Massimiliano Meineri

The impact of internet and simulation‐based training on transoesophageal echocardiography learning in anaesthetic trainees: a prospective randomised study

With the increasing role of transoesophageal echocardiography in clinical fields other than cardiac surgery, we decided to assess the efficacy of multi‐modular echocardiography learning in echo‐naïve anaesthetic trainees. Twenty‐eight trainees undertook a pre‐test to ascertain basic echocardiography knowledge, following which the study subjects were randomly assigned to two groups: learning via traditional methods such as review of guidelines and other literature (non‐internet group); and learning via an internet‐based echocardiography resource (internet group). After this, subjects in both groups underwent simulation‐based echocardiography training. More tests were then conducted after a review of the respective educational resources and simulation sessions. Mean (SD) scores of subjects in the non‐internet group were 28 (10)%, 44 (10)% and 63 (5)% in the pre‐test, post‐intervention test and post‐simulation test, respectively, whereas those in the internet group scored 29 (8)%, 59 (10)%, (p = 0.001) and 72 (8)%, p = 0.005, respectively. The use of internet‐ and simulation‐based learning methods led to a significant improvement in knowledge of transoesophageal echocardiography by anaesthetic trainees. The impact of simulation‐based training was greater in the group who did not use the internet‐based resource. We conclude that internet‐ and simulation‐based learning methods both improve transoesophageal echocardiography knowledge in echo‐naïve anaesthetic trainees.

Diastolic dysfunction, cardiopulmonary bypass, and atrial fibrillation after coronary artery bypass graft surgery

BACKGROUND Atrial fibrillation (AF) is a common complication after coronary artery bypass graft (CABG) surgery, and is associated with increased morbidity, mortality, and utilization of healthcare resources. Diastolic dysfunction (DD) causes a range of changes in left atrial structure and function that may predispose patients to increased risk of AF. We hypothesized that patients with either new or worsened grade of DD after cardiopulmonary bypass (CPB) would have higher prevalence of AF after CABG surgery. The current study sought to determine an association between the dynamic changes in diastolic function during the perioperative period and postoperative AF in patients undergoing CABG surgery. METHODS A total of 109 patients undergoing elective CABG surgery were assessed for the presence of DD before and after CPB. All patients were monitored for the development of AF after surgery for the entire hospital stay. RESULTS DD was present in 89 (81%) and 91 (83%) patients before and after CPB. Thirty-four (31%) patients had either new or worsened grade of DD after CPB. Postoperative AF was present in 30 (27.5%) patients, including 15 (44%) patients with either new or worsened DD, and 15 (20%) patients with either unchanged or improved DD (P=0.009). Independent predictors of postoperative AF included age ≥65 yr [odds ratio (OR) 4.207, 95% confidence interval (CI) 1.527, 11.588], and new or worsened DD (OR 4.145, 95% CI 1.519, 11.356). CONCLUSIONS New or worsened DD after CABG surgery is associated with an increased incidence of postoperative AF. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov; unique identifier NCT00188903.

The controversy of right ventricular systolic pressure: is it time to abandon the pulmonary artery catheter?

In this issue of Anaesthesia there are two papers that contribute to the growing controversy as to whether Doppler echocardiography can be used to diagnose pulmonary hypertension. Cowie et al. [1] and Soliman et al. [2] have sought to determine the role of transoesophageal echocardiography (TOE) in estimating right ventricular systolic pressure (RVSP) and systolic pulmonary artery pressure (sPAP), compared with the gold standard of pulmonary artery catheter measurements.

Early thrombus formation on a pulmonary artery catheter

D. Wijeysundera Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada A 42-year-old woman presented for replacement of a failing mechanical mitral valve prosthesis. After induction of anesthesia, endotracheal intubation, and real-time ultrasound-guided insertion of a right internal jugular vein sheath, a non-heparin-coated pulmonary artery catheter (PAC) was uneventfully inserted. A complete baseline transesophageal echocardiography (TEE) revealed a large independently mobile filamentous mass in the right atrium (RA), attached to the PAC (Fig. 1a), consistent with fresh thrombus. 2D/3D images in several planes confirmed the findings (Fig. 1b). Cardiopulmonary bypass was instituted after full heparinization and surgery was uneventful. After weaning from cardiopulmonary bypass, follow-up TEE showed no evidence of RA mass on the PAC. Postoperatively, the patient was transferred to the intensive care unit as planned. The PAC was removed on postoperative day 1. The patient’s recovery was uneventful.

Left Anterior Descending Coronary Artery Pseudoaneurysm Compressing the Main Pulmonary Artery in a Patient with Behçet's Disease

Behçets disease is a systemic inflammatory vascular disorder that may affect the cardiovascular system. Left anterior descending (LAD) artery aneurysm is a rare but potentially fatal complication of Behçets disease. An accurate diagnosis of this clinical entity requires multimodal imaging (computerized tomography, angiography, and echocardiography) and is essential to guide appropriate therapeutic management. We report the case of a 22‐year‐old female with LAD pseudoaneurysm who underwent surgical repair with transesophageal echocardiography guidance. We describe the importance of the use of an alternative view to define the origin and location of this unusual pathology. (Echocardiography 2012;29:E91‐E93)

Repair of Aorto‐Left Ventricular and Aorto‐Right Ventricular Fistulas Following Prosthetic Valve Endocarditis

We report a case of a 77‐year‐old male who presented with an aorto‐left ventricular fistula and an aorto‐right ventricular fistula secondary to prosthetic valve endocarditis. doi: 10.1111/jocs.12197 (J Card Surg 2013;28:654–659)

Correlation Between Transhepatic and Subcostal Inferior Vena Cava Views to Assess Inferior Vena Cava Variation: A Pilot Study

OBJECTIVES To assess the feasibility and reliability of transthoracic echocardiography to measure inferior vena cava (IVC) diameter variation using a transhepatic view. DESIGN Prospective cohort study. SETTING Single-center hospital. PATIENTS Forty consecutive patients undergoing elective cardiac surgery. INTERVENTIONS Bedside transthoracic echocardiography. MEASUREMENTS AND MAIN RESULTS Correlation between the two views was measured using Pearson R, while agreement was measured using the intraclass correlation coefficient (ICC). In a nested sub-study of 16 randomly selected participants, all images were re-rated by the same rater, who was blinded to the original measurement results, and by a second blinded operator. Correlation between the subcostal and transhepatic views was moderate when assessing maximum (R 0.46; 95% confidence interval [CI], 0.18-0.68), and minimum (R 0.55; CI, 0.29-0.74) IVC diameter. Correlation when measuring IVC diameter variation was higher (R 0.70; CI, 0.49-0.83). Agreement between the two views for IVC diameter variation measurement was substantial (ICC 0.73; CI, 0.49-0.85). Intra-rater reliability was excellent (ICC 0.95-0.99). CONCLUSIONS Agreement between subcostal and transhepatic views was substantial for the assessment of IVC diameter variation; however, the magnitude of agreement was less than anticipated. Further research is needed to determine if the transhepatic view can be used reliably in the assessment of fluid responsiveness.