Omair Shakil

Dynamic 3-Dimensional Echocardiographic Assessment of Mitral Annular Geometry in Patients With Functional Mitral Regurgitation

BACKGROUND Mitral valve (MV) annular dynamics have been well described in animal models of functional mitral regurgitation (FMR). Despite this, little if any data exist regarding the dynamic MV annular geometry in humans with FMR. In the current study we hypothesized that 3-dimensional (3D) echocardiography, in conjunction with commercially available software, could be used to quantify the dynamic changes in MV annular geometry associated with FMR. METHODS Intraoperative 3D transesophageal echocardiographic data obtained from 34 patients with FMR and 15 controls undergoing cardiac operations were dynamically analyzed for differences in mitral annular geometry with TomTec 4D MV Assessment 2.0 software (TomTec Imaging Systems GmbH, Munich, Germany). RESULTS In patients with FMR, the mean mitral annular area (14.6 cm(2) versus 9.6 cm(2)), circumference (14.1 cm versus 11.4 cm), anteroposterior (4.0 cm versus 3.0 cm) and anterolateral-posteromedial (4.3 cm versus 3.6 cm) diameters, tenting volume (6.2 mm(3) versus 3.5 mm(3)) and nonplanarity angle (NPA) (154 degrees ± 15 versus 136 degrees ± 11) were greater at all points during systole compared with controls (p < 0.01). Vertical mitral annular displacement (5.8 mm versus 8.3 mm) was reduced in FMR compared with controls (p < 0.01). CONCLUSIONS There are significant differences in dynamic mitral annular geometry between patients with FMR and those without. We were able to analyze these changes in a clinically feasible fashion. Ready availability of this information has the potential to aid comprehensive quantification of mitral annular function and possibly assist in both clinical decision making and annuloplasty ring selection.

Simulation in Echocardiography: An Ever-Expanding Frontier

cardiographic simulators in this context is particularly interesting. These simulators provide an opportunity for hands-on experience as a teaching aid to acquire proficiency in this complex clinical technique. The echocardiographic simulators available for training range from online software programs to mannequin-based transesophageal echocardiographic (TEE) and transthoracic echocardiographic (TTE) simulators. The available options include normal and abnormal cardiac anatomies and functions and recording feedback. There also is a wide variation in the available features, price, and quality/ robustness of the software programs. Therefore, the authors thought it prudent to provide the readership with an overview of the status of simulation in echocardiography. In this article, the authors review the significance of simulation in anesthesia in general and echocardiography in particular. Starting with a brief historical perspective, the challenges associated with the current paradigm of echocardiographic training and the opportunities offered by the echocardiographic simulators as teaching tools are discussed. Taking stock of the major advancements in technology for simulation in echocardiography, the available options are reviewed. The authors also make suggestions on what needs to be done to advance the potential of this unique teaching tool.

Impact of Three-Dimensional Echocardiography on Classification of the Severity of Aortic Stenosis

BACKGROUND Owing to its elliptical shape, the left ventricle outflow tract (LVOT) area is underestimated by two-dimensional (2D) diameter-based calculations which assume a circular shape. This results in overestimation of aortic stenosis (AS) by the continuity equation. In cases of moderate to severe AS, this overestimation can affect intraoperative clinical decision making (expectant management versus replacement). The purpose of this intraoperative study was to compare the aortic valve area calculated by 2D diameter based and three-dimensional (3D) derived LVOT area via transesophageal echocardiography (TEE) and its impact on severity of AS. METHODS The LVOT area was calculated using intraoperative 2D and 3D TEE data from patients undergoing aortic valve replacement (AVR) and coronary artery bypass graft (CABG) surgery using the 2D diameter (RADIUS), 3D planimetry (PLANE), and 3D biplane (π·x·y) measurement (ELLIPSE) methods. For each method, the LVOT area was used to determine the aortic valve area by the continuity equation and the severity of AS categorized as mild, moderate, or severe. RESULTS A total of 66 patients completed the study. The RADIUS method (3.5 ± 0.9 cm(2)) underestimated LVOT area by 21% (p < 0.05) compared with the PLANE method (4.1 ± 0.1 cm(2)) and by 18% (p < 0.05) compared with the ELLIPSE method (4.0 ± 0.9 cm(2)). There was no significant difference between the two 3D methods, namely, PLANE and ELLIPSE. Seven AVR patients (18%) and 1 CABG surgery patient (6%) who had originally been classified as severe AS by the 2D method were reclassified as moderate AS by the 3D methods (p < 0.001). CONCLUSIONS Three-dimensional echocardiography has the potential to impact surgical decision making in cases of moderate to severe AS.

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

Ischemic Mitral Regurgitation: An Intraoperative Echocardiographic Perspective

SEQUEL OF MYOCARDIAL INFARCTION (MI), ischemic mitral regurgitation (IMR), can present acutely as cardiogenic shock (papillary muscle rupture), insidiously with symptoms of congestive heart failure (CHF), or as an incidental finding on a clinical or echocardiographic examination. 1,2 Irrespective of presentation, IMR poses a clinical challenge in terms of diagnosis and treatment. 3 Because of the ambiguity in terminology, there is considerable variation in the diagnosis and management. The incidence of IMR has been postulated to be as high as 1.2 to 2.1 million patients, with a significant proportion having moderate or severe mitral regurgitation (MR). 4 Furthermore, almost one third of the patients presenting for coronary artery bypass graft (CABG) surgery have concomitant IMR. 5,6 Although clinical and intraoperative decision making is straightforward in cases of mild and severe MR, those with moderate MR present a predicament. The benefits to the patient have to be weighed against the risks associated with

Systolic Anterior Motion of the Mitral Valve and Three-Dimensional Echocardiography

From the *Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; †Department of Anesthesia and Pain Medicine, Peking University People’s Hospital, Beijing, China; and ‡Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. Address reprint requests to Luyang Jiang, MD, Department of Anesthesia and Pain Medicine, Peking University People’s Hospital, 11 Xi Zhi Men South Street, Beijing, China 100044. E-mail: jiangly1018@hotmail.com

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

Intracardiac Wegener's Granulomatosis

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

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

A healthy 22-year-old woman presented with acute ventricular tachycardia. Cardiac magnetic resonance imaging revealed a mass in the left ventricular cavity. On the basis of these findings, a provisional diagnosis of rhabdomyosarcoma was made and the patient was scheduled to undergo an immediate cardiac surgical procedure. During intraoperative transesophageal echocardiography, the anterolateral papillary muscle (PM) was found to have an abnormal consistency and appeared thickened in the midesophageal (Fig 1A, Fig 1B) and transgastric mid–short axis (Fig 1C) views. The PM was excised, and the patient underwent a mitral valve replacement with a mechanical valve. Gross exam-

Repair of a full-thickness tracheal tear using cardiopulmonary bypass.

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.