEU) during OLT is also underused. Its applications are as follows: (1) assistance in the difficult placement of pulmonary arterial catheters; (2) help with catheterization of great vessels for external veno-venous bypass placement; (3) intra-operative evaluation of surgical liver anastomosis patency, if feasible, through the liver window; and (4) intra-operative investigation of "acute hypoxemia" due to pulmonary and cardiac issues using trans-esophageal lung ultrasound (TELU). The aims of this review are as follows: (1) to summarize the uses of TEE and TEU throughout all phases of OLT, and (2) to describe other new feasible applications.

Cardiovascular Imaging Techniques in Systemic Rheumatic Diseases

The risk of cardiovascular (CV) events and mortality is significantly higher in patients with systemic rheumatic diseases than in the general population. Although CV involvement in such patients is highly heterogeneous and may affect various structures of the heart, it can now be diagnosed earlier and promptly treated. Various types of assessments are employed for the evaluation of CV risk such as transthoracic or transesophageal echocardiography, magnetic resonance imaging (MRI), and computed tomography (CT) to investigate valve abnormalities, pericardial disease, and ventricular wall motion defects. The diameter of coronary arteries can be assessed using invasive quantitative coronarography or intravascular ultrasound, and coronary flow reserve can be assessed using non-invasive transesophageal or transthoracic ultrasonography (US), MRI, CT, or positron emission tomography (PET) after endothelium-dependent vasodilation. Finally, peripheral circulation can be measured invasively using strain-gauge plethysmography in an arm after the arterial infusion of an endothelium-dependent vasodilator or non-invasively by means of US or MRI measurements of flow-mediated vasodilation of the brachial artery. All of the above are reliable methods of investigating CV involvement, but more recently, introduced use of speckle tracking echocardiography and 3-dimensional US are diagnostically more accurate.

Transesophageal Lung Ultrasonography

(Abstracted from Can J Anaesth, 63(11):1266–1276, 2016) This article gives an overview of transesophageal lung ultrasonography (TELU) as an alternative to prevailing techniques for examining hypoxemia. As acute deterioration in respiratory status happens regularly in patients who cannot be transported for imaging studies in perioperative or critical care settings, ultrasound (US) can be used to allow rapid diagnosis of respiratory conditions at the bedside.

Abstract TP122: Are Aortic and Carotid Atherosclerosis Parallel or Divergently Associated with Cerebrovascular Disease in Systemic Lupus Erythematous?

Introduction: Aortic (Ao) and carotid (Ca) atherosclerosis (Athero) and cerebrovascular disease (CVD) are common and associated with high morbidity and mortality in systemic lupus erythematosus (SLE). However, it is unknown whether Ao and Ca Athero are parallel or divergently associated with CVD. Methods: 77 SLE patients (age 37±12 years, 70 women) and 26 age-and-sex matched healthy controls (age 34±11 years, 22 women) underwent 1) transesophageal echocardiography and carotid ultrasonography for detection of Athero defined as intima-media thickening (≥2SD of the mean intima-media thickness in controls) or plaques (focal and protruding intima-media thickening that exceeds 50% of the surrounding vessel wall); 2) assessment of prevalent CVD defined as acute stroke/TIA, neurocognitive dysfunction, or focal brain injury on MRI; and 3) assessment of incident stroke/TIA, cognitive disability, or death during a median follow-up of 52 months. Results: Ao but not Ca Athero was more frequent in patients than in controls (42% versus 8%, p=0.006, and 17% versus 12%, p=0.75). Acute stroke/TIA occurred in 31% of patients, focal brain injury in 54%, neurocognitive dysfunction in 44%, or any CVD in 70% of patients. During follow-up, 26% of patients developed stroke/TIA, cognitive disability, or died. Ao but not Ca Athero was associated with prevalent focal brain injury (p=0.06), cognitive dysfunction (p=0.04), or any CVD (p=0.03) ( Table 1 ). Ca Athero was associated with acute stroke/TIA (p=0.02), but Ao Athero detected more patients with these conditions (50% versus 33%). Although Ao and Ca Athero were associated with incident stroke/TIA, cognitive disability, or death (both p≤0.01), Ao Athero identified more patients with these events (65% versus 45%). Conclusion: In patients with SLE Ao as compared to Ca Athero is associated with higher prevalence and incidence of CVD and mortality. Therefore, Ao Athero may be a stronger pathogenic factor or marker for CVD in SLE than Ca Athero.

Transesophageal lung ultrasonography: a novel technique for investigating hypoxemia.

Acute deterioration in respiratory status commonly occurs in patients who cannot be transported for imaging studies, particularly during surgical procedures and in critical care settings. Transthoracic lung ultrasonography has been developed to allow rapid diagnosis of respiratory conditions at the bedside. Nevertheless, the thorax is not always accessible, especially in the perioperative setting. Transesophageal lung ultrasonography (TELU) can be used to circumvent this problem. The aim of this narrative review is to provide a complete description of the TELU technique by summarizing the existing literature on the subject and describing our own experience that extrapolates from transthoracic lung ultrasonography. The use of TELU can provide point-of-care real-time information for quickly establishing the etiology of acute hypoxemia. The transesophageal probe is placed in close proximity to the posterior regions of the lungs where lung consolidation and pleural effusions are most often seen; however, most of the artefacts relied on by transthoracic ultrasound have yet to be validated with TELU. Moreover, the relative invasiveness of TELU compared with transthoracic ultrasonography may limit its use to specific situations when the probe is already in place, as during cardiac anesthesia or when the anterior thorax is inaccessible. The main advantage of TELU may lie in the ability to integrate both cardiac and pulmonary assessments in one single examination. Anesthesiologists and intensivists who already use transesophageal echocardiography on a regular basis should consider adding TELU to their clinical assessment of hypoxemia and related pulmonary pathologies. Nevertheless, the literature specifically supporting TELU is relatively limited, and further validation studies are needed.

V9-01 ROBOTIC-ASSISTED LEVEL III IVC TUMOR THROMBECTOMY: DUPLICATING THE OPEN APPROACH

You have accessJournal of UrologyRobotics - Renal1 Apr 2016V9-01 ROBOTIC-ASSISTED LEVEL III IVC TUMOR THROMBECTOMY: DUPLICATING THE OPEN APPROACH Daniel Ramirez, Matthew J. Maurice, Benjamin Cohen, Venkatesh Krishnamurthi, and Georges-Pascal Haber Daniel RamirezDaniel Ramirez More articles by this author , Matthew J. MauriceMatthew J. Maurice More articles by this author , Benjamin CohenBenjamin Cohen More articles by this author , Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author , and Georges-Pascal HaberGeorges-Pascal Haber More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1192AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To describe our surgical technique for robotic radical nephrectomy and thrombectomy for renal cell carcinoma (RCC) and associated level III inferior vena cava (IVC) thrombus. METHODS Robotic IVC tumor thrombectomy is a novel technique that has only recently been described. In our video we present the case of a 75 year-old Caucasian man with a 10 cm right renal neoplasm and associated level III tumor thrombus. After preoperative imaging was reviewed, a robotic approach was planned. Real-time intraoperative transesophageal ultrasonography was performed to assess cranial extent of tumor thrombus. The major steps of our robotic technique include early inter-aortocaval control of the right renal artery, circumferential mobilization of the IVC, contralateral renal vein control, cavotomy, thrombectomy and IVC reconstruction. RESULTS Operative time was 5 hours and 53 minutes (353 minutes) with 150 mL estimated blood loss (EBL). The patient was allowed to have a clear liquid diet immediately after surgery and was discharged home on post-operative day (POD) 3. Final pathology demonstrated a 9.8 cm clear cell renal cell carcinoma (RCC), nuclear grade 3 with a pT3bN1 stage. Technique considerations to facilitate robotic level III IVC thromectomy include initial preservation of lateral renal attachments, use of intraoperative transesophageal ultrasound to delineate cranial extension of the thrombus, and use of the third robotic arm and two 12 mm assistant ports. CONCLUSIONS With adequate team experience and preparation, robotic radical nephrectomy and IVC thrombectomy for level III tumor thrombus is challenging but feasible. This video demonstrates our robotic technique which duplicates the open approach. While open radical nephrectomy and tumor thrombectomy is the gold standard, this minimally invasive approach may offer lower EBL, improved pain control and expedited recovery in select patients. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e859 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Daniel Ramirez More articles by this author Matthew J. Maurice More articles by this author Benjamin Cohen More articles by this author Venkatesh Krishnamurthi More articles by this author Georges-Pascal Haber More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Ultrasonographic findings and outcomes of dogs with suspected migrating intrathoracic grass awns: 43 cases (2010-2013).

To describe ultrasonographic findings and outcomes for dogs with suspected migrating intrathoracic grass awns. Retrospective case series. 43 client-owned dogs. Records for dogs with suspected migrating intrathoracic grass awns examined between 2010 and 2013 were reviewed. Ultrasonographic images and additional information such as signalment and pleural fluid analysis, radiographic, bronchoscopic, and CT findings were collected. Surgical treatments and outcomes were also reviewed. Transthoracic or transesophageal ultrasonography revealed grass awns in the pleural space (n = 13) or pulmonary parenchyma (10) of 23 dogs. Surgical removal of grass awns was successful on the first attempt in 21 of these 23 dogs (including 11/23 that had intraoperative ultrasonography performed to aid localization and removal of the awn). In the remaining 2 dogs, a second surgery was required. Twenty dogs with evidence of migrating intrathoracic grass awns had no foreign body identified on initial ultrasonographic evaluation and were treated medically; 16 developed draining fistulas, and awns identified ultrasonographically at follow-up visits were subsequently removed from the sublumbar region (n = 10) or thoracic wall (6). The remaining 4 dogs had no grass awn visualized. Clinical signs resolved in all dogs. Transthoracic, transesophageal, and intraoperative ultrasonography were useful for localization and removal of migrating intrathoracic grass awns. Ultrasonography may be considered a valuable and readily available diagnostic tool for monitoring dogs with suspected migrating intrathoracic grass awns.

Robotic Level III IVC Tumor Thrombectomy: Duplicating the Open Approach

To describe our surgical technique for robotic radical nephrectomy and thrombectomy for renal cell carcinoma and associated level III inferior vena cava (IVC) thrombus with retroperitoneal lymph node dissection. The patient is a 75-year-old Caucasian man with a 10-cm right renal neoplasm and associated level III tumor thrombus. After preoperative imaging was reviewed, a robotic approach was planned. Real-time intraoperative transesophageal ultrasonography was performed to assess the cranial extent of tumor thrombus. The major steps of our technique include early inter-aortocaval control of the right renal artery, circumferential mobilization of the IVC, contralateral renal vein control, cavotomy, thrombectomy, and reconstruction of the IVC. Operative time was 5 hours and 53 minutes (353 minutes) with 150 mL estimated blood loss. The patient was allowed to have a clear liquid diet immediately after surgery and was discharged home on postoperative day 3. Final pathology demonstrated a 9.8-cm clear cell renal cell carcinoma, nuclear grade 3 with a pT3bN1 stage. With adequate team experience and preparation, robotic radical nephrectomy and IVC tumor thrombectomy for level III tumor thrombus is challenging but feasible in select patients. Herein we describe our robotic technique which duplicates the open approach. This minimally invasive approach may offer lower estimated blood loss, improved pain control, and expedited recovery.

Anaplastic lymphoma kinase-positive lung adenocarcinoma patient with development of sick sinus syndrome while on targeted treatment with crizotinib.

The anaplastic lymphoma kinase (ALK) positive non-small cell lung cancer (NSCLC) patients are younger and have never smoked, while pathologically are predominately adenocarcinomas. Crizotinib as an ALK inhibitor has been used in treating ALK positive NSCLC patients for several years and some adverse effects should be paid attention to. We now describe a case of ALK positive NSCLC patient with development of sick sinus syndrome (SSS) while on targeted treatment with crizotinib. A 46-year-old non-smoking woman with right hilar mass and underwent transesophageal endoscopic ultrasonography lymph node biopsy showed low differentiation adenocarcinoma, immunohistochemistry (IHC) of tumor samples revealed the ALK overexpression. The severe sinus bradycardia and RR interval prolongation were detected 3 months after crizotinib treatment, she underwent pacemaker implantation. Although the severe sinus bradycardia and RR interval prolongation were unusual adverse effects, physicians should be aware of these side effects when using crizotinib.

Abstract 20144: Aortic Arch Plaque Deteriorates With Advancing Chronic Kidney Disease Stage

Introduction: The patients with chronic kidney disease (CKD) are likely to suffer from cardiovascular diseases as well as end stage renal disease. CKD plays a role in development of atherothrombotic stroke. In the present study, we investigated the impact of advancing CKD stage on aortic arch plaque and carotid atherosclerosis which are important causes of atherothrombotic stroke. Methods: We enrolled 368 subjects (255 males, 66 ± 12 years) who underwent transesophageal echocardiography and carotid ultrasonography, and measured estimated glomerular filtration rate (eGFR). We defined arch plaque as wall thickness ≥4 mm and the presence of ulceration or mobile plaque in aortic arch. The common carotid artery maximum intima-media thickness (IMT-C max) and carotid artery plaque score was used as parameters of carotid atherosclerosis. Results: There were 31 patients with the history of atherothrombotic stroke. The eGFR correlated with IMT-C max, carotid plaque score and arch wall thickness. IMT-C max, carotid plaque score and arch wall thickness were increased with advancing CKD stage. An increase in IMT-C max was observed even in stage 2 and 3 while carotid plaque was frequently observed in stage 3b or higher. An increase in arch plaque was observed in stage 3a or higher. The patients with atherothrombotic stroke had significantly lower eGFR than those without. The prevalence of atherothrombotic stroke was increased in stage 3b or higher. Conclusions: Aortic arch plaque and carotid plaque deteriorated with advancing chronic kidney disease stage. Aortic arch plaque and carotid plaque were observed even in early stages of CKD.

PS-141 Haemodynamic Effects Of Neurally Adjusted Ventilatory Assist (nava) After Paediatric Cardiac Surgery - A Randomised Cross-over Study: Abstract PS-141 Table 1

Background and aims Neurally Adjusted Ventilatory Assist (NAVA) is an assist mode of mechanical ventilation that delivers an inspiratory pressure proportional to the electrical activity of the diaphragm. To date, no study has focused on its haemodynamic impact. The aim was to study haemodynamic effects of NAVA compared with conventional ventilation (CV). Methods Prospective randomised cross-over study was conducted in a paediatric intensive care unit between June 2012 and March 2013. After a baseline period, infant received CV and NAVA during two consecutive periods of 30 min in a randomised order. During the last 10 min of each period, haemodynamic and respiratory parameters (including cardiac index assessed by transoesophageal Doppler ultrasonography) were collected. Results Six infants (mean age 7.8 ± 4.1 months, mean weight 6.7 ± 1.2 kg) after cardiac surgery were enrolled. Results are expressed as percent variation in NAVA versus CV. Conclusions After paediatric cardiac surgery, NAVA provides efficient ventilation with lower inspiratory pressures than CV, and improves systolic blood pressure.

Transesophageal Ultrasonography for Lung Cancer Staging: Learning Curves of Pulmonologists

Accurate mediastinal nodal staging is essential for patients with resectable non-small-cell lung cancer and is achieved by combined endobronchial ultrasound and transesophageal endoscopic ultrasound (EUS). Training requirements for EUS-guided fine-needle aspiration (FNA) for lung cancer staging are unknown. Pulmonologists from Denmark and The Netherlands were enrolled in a dedicated, supervised training program. They performed standardized EUS-FNA procedures for mediastinal nodal analysis and their performances were assessed by EUS experts using a validated EUS assessment tool. Data were collected prospectively and used to plot learning curves and relate these to procedures performed by experienced investigators. Four participants performed 91 EUS-FNA procedures (range, 19-24). The performances of the participants improved significantly and became more consistent, but were still highly variable even in the latter part of the learning curves. Only two of the participants reached the mean score of experienced operators-after 17 and 23 procedures, respectively. Pulmonologists with knowledge of lung cancer staging and experience in bronchoscopy quickly improved their performance of EUS-FNA. However, acquisition of skills varies between individuals, and certification should be based on assessment of performance of multiple cases. Twenty procedures were not enough to secure consistent and competent performance of all trainees.

IMAGING DIAGNOSIS—TRANSESOPHAGEAL ULTRASOUND‐GUIDED REMOVAL OF A MIGRATING GRASS AWN FOREIGN BODY IN A DOG

A 3-year-old English Setter dog was presented for an acute onset of coughing. Tracheobronchoscopic examination allowed localization and removal of one grass awn foreign body. A second migrated grass awn was suspected to be present in the left caudal lung lobe. Transesophageal ultrasound revealed an area of pulmonary consolidation in the dorsomedial portion of left caudal lobe and a linear hyperechoic structure consistent with a grass awn foreign body within the area of consolidation. Transesophageal ultrasonography was also used to provide anatomical landmarks that facilitated successful thoracoscopic removal of the foreign body.

Transesophageal Doppler Measurement of Renal Arterial Blood Flow Velocities and Indices in Children

Doppler-derived renal blood flow indices have been used to assess renal pathologies. However, transesophageal ultrasonography (TEE) has not been previously used to assess these renal variables in pediatric patients. In this study, we (a) assessed whether TEE allows adequate visualization of the renal parenchyma and renal artery, and (b) evaluated the concordance of TEE Doppler-derived renal blood flow measurements/indices compared with a standard transabdominal renal ultrasound (TAU) in children. This prospective cohort study enrolled 28 healthy children between the ages of 1 and 17 years without known renal dysfunction who were undergoing atrial septal defect device closure in the cardiac catheterization laboratory. TEE was used to obtain Doppler renal artery blood velocities (peak systolic velocity, end-diastolic velocity, mean diastolic velocity, resistive index, and pulsatility index), and these values were compared with measurements obtained by TAU. Concordance correlation coefficient (CCC) was used to determine clinically significant agreement between the 2 methods. The Bland-Altman plots were used to determine whether these 2 methods agree sufficiently to be used interchangeably. Statistical significance was accepted at P ≤ 0.05. Obtaining 2-dimensional images of kidney parenchyma and Doppler-derived measurements using TEE in children is feasible. There was statistically significant agreement between the 2 methods for all measurements. The CCC between the 2 imaging techniques was 0.91 for the pulsatility index and 0.66 for the resistive index. These coefficients were sensitive to outliers. When the highest and lowest data points were removed from the analysis, the CCC between the 2 imaging techniques was 0.62 for the pulsatility index and 0.50 for the resistive index. The 95% confidence interval (CI) for pulsatility index was 0.35 to 0.98 and for resistive index was 0.21 to 0.89. The Bland-Altman plots indicate good agreement between the 2 methods; for the pulsatility index, the limits of agreement were -0.80 to 0.53. The correlation of the size of the measurement and the mean difference in methods (-0.14; 95% CI = -0.28, 0.01) was not statistically significant (r = 0.31, P = 0.17). For the resistive index, the limits of agreement were -0.22 to 0.12. The correlation of the size of the measurement and the mean difference in methods (-0.05; 95% CI = -0.09, -0.01) was not statistically significant (r = 0.10, P = 0.65). This study confirms the feasibility of obtaining 2-dimensional images of kidney parenchyma and Doppler-derived measurements using TEE in children. Angle-independent TEE Doppler-derived indices show significant concordance with those derived by TAU. Further studies are required to assess whether this correlation holds true in the presence of renal pathology. This technique has the potential to help modulate intraoperative interventions based on their impact on renal variables and may prove helpful in the perioperative period for children at risk of acute kidney injury.