Alan C. Finley

Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Scott T. Reeves, MD, FASE, Alan C. Finley, MD, Nikolaos J. Skubas, MD, FASE, Madhav Swaminathan, MD, FASE, William S. Whitley, MD, Kathryn E. Glas, MD, FASE, Rebecca T. Hahn, MD, FASE, Jack S. Shanewise, MD, FASE, Mark S. Adams, BS, RDCS, FASE, and Stanton K. Shernan, MD, FASE, for the Council on Perioperative Echocardiography of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists, Charleston, South Carolina; New York, New York; Durham, North Carolina; Atlanta, Georgia; Boston, Massachusetts

Heparin Sensitivity and Resistance: Management During Cardiopulmonary Bypass

Heparin resistance during cardiac surgery is defined as the inability of an adequate heparin dose to increase the activated clotting time (ACT) to the desired level. Failure to attain the target ACT raises concerns that the patient is not fully anticoagulated and initiating cardiopulmonary bypass may result in excessive activation of the hemostatic system. Although antithrombin deficiency has generally been thought to be the primary mechanism of heparin resistance, the reasons for heparin resistance are both complex and multifactorial. Furthermore, the ACT is not specific to heparin’s anticoagulant effect and is affected by multiple variables that are commonly present during cardiac surgery. Due to these many variables, it remains unclear whether decreased heparin responsiveness as measured by the ACT represents inadequate anticoagulation. Nevertheless, many clinicians choose a target ACT to assess anticoagulation, and interventions aimed at achieving the target ACT are routinely performed in the setting of heparin resistance. Treatments for heparin resistance/alterations in heparin responsiveness include additional heparin or antithrombin supplementation. In this review, we discuss the variability of heparin potency, heparin responsiveness as measured by the ACT, and the current management of heparin resistance.

Management of LVAD Patients for Noncardiac Surgery: A Single-Institution Study

OBJECTIVE To describe the experience regarding the perioperative management of patients with left ventricular assist devices (LVADs) who require anesthesia while undergoing noncardiac surgery (NCS) at a single medical center. DESIGN Retrospective chart review SETTING Academic medical center PARTICIPANTS Patients with LVADs INTERVENTIONS Medical records from April 1, 2009 through January 31, 2014 were reviewed for patients who underwent Heartmate II LVAD placement at this facility. Individual records were reviewed for NCS after LVAD placement, specifically investigating perioperative and anesthetic management. MEASUREMENTS AND MAIN RESULTS Seventy-one patients underwent LVAD placement during this time period. Thirty-five patients (49%) underwent a total of 101 NCS procedures. Arterial catheters were placed in 19 patients (19%), and 33 patients (33%) were intubated for their procedure. No complications or perioperative mortality occurred related to the NCS. CONCLUSIONS Noncardiac surgery is becoming more common in patients with LVADs. Anesthetic management of these patients outside of the cardiac operating room is limited. Patients with Heartmate II LVADs can safely undergo noncardiac surgery.

Echocardiography in the intensive care unit.

As ultrasound technology improves and ultrasound availability increases, echocardiography utilization is growing within intensive care units. Although not replacing the often-needed comprehensive echocardiographic evaluation, limited bedside echocardiography promises to provide intensivists with enhanced diagnostic ability and improved hemodynamic understanding of individual patients. Routine and emergency echocardiography within the intensive care unit focuses on identifying and optimizing medically treatable conditions in a timely manner. Methods for such goal-directed assessments are presented.

The use of transesophageal echocardiography for placement of apicoaortic conduit in a patient with a porcelain aorta.

Full Text Full Text (PDF) The Use of Transesophageal Echocardiography for Placement of Apicoaortic Conduit in a Patient with a Porcelain Ao...

Use of three-dimensional transesophageal echocardiography to evaluate mitral valve morphology for risk stratification prior to mitral valvuloplasty

Mitral stenosis is often managed percutaneously with an interventional procedure such as balloon commissurotomy. Although this often results in an increased mitral valve area and improved clinical symptoms, this procedure is not benign and may have serious complications including the development of hemodynamically significant mitral valve regurgitation. Multiple scoring systems have been developed to attempt to risk stratify these patients prior to their procedure. Case: A 64‐year‐old patient underwent an emergent mitral valve replacement after having percutaneous mitral balloon commissurotomy complicated by development of severe mitral regurgitation. Prior to valvuloplasty, her mitral valve was evaluated by traditional methods including calculation of a Wilkins score. Her mitral valve was evaluated after valvuloplasty and preoperatively with three‐dimensional transesophageal echocardiography. This examination demonstrated heterogeneous distribution of calcification affecting the mitral valve commissures more than the leaflets, which is consistent with the noncommissural leaflet tearing that occurred during her procedure, causing severe mitral regurgitation. In the future, careful 3D evaluation of mitral valve morphology including leaflets, annular calcification, and subvalvular apparatus may help risk stratify patients prior to intervention.

How Deep to Sleep for Procedural Echocardiography

RomanSniecinski, MD, FASE Moderate sedation, often referred to as ‘‘conscious sedation,’’ for procedures involving echocardiography seems to be getting a lot of attention lately. Within the ASE, the Council of Perioperative Echocardiography (COPE) offers a unique perspective on this subject since a large percentage of COPE members are anesthesiologists. Before commenting on some of the recent dialogue, a brief review of the continuum of depth of sedation is warranted. The degree of sedation provided to a patient does not have discrete levels, but is rather a continuum ranging from minimal sedation to general anesthesia. The level of sedation is independent of the route of drug administration, and deep levels of sedation can be achieved with many different medications. Even though practitioners may intend to perform moderate sedation, predicting an individual’s response to the various agents used can be difficult. This mandates that practitioners administering the sedation also have the ability to ‘‘rescue’’ patients who have achieved a deeper level of sedation than what was intended. Of central concern to this issue is monitoring andmaintaining adequate ventilation and the potential need of placing an advanced airway. Monitored anesthesia care (MAC) is an often-misunderstood term which refers to a specific anesthesia service. MAC does not describe a specific depth of sedation, but includes everything along the continuum. MAC differs from sedation provided by a non-anesthesia provider in that someone is present who can escalate care to general anesthesia should the need arise. In an effort to optimize the care for patients undergoing moderate sedation, the American Society of Anesthesiology has partnered with societies from various specialties and will soon be publishing an updated Practice Guidelines for Moderate Sedation and Analgesia. This document is too extensive to outline in its entirety, but the intent is to educate the proceduralist who directs sedation on topics such as appropriate patient selection, preprocedural preparation, intraprocedural monitoring, medication administration, and emergency support. Many ASE members will be focused on moderate sedation when it is performed during a transesophageal echocardiographic (TEE) examination. During a TEE examination, moderate sedation is often administered without the presence of an anesthesiologist and, with few exceptions, it is effective in providing the necessary analgesia and anxiolysis. However, inadequate sedation does occur and has the potential to cause unnecessary patient discomfort or injury. This is especially true when an additional procedure is added on to a TEE, such as a cardioversion for atrial fibrillation. Conversely, performing moderate sedation has the potential to result in a deeper level of sedation and significant cardiac and/or respiratory compromise must be recognized and managed appropriately. Failure to respect this possibility and disregarding standard safety measures can lead to catastrophic complications. The risk of over-sedation is greatest when a sedative or analgesic medication designed for general anesthesia is administered with the intention of maintaining only moderate sedation. Because of the agent used, the care provided must remain consistent with that required for general anesthesia. For example, if a medication such as propofol is chosen for moderate sedation, then the risk of inadvertently administering a general anesthetic is high. In this case, an anes-

A Unique Strategy for Lung Isolation During Tracheobronchoplasty

TRACHEOBRONCHOMALACIA (TBM) IS A CONDITION that consists of excessive weakening of the walls of the trachea and bronchi causing collapse of the airway with expiration. The integrity of the posterior and anterior cartilaginous rings is lost, leading to dynamic obstruction. Patients with TBM present with life-altering symptoms such as dyspnea on exertion, cough, and occasionally hemoptysis. Surgical correction via tracheobronchoplasty (TBP) involves external splinting of the collapsing sections of the tracheobronchial tree, thereby increasing the airway diameter and providing symptom relief (Fig 1). The surgical approach is through a right thoracotomy. It is important to note that the surgical procedure does not involve opening trachea or bronchi; thus, the airway remains intact. Airway management is complicated by the requirement for initial right-lung deflation without any device in the right main bronchus and subsequent right-lung deflation without any device in the left main bronchus. A left-sided or right-sided double-lumen

Using transesophageal echocardiography to assess cardiovascular implantable electronic device endocarditis.

May 2015 • Volume 120 • Number 5 A 47-year-old male patient with a history of atrial fibrillation and hypertrophic obstructive cardiomyopathy status-post alcohol septal ablation dual-chamber automatic implantable cardioverter defibrillator (AICD) implantation presented for surgical AICD lead extraction for presumed infection. The patient developed bacteremia weeks after implantation of the AICD and was evaluated by transthoracic echocardiographic examination (TTE), which failed to show clear evidence of lead-related infective endocarditis. Despite a prolonged course of antibiotics, a systemic infection continued as evidenced by the bacteremia; therefore, the patient was scheduled for AICD removal. An intraoperative transesophageal echocardiographic (TEE) examination was performed during extraction of the leads to assess for valvular endocarditis as well as a pericardial effusion postlead extraction. On examination, a rightsided, lead-related vegetation was demonstrated by TEE, which had not been visualized by TTE. From the midesophageal (ME) 4-chamber, ME right ventricular (RV) inflowoutflow, and ME bicaval views, the vegetation appeared to surround the RV lead from RV apex to the superior vena cava (SVC)-right atrial (RA) junction (Supplemental Digital Content 1, Video 1, http://links.lww.com/AA/B64). Additionally, the transgastric RV inflow view showed an echodense, thickened fibrin sheath adhering to the RV lead (Fig. 1; Supplemental Digital Content 1, Video 1, http:// links.lww.com/AA/B64). No masses were seen attached to the RA lead. After the leads were removed without complication, a repeat TEE revealed a free-floating mobile mass (approximately 3.1 × 1.3 cm) with complex morphology extending from the SVC into the RA. This mass was best visualized from the ME RV inflow-outflow and ME bicaval views (Fig. 2; Supplemental Digital Content 2, Video 2, http:// links.lww.com/AA/B65). No flow disturbances were detected with color flow mapping secondary to the mass, and the risk of paradoxical embolism was deemed to be absent because a patent foramen ovale was not visualized. The mass was not removed, and the patient recovered uneventfully from the lead removal without signs of hemodynamic compromise from either a pericardial effusion or embolization of the mass. TEE is believed to be more sensitive than TTE for the detection of lead-related infective endocarditis, and because of the high potential for a nondiagnostic study, both the American Heart Association and the American Society of Echocardiography recommend TEE to assess lead-related infective endocarditis.1,2 The poor sensitivity of TTE is explained at least partially by the location of vegetations

Management of a symptomatic patient with a high transvalvular gradient across a stentless aortic valve.

A 56-year-old woman with a bioprosthetic aortic valve (AV) presented with “severe” aortic stenosis (AS) and a mean gradient of 60 mm Hg on transthoracic echocardiogram. In 2005, she had a 23-mm Medtronic Freestyle bioprosthetic AV implanted in the subcoronary position for severe aortic insufficiency. A transesophageal echocardiogram was performed, because a redo AV replacement was being considered. We present her case after obtaining informed consent for this publication. Her baseline variables consisted of a weight of 86 kg, height of 163 centimeters, heart rate of 50 beats per minute, mean arterial blood pressure of 100 mm Hg, estimated left ventricular ejection fraction of 60%, and a cardiac output of 3.5 L/min. The left ventricular outflow tract (LVOT) diameter measured 19 mm with reduced excursion of the bioprosthetic valve leaflets and turbulent flow across the AV (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A316). The AV short axis demonstrated adequate AV area, but also showed turbulent flow (Fig. 1) (Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A317). Doppler interrogation of the AV and LVOT (Fig. 2) demonstrated a mean transvalvular gradient of 21 mm Hg, a peak gradient of 36 mm Hg, and a maximum velocity of 2.96 m/s. The LVOT had a maximum velocity of 1.03 m/s, and the ratio of LVOT peak velocity to AV peak velocity, also known as Doppler velocity index (DVI), was 0.35. AV effective orifice area (EOA) and indexed EOA (iEOA) were calculated to be 1.0 cm and 0.51 cm/m, respectively (Table 1). Transvalvular pressure gradients are frequently correlated with valve area but are also related to transvalvular flow. In low cardiac output states, lower gradients are generated and will underestimate the severity of AS. Alternatively, high cardiac outputs can yield high gradients and overestimate stenosis in a mildly stenotic valve. Thus, complete assessment of prosthetic valves should include other indices less affected by blood flow such as the EOA and DVI. Calculation of the EOA is performed using the simplified continuity equation, a mathematical concept that describes the transport of a conserved quantity of blood, i.e., the blood entering the LVOT must equal the blood leaving across the AV. The quantity of blood is calculated by use of the stroke volume (Table 1). The calculated EOA is essentially the functional area of the valve and must be compared with the reference EOA provided by the manufacturer. Although EOA is not affected by cardiac output, it is limited by the potential error introduced during measurement of an asymmetrical LVOT. The LVOT diameter is squared in the calculation of the cross-sectional areaLVOT, 2 and an error in its measurement potentially underestimates cross-sectional areaLVOT and thus overestimates AS severity. EOA calculation is also confounded by its failure to consider the patient’s body size. This limitation can be overcome by calculating the iEOA (Table 1). From the Departments of *Anesthesia and Perioperative Medicine, and †Surgery, Medical University of South Carolina, Charleston, South Carolina.