Jack S. Shanewise

Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Scott T. Reeves, MD, FASE, Kathryn E. Glas, MD, FASE, Holger Eltzschig, MD, Joseph P. Mathew, MD, FASE, David S. Rubenson, MD, FASE, Gregg S. Hartman, MD, and Stanton K. Shernan, MD, FASE, for the Council for Intraoperative Echocardiography of the American Society of Echocardiography, Charleston, South Carolina; Atlanta, Georgia; Tubingen, Germany; Durham, North Carolina; La Jolla, California; and Lebanon, New Hampshire

ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography.

Since the introduction of transesophageal echocardiography (TEE) to the operating room in the early 1980s,1-4 its effectiveness as a clinical monitor to assist in the hemodynamic management of patients during general anesthesia and its reliability to make intraoperative diagnoses during cardiac operations has been well established.5-26 In recognition of the increasing clinical applications and use of intraoperative TEE, the American Society of Echocardiography (ASE) established the Council for Intraoperative Echocardiography in 1993 to address issues related to the use of echocardiography in the operating room. In June 1997, the Council board decided to create a set of guidelines for performing a comprehensive TEE examination composed of a set of anatomically directed cross-sectional views. The Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography has endorsed these guidelines and standards of nomenclature for the various anatomically directed cross-sectional views of the comprehensive TEE examination. This document, therefore, is the collective result of an effort that represents the consensus view of both anesthesiologists and cardiologists who have extensive experience in intraoperative echocardiography. The writing group has several goals in mind in creating these guidelines. The first is to facilitate training in intraoperative TEE by providing a framework in which to develop the necessary knowledge and skills. The guidelines may also enhance quality improvement by providing a means to assess the technical quality and completeness of individual studies. More consistent acquisition and description of intraoperative echocardiographic data will facilitate communication between centers and provide a basis for multicenter investigations. In recognition of the increasing availability and advantages of digital image storage, the guidelines define a set of cross-sectional views and nomenclature that constitute a comprehensive intraoperative TEE examination that could be stored in a digital format. These guidelines will encourage industry to develop echocardiography systems that allow quick and easy acquisition, labeling, and storage of images in the operating room, as well as a simple mechanism for side-by-side comparison of views made at different times. ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography

American society of echocardiography and society of cardiovascular anesthesiologists task force guidelines for training in perioperative echocardiography

W hen expertly utilized, perioperative echocardiography can lead to improved outcome in patients requiring cardiovascular surgery and in those suffering perioperative cardiovascular instability. However, prior publications have not specified the requisite training for perioperative echocardiography. Therefore, the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) appointed a joint task force to delineate guidelines for training in perioperative echocardiography including the prerequisite medical knowledge and training, echocardiographic knowledge and skills, training components and duration, training environment and supervision, and equivalence requirements for postgraduate physicians already in practice. This document is the result of the task force’s deliberations and recommendations. For the purposes of these guidelines, perioperative echocardiography is defined as transesophageal echocardiography (TEE), epicardial echocardiography, or epiaortic ultrasonography performed in surgical patients immediately before, during, or after surgery. Although transthoracic echocardiography may be indicated and is often performed before and after surgery, it is rarely performed during surgery. Thus, these guidelines do not apply to perioperative transthoracic echocardiography, nor do they apply to TEE performed in nonsurgical patients.

Transcatheter aortic valve implantation: anesthetic considerations.

Aortic valvular stenosis remains the most common debilitating valvular heart lesion. Despite the benefit of aortic valve (AV) replacement, many high-risk patients cannot tolerate surgery. AV implantation treats aortic stenosis without subjecting patients to sternotomy, cardiopulmonary bypass (CPB), and aorta cross-clamping. This transcatheter procedure is performed via puncture of the left ventricular (LV) apex or percutaneously, via the femoral artery or vein. Patients undergo general anesthesia, intense hemodynamic manipulation, and transesophageal echocardiography (TEE). To elucidate the role of the anesthesiologist in the management of transcatheter AV implantation, we review the literature and provide our experience, focusing on anesthetic care, intraoperative events, TEE, and perioperative complications. Two approaches to the aortic annulus are performed today: transfemoral retrograde and transapical antegrade. Iliac artery size and tortuosity, aortic arch atheroma, and pathology in the area of the (LV) apex help determine the preferred approach in each patient. A general anesthetic is tailored to achieve extubation after procedure completion, whereas IV access and pharmacological support allow for emergent sternotomy and initiation of CPB. Rapid ventricular pacing and cessation of mechanical ventilation interrupts cardiac ejection and minimizes heart translocation during valvuloplasty and prosthesis implantation. Although these maneuvers facilitate exact prosthesis positioning within the native annulus, they promote hypotension and arrhythmia. Vasopressor administration before pacing and cardioversion may restore adequate hemodynamics. TEE determines annulus size, aortic pathology, ventricular function, and mitral regurgitation. TEE and fluoroscopy are used for positioning the introducer catheter within the aortic annulus. The prosthesis, crimped on a valvuloplasty balloon catheter, is implanted by inflation. TEE immediately measures aortic regurgitation and assesses for aortic dissection. After repair of femoral vessels or LV apex, patients are allowed to emerge and assessed for extubation. Observed and published complications include aortic regurgitation, prosthesis embolization, mitral valve disruption, hemorrhage, aortic dissection, CPB, stroke, and death. Transcatheter AV implantation relies on intraoperative hemodynamic manipulation for success. Transfemoral and transapical approaches pose unique management challenges, but both require rapid ventricular pacing, the management of hypotension and arrhythmias during beating-heart valve implantation, and TEE. Anesthesiologists will care for debilitated patients with aortic stenosis receiving transcatheter AV implantation.

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

Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.

TABLE OF CONTENTSIntroduction 921General Guidelines 922Training and Certification 922Indications for TEE 923Management of Patient Sedation 927Sedation and Anesthesia 929Probe Insertion Techniques 930Instrument Controls 930Instrument Manipulation 931Comprehensive Imaging Examination 932ME Views 932TG

The effect of milrinone on hemodynamics and left ventricular function after emergence from cardiopulmonary bypass

Although milrinone effectively increases cardiac function, few studies have specifically evaluated its efficacy during cardiac surgery.We investigated the effects of milrinone on hemodynamics and left ventricular function in cardiac surgical patients who were already treated with catecholamines. Thirty-seven patients undergoing cardiac surgery were studied. Immediately after emergence from cardiopulmonary bypass (CPB), patients were randomly assigned to a control group (n = 10) or to one of these milrinone groups: milrinone 50 micro g/kg intravenously (n = 8), 50 micro g/kg + 0.5 micro g [centered dot] kg-1 [centered dot] min-1 (n = 10), or 75 micro g/kg + 0.75 micro g [centered dot] kg-1 [centered dot] min-1 (n = 9). Hemodynamics and transesophageal echocardiogram were recorded while constant filling pressures were maintained by volume reinfusion from the CPB reservoir. Arterial blood samples were obtained for the measurement of milrinone plasma concentrations and to determine the dose response curve. In all three milrinone groups, cardiac index and velocity of circumferential fiber shortening (Vcfc) significantly increased from the baseline, and both were significantly higher at 5 and 10 min than those in the control group. The plasma concentration of milrinone with half of maximum increase in Vcfc was 139.3 ng/mL based on the dose-response curve. Thus, milrinone improves hemodynamics and left ventricular function when constant loading conditions are maintained. (Anesth Analg 1997;85:16-22)

Perfusion-assisted direct coronary artery bypass: selective graft perfusion in off-pump cases

BACKGROUND Hemodynamic instability during multivessel off-pump coronary artery bypass grafting can lead to hypotension, progressive myocardial ischemia, further hypotension, and the need for urgent cardiopulmonary bypass. METHODS In 10 patients undergoing off-pump coronary artery bypass grafting, a novel technique of pressure-controlled blood delivery has been used that allows the immediate restoration of arterial blood to distal coronary beds after distal coronary anastomosis. This technique utilizes a servo-controlled pump to allow delivery of blood at systemic or suprasystemic pressures, and provides the option for infusion of supplemental additives for myocardial resuscitation, myocardial vasodilation, and enhancement of myocardial performance. RESULTS Myocardial perfusion was successfully enhanced via one or two grafts in all 10 patients with an average graft flow of 98+/-8 mL/min. In 3 patients, a 27% increase in perfusion pressure led to a 59% increase in perfusate flow. All patients were hemodynamically stable after initiation of selective graft perfusion. CONCLUSIONS Based on this preliminary patient series, the selective perfusion of grafted vessels seems to facilitate multivessel off-pump coronary artery bypass grafting by promoting rapid recovery of grafted segments, by enhanced hemodynamic stability during subsequent anastomoses, and by providing increased flexibility in the sequence of grafting.

Guidelines for the Performance of a Comprehensive Intraoperative Epiaortic Ultrasonographic Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons

The introduction of transesophageal echocardiography (TEE) in the mid-1980s extended the use of ultrasound to the intraoperative diagnosis and monitoring of cardiac and great vessel pathology. Intraoperative epicardial echocardiography has been used both as an adjunct to TEE, and as a primary diagnostic tool in patients with contraindications to TEE. The earliest applications of intraoperative epicardial imaging included the diagnosis of intracardiac pathology such as valvular heart disease. More recently, direct epivascular or epiaortic ultrasonographic (EAU) imaging of the ascending aorta and aortic arch has gained prominence as part of a multipronged intraoperative strategy to reduce atherosclerotic emboli. Although atheromatous disease of the descending aorta has been used to screen for disease in the ascending aorta, Konstadt et al. demonstrated that the interposition of the bronchus might prevent adequate visualization of the ascending aorta by TEE, making it unsatisfactory for a comprehensive atheroma evaluation. Furthermore, surgical palpation as a method of assessing atherosclerotic From the *Department of Anesthesiology, Emory University, Atlanta, GA; †Department of Anesthesiology, Duke University Medical Center, Durham, NC; ‡Department of Anesthesiology, Medical University of South Carolina, Charleston, South Carolina; §Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York City, New York; Division of Cardiovascular Diseases, Scripps Clinic Medical Group, LA Jolla, California; ¶Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina; and #Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Accepted for publication January 15, 2008. Originally published in the Journal of The American Society of Echocardiography: J AM Soc Echocardiogr 2007;20:1227–35. Address correspondence and reprint requests to American Society of Echocardiography, 1500 Sunday Dr, Suite 102, Raleigh, NC 27607. Address e-mail to aprather@asecho.org. Copyright

ASE/SCA Recommendations and Guidelines for Continuous Quality Improvement in Perioperative Echocardiography

Joseph P. Mathew, MD, FASEKathryn Glas, MD, FASEChristopher A. Troianos, MDPamela Sears-Rogan, MD, FASERobert Savage, MDJack Shanewise, MD, FASEJoseph Kisslo, MD, FASESolomon Aronson, MD, FASEStanton Shernan, MD, FASEfor the Council for IntraoperativeEchocardiography of theAmerican Society ofEchocardiography*