Bilal Mahmood

Detection of Myocardial Dysfunction in Septic Shock: A Speckle-Tracking Echocardiography Study.

BACKGROUND:Patients with septic shock are at increased risk of myocardial dysfunction. However, the left ventricular ejection fraction (EF) typically remains preserved in septic shock. Strain measurement using speckle-tracking echocardiography may quantify abnormalities in myocardial function not detected by conventional echocardiography. To investigate whether septic shock results in greater strain changes than sepsis alone, we evaluated strain in patients with sepsis and septic shock. METHODS:We prospectively identified 35 patients with septic shock and 15 with sepsis. These patients underwent serial transthoracic echocardiograms at enrollment and 24 hours later. Measurements included longitudinal, radial, and circumferential strain in addition to standard echocardiographic assessments of left ventricular function. RESULTS:Longitudinal strain worsened significantly over 24 hours in patients with septic shock (P < 0.0001) but did not change in patients with sepsis alone (P = 0.43). No significant changes in radial or circumferential strain or EF were observed in either group over the 24-hour measurement period. In patients with septic shock, the significant worsening in longitudinal strain persisted after adjustment for left ventricular end-diastolic volume and vasopressor use (P < 0.0001). In patients with sepsis, adjustment for left ventricular end-diastolic volume and vasopressor use did not alter the finding of no significant differences in longitudinal strain (P = 0.48) or EF (P = 0.96). CONCLUSIONS:In patients with septic shock, but not sepsis, myocardial strain imaging using speckle-tracking echocardiography identified myocardial dysfunction in the absence of changes in EF. These data suggest that strain imaging may play a role in cardiovascular assessment during septic shock.

Simulation Training in Echocardiography : The Evolution of Metrics

IN THE CONTEXT of simulation-based task training, metrics can be defined as a set of tools to track and objectively quantify repeat performances of a predefined action. An ideal metric should be able to reliably determine a trainee’s readiness for a clinical procedure by objectively comparing his or her performance in virtual reality to that of an expert’s during an actual task. Metrics have been utilized in a broad range of surgical and medical specialties for tracking progression of manual dexterity skills during procedural training, and simulator-based task training has been shown to improve handeye coordination and fine motor skills during actual clinical procedures in surgical trainees. Clinical echocardiography is based on multiple, intuitive, and subconscious fine probe adjustments for optimal image display. Achieving proficiency in echocardiography requires significant manual dexterity in addition to cognitive understanding. While the latter is established by satisfactory performance in standardized examinations, the former is assumed after an accredited clinical apprenticeship (fellowship training). In clinical settings, time to acquire a specific echocardiographic image of acceptable quality generally is used to differentiate novices from experts. And although time may be a global measure, it does not quantify the number or purposefulness of probe manipulations or the quality of the acquired echocardiographic image. Introduction of metrics that take these factors into account to echocardiographic simulation has the potential to improve the current model of subjective evaluation. Recently, a unique echocardiography metrics system has become commercially available. Apart from measuring the time taken to acquire an image, it also is possible to track the fine probe movements made by the operator in three-dimensional (3D) space. Additionally, the trainee-acquired image can be recorded and its quality compared with other operators and experts’ performances. Due to its objective nature, this

Mitral Annulus: An Intraoperative Echocardiographic Perspective

From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Address reprint requests to Feroze Mahmood, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Road, CC470, Boston, MA 02215. E-mail: fmahmood@bidmc.harvard.edu & 2013 Elsevier Inc. All rights reserved. 1053-0770/2605-0004

The Effect of Hospital Volume on Mortality in Patients Admitted with Severe Sepsis

36.00/0 http://dx.doi.org/10.1053/j.jvca.2013.02.008

Tricuspid Valve: An Intraoperative Echocardiographic Perspective

Importance The association between hospital volume and inpatient mortality for severe sepsis is unclear. Objective To assess the effect of severe sepsis case volume and inpatient mortality. Design Setting and Participants Retrospective cohort study from 646,988 patient discharges with severe sepsis from 3,487 hospitals in the Nationwide Inpatient Sample from 2002 to 2011. Exposures The exposure of interest was the mean yearly sepsis case volume per hospital divided into tertiles. Main Outcomes and Measures Inpatient mortality. Results Compared with the highest tertile of severe sepsis volume (>60 cases per year), the odds ratio for inpatient mortality among persons admitted to hospitals in the lowest tertile (≤10 severe sepsis cases per year) was 1.188 (95% CI: 1.074–1.315), while the odds ratio was 1.090 (95% CI: 1.031–1.152) for patients admitted to hospitals in the middle tertile. Similarly, improved survival was seen across the tertiles with an adjusted inpatient mortality incidence of 35.81 (95% CI: 33.64–38.03) for hospitals with the lowest volume of severe sepsis cases and a drop to 32.07 (95% CI: 31.51–32.64) for hospitals with the highest volume. Conclusions and Relevance We demonstrate an association between a higher severe sepsis case volume and decreased mortality. The need for a systems-based approach for improved outcomes may require a high volume of severely septic patients.

Endovascular repair of a right-sided aortic arch aneurysm and tracheal injury.

From the *Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; †Department of Anesthesia, Hospital Mexico, University of Costa Rica, San Jose, Costa Rica; ‡Department of Anesthesiology, University Medical Center, Groningen, University of Groningen, Groningen, Netherlands; and §Department of Anesthesia and Pain Medicine, Peking University People’s Hospital, Beijing, China. Address reprint requests to Feroze Mahmood, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Anesthesia, Critical Care, and Pain Medicine, One Deaconess Road, CC 470, Boston, MA 02215. E-mail: fmahmood@bidmc.harvard.edu

Preoperative asymptomatic leukocytosis and postoperative outcome in cardiac surgery patients

Implications of an aortic arch endoprosthesis on tracheal anatomy are underrecognized, especially given their close anatomic relationship. We present a unique case of an elderly woman who suffered an iatrogenic tracheal injury due to both an aberrant aortic arch anatomy and a thoracic endoprosthesis.

Impact of gender and body surface area on outcome after abdominal aortic aneurysm repair

Background Despite showing a prognostic value in general surgical patients, preoperative asymptomatic elevated white blood cell (WBC) count is not considered a risk factor for cardiac surgery. Whereas there is sporadic evidence of its value as a preoperative risk marker, it has not been looked at methodically as a specific index of outcome during cardiac surgery. Using a national database we sought to determine the relationship between preoperative WBC count and postoperative outcome in cardiac surgical patients. Methods Cardiac surgeries were extracted from the 2007–2013 American College of Surgeons National Surgical Quality Improvement Program database. Leukocytosis was defined by a preoperative WBC count greater than 11,000 cells/μL. A univariate analysis compared the incidence of adverse outcomes for patients with and without leukocytosis. A multivariate logistic regression model was constructed in order to test whether leukocytosis was an independent predictor of morbidity and mortality. Results Out of a total of 10,979 cardiac surgery patients 863 (7.8%) had preoperative leukocytosis. On univariate analysis, patients with leukocytosis experienced greater incidences of 30-day mortality, wound complications, and medical complications. Wound complications included surgical site infection as well as wound dehiscence. The medical complications included all other non-surgical causes of increased morbidity and infection leading to urinary tract infection, pneumonia, ventilator dependence, sepsis and septic shock. After stepwise model adjustment, leukocytosis was a strong predictor of medical complications (OR 1.22, 95% CI: 1.09–1.36, p = 0.002) with c-statistic of 0.667. However, after stepwise model adjustment leukocytosis was not a significant predictor of 30-day mortality and wound complications. Conclusion Preoperative leukocytosis is associated with adverse postoperative outcome after cardiac surgery and is an independent predictor of infection-related postoperative complications.