Robert M. Savage

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

Characterization and outcome of patients with severe symptomatic aortic stenosis referred for percutaneous aortic valve replacement

OBJECTIVE Many high-risk patients with severe symptomatic aortic stenosis are not referred for surgical aortic valve replacement. Although this patient population remains ill-defined, many of these patients are now being referred for percutaneous aortic valve replacement. We sought to define the characteristics and outcomes of patients referred for percutaneous aortic valve replacement. METHODS Between February 2006 and March 2007, 92 patients were screened for percutaneous aortic valve replacement. Clinical and echocardiographic characteristics of patients undergoing surgical aortic valve replacement, percutaneous aortic valve replacement, balloon aortic valvuloplasty, or no intervention were compared. The primary end point was all-cause mortality. RESULTS Nineteen patients underwent successful surgical aortic valve replacement, 18 patients underwent percutaneous aortic valve replacement, and 36 patients had no intervention. Thirty patients underwent balloon aortic valvuloplasty, and of these, 8 patients were bridged to percutaneous aortic valve replacement and 3 were bridged to surgical aortic valve replacement. Of the remaining 19 patients undergoing balloon aortic valvuloplasty, bridging to percutaneous aortic valve replacement could not be accomplished because of death (n = 9 [47%)], exclusion from the percutaneous aortic valve replacement protocol (n = 6 [32%]), and some patients improved after balloon aortic valvuloplasty and declined percutaneous aortic valve replacement (n = 4 [21%]). The most common reasons for no intervention included death while awaiting definitive treatment (n = 10 [28%]), patient uninterested in percutaneous aortic valve replacement (n = 10 [28%]), and questionable severity of symptoms or aortic stenosis (n = 9 [25%]). Patients not undergoing aortic valve replacement had higher mortality compared with those undergoing aortic valve replacement (44% vs 14%) over a mean duration of 220 days. CONCLUSION Symptomatic patients with severe aortic stenosis have high mortality if timely aortic valve replacement is not feasible. Twenty percent of the patients referred for percutaneous aortic valve replacement underwent surgical aortic valve replacement with good outcome. Patients undergoing balloon aortic valvuloplasty alone or no intervention had unfavorable outcomes.

Intraoperative echocardiography is indicated in high-risk coronary artery bypass grafting

BACKGROUND Intraoperative echocardiography is a valuable monitoring and diagnostic technology used in cardiac surgery. This reports our clinical study of the usefulness of intraoperative echocardiography to both surgeons and anesthesiologists for high-risk coronary artery bypass grafting. METHODS From March to November 1995, 82 consecutive high-risk patients undergoing coronary artery bypass grafting were studied in a four-stage protocol to determine the efficacy of intraoperative echocardiography in management planning. Alterations in surgical and anesthetic/hemodynamic management initiated by intraoperative echocardiography findings were documented in addition to perioperative morbidity and mortality. RESULTS Intraoperative echocardiography initiated at least one major surgical management alteration in 27 patients (33%) and at least one major anesthetic/hemodynamic change in 42 (51%). Mortality and the rate of myocardial infarction in this consecutive high-risk study population using intraoperative echocardiography and in a similar group of patients without the use of intraoperative echocardiography was 1.2% versus 3.8% (not significant) and 1.2% versus 3.5% (not significant), respectively. CONCLUSIONS We conclude that when all of the isolated diagnostic and monitoring applications of perioperative echocardiography are routinely and systematically performed together, it is a safe and viable tool that significantly affects the decision-making process in the intraoperative care of high-risk patients undergoing primary isolated coronary artery bypass grafting and may contribute to the optimal care of these patients.

Hemodynamic and physiologic changes during support with an implantable left ventricular assist device

To evaluate hemodynamic effectiveness and physiologic changes on the HeartMate 1000 IP left ventricular assist device (Thermo Cardiosystems, Inc., Woburn, Mass.), we studied 25 patients undergoing bridge to heart transplantation (35 to 63 years old, mean 50 years). All were receiving inotropic agents before left ventricular assist device implantation, 21 (84%) were supported with a balloon pump, and 7 (28%) were supported by extracorporeal membrane oxygenation. Six patients died, primarily of right ventricular dysfunction and multiple organ failure. Nineteen (76%) were rehabilitated, received a donor heart, and were discharged (100% survival after transplantation). Pretransplantation duration of support averaged 76 days (22 to 153 days). No thromboembolic events occurred in more than 1500 patient-days of support with only antiplatelet medications. Significant hemodynamic improvement was measured (before implantation to before explantation) in cardiac index (1.7 +/- 0.3 to 3.1 +/- 0.8 L/min per square meter; p < 0.001), left atrial pressure (23.7 +/- 7 to 9 +/- 7.5 mm Hg; p < 0.001), pulmonary artery pressure, pulmonary vascular resistance, and right ventricular volumes and ejection fraction. Both creatinine and blood urea nitrogen levels were significantly higher before implantation in patients who died while receiving support. Renal and liver function returned to normal before transplantation. We conclude that support with the HeartMate device improved hemodynamic and subsystem function before transplantation. Long-term support with the HeartMate device has a low risk of thromboemboli and makes a clinical trial of a portable HeartMate device a realistic alternative to medical therapy.

Educational program for intraoperative transesophageal echocardiography

A lthough both disciplines have cooperated for many years, cardiovascular anesthesiology and echocardiography have recently grown and merged in part. Intraoperative echocardiography has demonstrated its usefulness in many aspects of cardiovascular surgery, including valvular repair and replacement, myocardial function, aortic aneurysm repair, congenital heart disease, pericardial disease, complications of surgery, endocarditis, myocardial ischemia, and many others. Given the enlarging scope of cardiovascular surgery, echocardiography can address the compelling need for precise and accurate intraoperative diagnostic and monitoring capabilities. With the rapid development and clinical application of this technology, little attention has been focused on the necessary skills, training, and means of confirming competency for physicians performing intraoperative echocardiography. This article will not address all the questions surrounding this subject, but will explore some of the relevant issues regarding the training of physicians in intraoperative echocardiography and describe the training program developed for anesthesiologists at the Cleveland Clinic. We present our program in the hope of stimulating further discussion and research. The ultimate objective in developing an organized training program in intraoperative echocardiography is to enhance patient care at our institution through the proficient use of echocardiography in the operating arena by physicians from varying specialties and practice backgrounds.

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*

Development and analysis of a new certifying examination in perioperative transesophageal echocardiography.

A key element in developing a process to determine knowledge and ability in applying perioperative echocardiography has included an examination. We report on the development of a certifying examination in perioperative echocardiography. In addition, we tested the hypothesis that examination performance is related to clinical experience in echocardiography. Since 1995, more than 1200 participants have taken the examination, and more than 70% have passed. Overall examination performance was related positively to longer than 3 mo of training (or equivalent) in echocardiography and performance and interpretation of at least six examinations a week. We concluded that the certifying examination in perioperative echocardiography is a valid tool to help determine individual knowledge in perioperative echocardiography application.

Changes in Regional Myocardial Function after Coronary Artery Bypass Graft Surgery Are Predicted by Intraoperative Low-dose Dobutamine Echocardiography

BACKGROUND Left ventricular dysfunction is often reversed after coronary artery bypass graft (CABG) surgery; however, this change is not easily predicted. The authors hypothesized that functional changes after a low dose of dobutamine (5 microgram. kg-1. min-1) intraoperatively would predict functional changes when complete revascularization was achieved. METHODS The authors analyzed 560 segments in 40 patients scheduled for elective CABG surgery for regional wall motion (1-5 scoring system) at four stages: baseline (after induction and intubation), with administration of low-dose dobutamine before cardiopulmonary bypass, after separation from cardiopulmonary bypass (early), and after administration of protamine (late). Two independent observers scored the myocardial regions according to a 16-segment model in multiple imaging planes. For each segment, the response to dobutamine was dichotomized as improved or not improved from baseline and analyzed with logistic regression. The influence of covariates (ejection fraction, myocardial infarction, diabetes mellitus, and beta blockers) was also determined with logistic regression models. P < 0.05 was considered significant. RESULTS Changes in myocardial function after low-dose dobutamine were highly predictive for early (P < 0.0001) and late (P < 0.0001) changes in myocardial function from baseline regional scores. The overall odds ratio for early and late improvement increased by 20.7 and 34.6, respectively, when improvement was observed after low-dose dobutamine was administered. The overall positive predictive value of improved regional wall motion after CABG did not vary with left ventricular ejection fraction, a history of myocardial infarction, or beta blocker use, and it varied little with diabetic status (range, 0.86-0.96) if regional wall motion improved with low-dose dobutamine before CABG. The overall negative predictive value was 0.70; however, the range varied with diabetic status (i.e., lowest in diabetic patients and highest in nondiabetic patients). CONCLUSION Intraoperative low-dose dobutamine is a reliable method to predict myocardial functional reserve and to determine functional recovery expected after coronary revascularization.

Systolic anterior motion of mitral valve after the posterior leaflet sliding advancement procedure

The posterior leaflet sliding advancement procedure was developed to prevent the occurrence of systolic anterior motion of mitral valve and consequently outflow obstruction after mitral annuloplasty. We present a patient with extremely redundant posterior mitral leaflet in whom outflow obstruction developed despite employment of this procedure. This case underscores the utility of preoperative and intraoperative echocardiography in surgical decision making. Systolic anterior motion can develop in some patients despite this new surgical technique.

Cardiac surgery in a patient taking monoamine oxidase inhibitors: an adverse fentanyl reaction.

M onoamine oxidase inhibitors (MAOIs), are used to treat endogenous psychotic depression. The MAOIs do not inhibit catecholamine synthesis; rather they block the oxidative deamination of endogenous catecholamines into inactive vanillylmandilic acid. This block of MA0 produces an accumulation of endogenous catecholamines in adrenergically active tissues, such as the brain, which is thought to be responsible for alleviation of depression. Major concerns with the clinical use of MAOIs are related to 1) the risk of dietary intake of tyramine, an indirect sympathomimetic, which can trigger a release of accumulated catecholamines, 2) drug interactions, specifically with opioids, which have been reputed to cause a syndrome of hyperpyrexia, hypertension, tachycardia, and coma (1 1, and 3) hepatotoxicity, which does not seem to be related to dose or duration of treatment. When patients on MAOIs require urgent surgery or the relief of severe pain, there is concern about these potentially fatal drug interactions. Despite such potential interactions and risks, adverse outcomes are rarely reported in clinical practice. However, there are 12 case reports in the world literature implicating the combination of meperidine and MAOIs as potentially fatal, this being related to an inhibition of 5-hydroxytryptamine (5-HT) uptake by both the opioid and MA01 in the brain leading to increased levels of 5-HT at the synaptic cleft and consequent adverse reactions including hyperpyrexia, hypertension, hypotension, tachycardia, or convulsions (2-12). There has been only one case described of an adverse morphine/MAOI interaction (13). This involved a patient who became hypotensive and unconscious after receiving morphine (6 mg intravenously [IV]), but the etiology was uncertain. Five cases have been reported of fentanyl being administered to patients on chronic MA01 therapy (14-16); four of these cases did not have an adverse outcome