Use Of Intraoperative Transesophageal Echocardiography Research Articles

Usefulness of intraoperative transesophageal echocardiography for hemodynamic management of liver transplantation in a patient with massive polycystic liver disease: a case report

BackgroundHemodynamic management during anesthesia in liver transplantation for patients with polycystic liver disease (PLD) can be more challenging because of the bleeding and hemodynamic alterations due to the markedly enlarged liver. We hereby report a case of PLD wherein transesophageal echocardiography (TEE) was employed for optimal hemodynamic monitoring during liver transplantation.Case presentationA 61-year-old man was scheduled to undergo liver transplantation for massive PLD. Hemodynamic instability was associated with mechanical displacement of the giant cystic liver. TEE results revealed the collapse of the inferior vena cava due to liver displacement. TEE also detected intrathoracic hemorrhage triggered by detachment from the markedly enlarged liver.ConclusionTEE is a valuable monitoring tool for sharing information with surgeons and diagnostic modality for finding the source of bleeding in liver transplantation for PLD and may contribute majorly to the quality of perioperative management.

Abstract P3013: Rare Case Of Catheter-related Right Atrial Thrombosis In A Pediatric Multi-visceral Transplant Patient

Introduction: There has been a recent increase in the use of intraoperative transesophageal echocardiography (TEE) in liver transplant surgeries to identify intracardiac thrombi and pulmonary embolism (PE). These are rare but serious complications of transplant surgery that carry a high mortality risk. However, there is a lack of literature supporting the use of TEE during liver transplants, especially in pediatric cases. Case Presentation: We present a rare case of intraoperative catheter-related right atrial thrombus (CRAT) in a nine-year-old multi-visceral transplant (MVT) patient. This patient’s medical history was notable for preterm birth and gastroschisis complicated by neonatal necrotizing enterocolitis resulting in short-gut syndrome. He had a significant surgical history, including intestinal resection, Hartmann Procedure, and cholecystectomy, after which he developed non-cholestatic liver disease. He was admitted for MVT for intestinal failure associated with ESLD. The procedure was complicated by massive hemorrhage during the dissection phase, significant coagulopathy after engrafting the donor liver, profound hemodynamic instability requiring inotropic drug support, and multiple instances of intraoperative CPR. Intraoperative TEE identified right atrial thrombi around the central venous line. The patient developed RV dysfunction and PEA secondary to PE on two occasions and received a total of 4 mg tissue plasminogen activator (tPA). In both cases, ROSC was achieved after thrombolysis. Due to profound coagulopathy and massive blood loss (70 liters), the completion of the surgery was postponed, and the patient left the operating room with an open abdomen. The patient’s postoperative course was complicated by hemodiafiltration, ureteral resection with reimplantation to bladder, pyloroplasty, appendectomy, small bowel resection, end colostomy and double-barrel ileostomy. The patient eventually developed a subarachnoid hemorrhage on POD3 and expired. Conclusion: This case highlights the importance of utilizing intraoperative TEE in pediatric liver transplant surgeries to diagnose intracardiac thrombi and PE.

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.

UpToDate®

UpToDate| September 2022 UpToDate® ASA Monitor September 2022, Vol. 86, 41. https://doi.org/10.1097/01.ASM.0000874300.60733.69 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation UpToDate®. ASA Monitor 2022; 86:41 doi: https://doi.org/10.1097/01.ASM.0000874300.60733.69 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: aortic surgery, heart valves, transesophageal echocardiography UpToDate® and ASA Monitor are collaborating to present select content abstracts on “What's New in Anesthesiology.” UpToDate is an evidence-based, clinical support resource used worldwide by health care practitioners to make decisions at the point of care. For complete, current “What's New” content, or to become a subscriber for full content access, go to www.uptodate.com. “What's New” abstract information is free for all medical professionals. Intraoperative transesophageal echocardiography (TEE) is commonly used during cardiac valve surgery to assess valve function prior to and following repair/replacement and to manage complications. In a matched cohort study including more than 850,000 patients in the Society of Thoracic Surgeons database, use of intraoperative TEE was associated with lower 30-day mortality after open cardiac valve or proximal aortic surgery compared with not using TEE [1]. Composite outcomes were also lower (i.e., stroke or 30-day mortality; reoperation or 30-day mortality). As these... You do not currently have access to this content.

Echo Rounds: Intraoperative Doppler Assessment of Transjugular Intrahepatic Shunt Flow Using Transesophageal Echocardiography.

The use of intraoperative transesophageal echocardiography (TEE) to assess venous congestion of the liver due to right heart dysfunction is well established, predominately through the Doppler interrogation of the hepatic and portal venous waveforms. Transjugular intrahepatic portosystemic shunts (TIPSs) are artificial intraparenchymal tracts through the liver that are placed to decompress the portal circulation in the setting of portal hypertension, most commonly due to cirrhosis. Herein, we describe the Doppler interrogation of a TIPS using intraoperative TEE, and how changes in the transmitted portal venous waveform were used to assess the severity of tricuspid regurgitation and inform management. (A&A Practice. 2022;16:e01607.).

Method of intraoperative transesophageal echocardiography during the Ozaki procedure (Clinical case)

Modern imaging techniques including various echocardiographic technologies have become firmly established in the practice of cardiac surgery. The method of intraoperative transesophageal echocardiography (TEE) is of particular significance for ensuring the safety of patients during open heart surgery. This method is necessary for performing reconstructive interventions on the valve apparatus of the heart in patients with initial myocardial dysfunction to assess the anatomical and functional state of the heart and its structures at all stages of surgical treatment. Information obtained in the operation room using TEE allows the surgeon to choose the optimal tactics of surgical intervention, evaluate the results of surgery, and predict the course of early postoperative period. The presented clinical case demonstrates the capabilities of intraoperative use of TEE during the Ozaki procedure in a patient with congenital bicuspid aortic valve.

Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia.

Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors. Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%). Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys. The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices.

An Approach to Standard Perioperative Transthoracic Echocardiography Practice for Anesthesiologists—Perioperative Transthoracic Echocardiography Protocols

The use of intraoperative transesophageal echocardiography (TEE) has become the standard of care for most cardiac surgical procedures. There are guidelines established for training, practice, and quality improvement in perioperative TEE by the joint efforts of the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists. Cardiac point-of-care ultrasound (POCUS) increasingly is being incorporated into anesthesiologists’ training and practice. While a special “certification in Critical Care Echocardiography” was created by the National Board of Echocardiography in 2019, there currently exist no guidelines for training, certification, and practice of perioperative TTE by anesthesiologists. In this review, the authors describe the categories, indications and applications of perioperative TTE and provide a recommended sequence for performing an examination tailored to the evaluation of perioperative patients. Although the authors describe a protocol utilized at their institution, there are no standards described in the literature for PTTE. Cardiac anesthesiologists and cardiac anesthesia societies (Society of Cardiovascular Anesthesiologists, European Association of Cardiothoracic Anesthesiologists) must come forward to establish standards working in collaboration with echocardiography societies (American Society of Echocardiography, European Society of Cardiology).

Transesophageal Echocardiography in Patients Undergoing Coronary Artery Bypass Graft Surgery

BackgroundThe impact of utilization of intraoperative transesophageal echocardiography (TEE) at the time of isolated coronary artery bypass grafting (CABG) on clinical decision making and associated outcomes is not well understood. ObjectivesThe purpose of this study was to determine the association of TEE with post-CABG mortality and changes to the operative plan. MethodsA retrospective cohort study of planned isolated CABG patients from the Society of Thoracic Surgeons Adult Cardiac Surgery Database between January 1, 2011, and June 30, 2019, was performed. The exposure variable of interest was use of intraoperative TEE during CABG compared with no TEE. The primary outcome was operative mortality. The association of TEE with unplanned valve surgery was also assessed. ResultsOf 1,255,860 planned isolated CABG procedures across 1218 centers, 676,803 (53.9%) had intraoperative TEE. The percentage of patients receiving intraoperative TEE increased over time from 39.9% in 2011 to 62.1% in 2019 (p trend <0.0001). CABG patients undergoing intraoperative TEE had lower odds of mortality (adjusted odds ratio: 0.95; 95% confidence interval: 0.91 to 0.99; p = 0.025), with heterogeneity across STS risk groups (p interaction = 0.015). TEE was associated with increased odds of unplanned valve procedure in lieu of planned isolated CABG (adjusted odds ratio: 4.98; 95% confidence interval: 3.98 to 6.22; p < 0.0001). ConclusionsIntraoperative TEE usage during planned isolated CABG is associated with lower operative mortality, particularly in higher-risk patients, as well as greater odds of unplanned valve procedure. These findings support usage of TEE to improve outcomes for isolated CABG for high-risk patients.

Real-time intraoperative co-registration of transesophageal echocardiography with fluoroscopy facilitates transcatheter mitral valve-in-valve implantation in cases of invisible degenerated bioprosthetic valves.

Transcatheter mitral valve-in-valve (TMViV) implantation is an alternative treatment to surgery for high-risk patients with degenerated bioprosthetic mitral valves. Some types of bioprostheses are fluoroscopically translucent, resulting in an 'invisible' target deployment area. In this study, we describe the feasibility and outcomes of this procedure using intraoperative fusion of transoesophageal echocardiography (TEE) and live fluoroscopy to facilitate valve deployment in cases of invisible bioprosthetic valves. We reviewed all TMViV implantations at our centre from July 2014 to July 2019. Patient, procedure and outcome details were compared between those with a visible bioprosthesis (N = 22) to those with an invisible one (N = 12). Intra-operative TEE and live Fluoroscopy co-registration were used for real-time guidance for all invisible targets. All valve implantations were completed successfully in both groups without cardiovascular injury, valve migration or left ventricular outflow-tract obstruction. Technical success was 100% in both groups. One-year survival was 83% [95% confidence interval (CI) 70-96] for the entire cohort, with 79% (95% CI 63-100) survival for the visible group and 92% (95% CI 77-100) for the invisible group. Probability of 1-year survival free from mitral valve reintervention, significant valve dysfunction, stroke or myocardial infraction was 78% (95% CI 63-93) for all patients whereby the probability was 72% (95% CI 54-97) in the visible group and 80% (95% CI 59-100) for the invisible group. The use of intraoperative TEE and live fluoroscopy image fusion facilitates accurate TMViV among patients with a fluoroscopically invisible target-landing zone.

Diagnosis of an iatrogenic complication using intraoperative transoesophageal echocardiography after coronary artery bypass graft surgery

IntroductionThe systematic use of intraoperative transesophageal echocardiography (iTEE) is a matter of debate and controversy. We describe a case showing the usefulness of iTEE for the diagnosis of a life-threating complication during an urgent Coronary Artery Bypass Graft (CABG) surgery.MethodsAn 82-year-old man was admitted in our center with a non-ST-segment elevation myocardial infarction. The coronary angiogram revealed a severe three vessel coronary disease. The patient underwent an on-pump CABG surgery through a median sternotomy approach and a total mammary technique was employed.ResultsThe left anterior descending artery was intramyocardial and its dissection was complicated with a laceration of the free wall of the right ventricle (RV). The cardiac surgeon quickly sutured the laceration and infiltrated sealant fibrin into the myocardium and finally, he sprayed the fibrin on the surface of the anatomical defect.The weaning of the Cardiopulmonary Bypass (CPB) was without incidences. However, immediately after the administration of protamine, the patient had a severe hypotension refractory to vascular filling and to high doses of vasoconstrictor agents. iTEE examination showed a echogenic mobile mass inside of the RV outflow tract. This mass progressively the mass progressively progressed towards the pulmonary valve with each RV contraction. It was decided to return to CPB for exploration of the RV cavity through the tricuspid valve and extraction of the floating mass.DiscussionIn this case, the use of iTEE during CABG surgery modified the normal course of procedure and allowed the early detection of a serious perioperative complication, avoiding a possible fatal outcome in the patient. The systematic use of intraoperative transesophageal echocardiography (iTEE) is a matter of debate and controversy. We describe a case showing the usefulness of iTEE for the diagnosis of a life-threating complication during an urgent Coronary Artery Bypass Graft (CABG) surgery. An 82-year-old man was admitted in our center with a non-ST-segment elevation myocardial infarction. The coronary angiogram revealed a severe three vessel coronary disease. The patient underwent an on-pump CABG surgery through a median sternotomy approach and a total mammary technique was employed. The left anterior descending artery was intramyocardial and its dissection was complicated with a laceration of the free wall of the right ventricle (RV). The cardiac surgeon quickly sutured the laceration and infiltrated sealant fibrin into the myocardium and finally, he sprayed the fibrin on the surface of the anatomical defect. The weaning of the Cardiopulmonary Bypass (CPB) was without incidences. However, immediately after the administration of protamine, the patient had a severe hypotension refractory to vascular filling and to high doses of vasoconstrictor agents. iTEE examination showed a echogenic mobile mass inside of the RV outflow tract. This mass progressively the mass progressively progressed towards the pulmonary valve with each RV contraction. It was decided to return to CPB for exploration of the RV cavity through the tricuspid valve and extraction of the floating mass. In this case, the use of iTEE during CABG surgery modified the normal course of procedure and allowed the early detection of a serious perioperative complication, avoiding a possible fatal outcome in the patient.

Nontraditional Transesophageal Echocardiographic Views to Evaluate Hepatic Vasculature in Orthotopic Liver Transplantation and Liver Resection Surgery

Background.Utilization of intraoperative transesophageal echocardiography (TEE) during orthotopic liver transplantation (OLT) is expanding annually in high-volume transplant centers. During OLT intraoperative TEE is used to gather real-time information on cardiovascular function and intravascular volume status. Although standardized TEE views exist, there are nontraditional views described in the literature which have the potential to diagnose evolving pathology and define normal variants of hepatic vasculature.Methods.A literature review was completed utilizing the PubMed database for English-only, peer-reviewed publications discussing nontraditional use of intraoperative TEE during OLT and hepatic vascular-related surgeries from 2009 to 2019. Both case reports and review articles were considered.Results.The PubMed literature search offered 8 publications for analysis, including 7 case reports and 1 article review, revealing several nontraditional TEE views not included in a comprehensive transesophageal echocardiographic examination. These nontraditional views were generally obtained using modifications to the transgastric and bicaval views to visualize liver vasculature. We present the various techniques for obtaining these views from the 8 articles identified.Conclusions.At high-volume transplant centers, TEE use during OLT is increasing. Intraoperative TEE is a valuable tool to assess hepatic vascular structures critical to allograft/organ function without interruption of the surgical procedure. Nontraditional use of TEE to diagnose intraoperative noncardiac pathology in OLT appears underutilized and underreported. The modified hepatic and modified transgastric views we describe can be used to evaluate hepatic vasculature, influence surgical decision-making and ultimately improve patient care.

Transesophageal Echocardiography, Mortality, and Length of Hospitalization after Cardiac Valve Surgery

Despite recommendations regarding the use of intraoperative transesophageal echocardiography (TEE), there is no randomized evidence to support its use in cardiac valve surgery. The purpose of this study was to compare the clinical outcomes of patients undergoing open cardiac valve repair or replacement surgery with and without transesophageal echocardiographic monitoring. The hypothesis was that transesophageal echocardiographic monitoring would be associated with lower 30-day mortality and shorter length of hospitalization. In this observational retrospective cohort study, Medicare claims were used to test the association between perioperative TEE and 30-day all-cause mortality and length of hospitalization among patients undergoing open cardiac valve repair or replacement surgery between January 1, 2010, and October 1, 2015. Baseline characteristics were defined by inpatient and outpatient claims. Medicare death records were used to ascertain 30-day mortality. Statistical analyses included regression models and propensity score matching. A total of 219,238 patients underwent open cardiac valve surgery, of whom 85% underwent TEE. Patients who underwent TEE were significantly older and had greater comorbidities. After adjusting for patient demographics, clinical comorbidities, surgical characteristics, and hospital factors, including annual surgical volume, the TEE group had a lower adjusted odds of 30-day mortality (odds ratio, 0.77; 95% CI, 0.73 to 0.82; P<.001), with no difference in length of hospitalization (<0.01%; 95% CI, -0.61% to 0.62%; P=.99). Results were similar across all analyses, including a propensity score-matched cohort. Transesophageal echocardiographic monitoring in cardiac valve repair or replacement surgery was associated with lower 30-day risk-adjusted mortality, without a significant increase in length of hospitalization. These findings support the use of TEE as routine practice in open cardiac valve repair or replacement surgery.

Pulmonary Venous Flow After Lung Transplantation: Turbulence and High Velocities

Lung transplantation is the definitive treatment for end-stage lung disease. The pulmonary venous anastomosis has the potential for significant obstructive complications that can lead to considerable morbidity and mortality. The use of intraoperative transesophageal echocardiography, including color-flow and spectral Doppler, is instrumental in evaluating the pulmonary veins after lung transplantation. In this E-challenge, a case of intraoperative pulmonary venous obstruction after bilateral lung transplantation is described, the echocardiographic principles required to evaluate the pulmonary veins and screen for complications are reviewed, and when intervention may be required is discussed.

A large eustachian valve, rare to spot

Intraoperative use of transesophageal echocardiography (TEE) can detect a structure that is in reality a rare variant. We are reporting a case where we incidentally found large eustachian valve (EV) on transesophageal echocardiography which was missed on transthoracic echocardiography. It was giving right atrium two chamber appearance. We will recommend the importance of obtaining multiple echocardiographic views routinely during TEE to diagnose and differentiate such structures and its implications.

Cost-effectiveness of routine transoesophageal echocardiography during cardiac surgery: a discrete-event simulation study

BackgroundThe aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used. MethodsThe impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost–effectiveness ratio of €30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness. ResultsRoutine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation. ConclusionsRoutine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events.

Surgical correction of postpneumonectomy syndrome with adjustable saline implants and transoesophageal echocardiography.

Postpneumonectomy syndrome can have a significant clinical impact on a patient. It presents as progressive dyspnoea due to compression of the contralateral bronchus and/or pulmonary veins. Herein, we present a patient who over a 2-year period developed progressive dyspnoea on exertion and eventually also at rest, due to compression of her left mainstem bronchus and her left inferior pulmonary vein. Surgical correction with implantable adjustable saline implants was undertaken to ameliorate her symptoms. Concurrent use of intraoperative transoesophageal echocardiography permitted real-time adjustment of the implants. This allowed objective measurement and demonstration of normalization of pulmonary vein velocity, which resulted in complete symptom resolution.

Intraoperative TOE guided management of newly diagnosed severe tricuspid regurgitation and pulmonary hypertension during orthotopic liver transplantation: a case report demonstrating the importance of reversibility as a favorable prognostic factor

BackgroundTricuspid regurgitation (TR) and pulmonary hypertension (PHT) are highly dynamic cardiovascular lesions that may progress rapidly, particularly in the orthotopic liver transplantation (OLT) waitlist population. Severe TR and PHT are associated with poor outcomes in these patients, however it is rare for the two to be newly diagnosed intraoperatively at the time of OLT. Without preoperative information on pulmonary vascular and right heart function, the potential for reversibility of severe TR and PHT is unclear, making the decision to proceed to transplant fraught with difficulty.Case presentationWe present a case of successful orthotopic liver transplantation (OLT) in a 48 year old female with severe (PHT) (mean pulmonary arterial pressure > 55 mmHg) and severe TR diagnosed post induction of anaesthesia. The degree of TR was associated with systemic venous pressures of > 100 mmHg resulting in massive haemorrhage during surgery and difficulty in distinguishing venous from arterial placement of vascular access devices. Intraoperative transoesophageal echocardiography (TOE) proved crucial in diagnosing functional TR due to tricuspid annular and right ventricular (RV) dilatation, and dynamically monitoring response to treatment. In response to positioning, judicious volatile anaesthesia administration, pulmonary vasodilator therapy and permissive hypovolemia during surgery we noted substantial improvement of the TR and pulmonary arterial pressures, confirming the reversibility of the TR and associated PHT.ConclusionTR and PHT are co-dependent, dynamic, load sensitive right heart conditions that are interdependent with chronic liver disease, and may progress rapidly in patients waitlisted for OLT. Use of intraoperative TOE and pulmonary artery catheterisation on the day of surgery will detect previously undiagnosed severe TR and PHT, enable rapid assessment of the cause and the potential for reversibility. These dynamic monitors permit real-time assessment of the response to interventions or events affecting right ventricular (RV) preload and afterload, providing critical information for prognosis and management. Furthermore, we suggest that TR and PHT should be specifically sought when waitlisted OLT patients present with hepatic decompensation.

Infections and outcomes after cardiac surgery-The impact of outbreaks traced to transesophageal echocardiography probes.

BackgroundInfections are a frequent complication of cardiac surgery. The intraoperative use of transesophageal echocardiography (TEE) may be an underrecognized risk factor for post‐operative infections. The aim of this study was to investigate infection rates and outcomes after cardiac surgery in a nationwide cohort, especially in relation to periods where surface damaged TEE probes were used.MethodsThis was a retrospective, observational study at Landspitali University Hospital. All consecutive cardiac surgery patients from 1 January 2013 to 31 December 2017 were included. Patients’ charts were reviewed for evidence of infection, post‐operative complications or death.ResultsDuring the study period, 973 patients underwent cardiac surgery at Landspitali and 198 (20.3%) developed a post‐operative infection. The most common infections were: Pneumonia (9.1%), superficial surgical site (5.7%), bloodstream (2.8%) and deep sternal wound (1.7%). Risk factors for developing an infection included: The duration of procedure, age, insulin‐dependent diabetes, EuroScore II, reoperation for bleeding and an operation in a period with a surface damaged TEE probe in use. Twenty‐two patients were infected with a multidrug resistant strain of Klebsiella oxytoca, 10 patients with Pseudomonas aeruginosa and two patients developed endocarditis with Enterococcus faecalis. All three pathogens were cultured from the TEE probe in use at respective time, after decontamination. The 30‐day mortality rate in the patient cohort was 3.2%.ConclusionsThe intraoperative use of surface damaged TEE probes caused two serious infection outbreaks in patients after cardiac surgery. TEE probes need careful visual inspection during decontamination and probe sheaths are recommended.

Alcapa Sendromunda Anestezi Yönetimi ve İntraoperatif Transözofageal Ekokardiyografi Kullanımı

Alcapa Sendromunda Anestezi Yönetimi ve İntraoperatif Transözofageal Ekokardiyografi Kullanımı