Tara R. Brakke

Transesophageal Speckle-Tracking Echocardiography Improves Right Ventricular Systolic Function Assessment in the Perioperative Setting

Background: Perioperative evaluation of right ventricular (RV) systolic function is important to follow intraoperative changes, but it is often not possible to assess with transthoracic echocardiographic (TTE) imaging, because of surgical field constraints. Echocardiographic RV quantification is most commonly performed using tricuspid annular plane systolic excursion (TAPSE), but it is not clear whether this method works with transesophageal echocardiographic (TEE) imaging. This study was performed to evaluate the relationship between TTE and TEE TAPSE distances measured with M‐mode imaging and in comparison with speckle‐tracking TTE and TEE measurements. Methods: Prospective observational TTE and TEE imaging was performed during elective cardiac surgical procedures in 100 subjects. Speckle‐tracking echocardiographic TAPSE distances were determined and compared with the TTE M‐mode TAPSE standard. Both an experienced and an inexperienced user of the speckle‐tracking echocardiographic software evaluated the images, to enable interobserver assessment in 84 subjects. Results: The comparison between TTE M‐mode TAPSE and TEE M‐mode TAPSE demonstrated significant variability, with a Spearman correlation of 0.5 and a mean variance in measurement of 6.5 mm. There was equivalence within data pairs and correlations between TTE M‐mode TAPSE and both speckle‐tracking TTE and speckle‐tracking TEE TAPSE, with Spearman correlations of 0.65 and 0.65, respectively. The average variance in measurement was 0.6 mm for speckle‐tracking TTE TAPSE and 1.5 mm for speckle‐tracking TEE TAPSE. Conclusions: Using TTE M‐mode TAPSE as a control, TEE M‐mode TAPSE results are not accurate and should not be used clinically to evaluate RV systolic function. The relationship between speckle‐tracking echocardiographic TAPSE and TTE M‐mode TAPSE suggests that in the perioperative setting, speckle‐tracking TEE TAPSE might be used to quantitatively evaluate RV systolic function in the absence of TTE imaging. HighlightsTTE M‐mode TAPSE and TEE M‐mode TAPSE do not agree, and TEE M‐mode TAPSE should not be used to quantify RV systolic function.Speckle‐tracking echocardiography allows accurate TAPSE measurements for TTE and TEE imaging compared with TTE M‐mode TAPSE.Speckle‐tracking TEE TAPSE could be used to quantify RV systolic function in the perioperative setting when standard TTE methods are not possible.

Liver Transplantation: Intraoperative Transesophageal Echocardiography Findings and Relationship to Major Postoperative Adverse Cardiac Events

OBJECTIVE The primary aim of the study was to describe the most common intraoperative transesophageal echocardiography (TEE) findings during the 3 separate phases of orthotopic liver transplantation (OLT). The secondary aim of the study was to determine if the abnormal TEE findings were associated with major postoperative adverse cardiac events (MACE) and thus may be amenable to future management strategies. DESIGN Data were collected retrospectively from the electronic medical record and institutional echocardiography database. SETTING Single university hospital. PARTICIPANTS A total of 100 patients undergoing OLT via total cavaplasty technique. INTERVENTIONS Intraoperative TEE was performed in all 3 phases of OLT. MEASUREMENT AND MAIN RESULTS TEE findings of 100 patients who had TEE during OLT during the dissection, anhepatic, and reperfusion phases of transplantation were recorded after blind review. Findings then were analyzed to see if those findings were predictive of postoperative MACE. Intraoperative TEE findings varied among the different phases of OLT. Common TEE findings at reperfusion were microemboli (n = 40, 40%), isolated right ventricular dysfunction (n = 22, 22%), and intracardiac thromboemboli (n = 20, 20%). CONCLUSIONS Intraoperative echocardiography findings during liver transplantation varied during each phase of transplantation. The presence of intracardiac thromboemboli or biventricular dysfunction on intraoperative echocardiography was predictive of short- and long-term major postoperative adverse cardiac events.

Echocardiography‐Based Hemodynamic Management of Left Ventricular Diastolic Dysfunction: A Feasibility and Safety Study

Patients with left ventricular diastolic dysfunction (LVDD) are at increased risk of postoperative adverse events. The primary aim of this study was to evaluate the safety and feasibility of using echocardiography‐guided hemodynamic management (EGHEM) during surgery in subjects with LVDD compared to conventional management. The feasibility of using echocardiography to direct a treatment algorithm and clinical outcomes were compared for safety between groups.

The development of a perioperative echocardiography consult service: the Nebraska experience.

From the *Department of Anesthesiology; and †Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska. The administrative development of a perioperative echocardiography consult service at the University of Nebraska Medical Center was supported by the 2012 Society of Cardiovascular Anesthesiologists Foundation Kaplan Leadership Grant. Address reprint requests to Sasha K. Shillcutt, MD, FASE, 984455 Nebraska Medical Center, Omaha, NE 68198-4455. E-mail: sshillcu@ unmc.edu

Transthoracic Echocardiography: Training Options for Practicing Physicians

1. Burgess FW, Anderson DM, Colonna D, et al: Ipsilateral houlder pain following thoracic surgery. Anesthesiology 78:36568, 1993 2. Li WW, Lee TW, Yim AP: Shoulder function after thoracic urgery. Thorac Surg Clin 14:331-343, 2004 3. Barak M, Ziser A, Katz Y: Thoracic epidural local anesthetics are neffective in alleviating post-thoracotomy ipsilateral shoulder pain. Cardiothorac Vasc Anesth 18:458-460, 2004 4. Scawn ND, Pennefather SH, Soorae A, et al: Ipsilateral shoulder ain after thoracotomy with epidural analgesia: The influence of hrenic nerve infiltration with lidocaine. Anesth Analg 93:260-264, 001 5. Gerner P: Post-thoracotomy pain management problems. Aneshesiol Clin 26:355-367, 2008 6. Mark JB, Brodsky JB: Ipsilateral shoulder pain following thoracic perations. Anesthesiology 79:192, 1993 7. Tan N, Agnew NM, Scawn ND, et al: Suprascapular nerve block or ipsilateral shoulder pain after thoracotomy with thoracic epidural nalgesia: A double-blind comparison of 0.5% bupivacaine and 0.9% aline. Anesth Analg 94:199-202, 2002 8. Benumof JL: Routine surgical considerations that have anesthetic mplication, in Benumof JL (ed): Anesthesia for Thoracic Surgery (ed ). Philadelphia, PA, Saunders, 1994, pp 390-405 9. Johnson D, Ellis H: Pectoral girdle, shoulder region and axilla, in tandring S (ed): Gray’s Anatomy (ed 39). Spain, Elsevier Churchill ivingstone, 2005, pp 817-850 10. Mac TB, Girard F, Chouinard P, et al: Acetaminophen decreases arly post-thoracotomy ipsilateral shoulder pain in patients with thoacic epidural analgesia: A double-blind placebo-controlled study. Cardiothorac Vasc Anesth 19:475-478, 2005 11. Hazelrigg SR, Landreneau RJ, Boley TM, et al: The effect of uscle-sparing versus standard posterolateral thoracotomy on pulmoary function, muscle strength, and postoperative pain. J Thorac Cariovasc Surg 101:394-401, 1991 12. Ng KP, Chow YF: Brachial plexus block for ipsilateral houlder pain after thoracotomy. Anaesth Intensive Care 25:74-76, 997 13. Garner L, Coats RR: Ipsilateral stellate ganglion block effective or treating shoulder pain after thoracotomy. Anesth Analg 78:1195196, 1994 14. Ramamurthy S, Hickey R, Maytorena A, et al: Long thoracic erve block. Anesth Analg 71:197-199, 1990

Intraoperative transesophageal echocardiography diagnosis of rare source of right ventricular failure after heart transplant.

A 44-year-old male born with d-transposition of the great arteries underwent a Mustard atrial switch procedure after birth (Fig. 1) and eventually developed failure of the morphologic right ventricle (RV). He was admitted for New York Heart Association Class IV heart failure symptoms requiring continuous inotropic therapy and an intraaortic balloon pump to reduce the work of his systemic ventricle, the RV. Heart transplantation was performed, restoring the patient to normal anatomy. Failure of the allograft RV was diagnosed on postoperative day 1 using transthoracic echocardiography (Video 1A and B, see Supplemental Digital Content 1, http://links.lww.com/ AA/A406). No improvement was subsequently seen and he was scheduled for RV assist device (RVAD) placement on postoperative day 10. General anesthesia was induced and transesophageal echocardiography (TEE) was performed showing a dilated RV with depressed systolic function (Video 2A, see Supplemental Digital Content 2, http://links.lww.com/AA/A407). A narrowing of the pulmonary artery (PA) anastomosis, diameter of 1.14 cm, was seen approximately 2.5 cm above the pulmonic valve (Fig. 2A) (Video 2B, http://links.lww. com/AA/A407). Evaluation with 2-dimensional (2D) and color-flow Doppler (CFD) of the anastomosis was performed and showed flow acceleration at the anastomosis and turbulence distal to the narrowed region (Video 2C, http://links.lww.com/AA/A407). Continuous-wave Doppler showed a maximum velocity of 343 cm/second across this narrowing, representing a peak gradient of 47 mm Hg (Fig. 3A). This anastomosis was revised during cardiopulmonary bypass (CPB) secondary to these findings and as planned, a Thoratec PVAD (Thoratec Corporation, Pleasanton, CA) pulsatile ventricular assist device (VAD) for the RV was implanted. Post-CPB imaging showed improved PA internal diameter and decreased peak gradient to 12 mm Hg with the RVAD flow paused (Fig. 3B). The pulsatile RVAD was used until RV function improved and removal of the device occurred 17 days later. DISCUSSION This patient underwent the Mustard procedure for correction of d-transposition of the great arteries, which directs systemic venous blood through the left atrium, left ventricle, and into the PA and directs pulmonary venous blood through the right atrium, the morphologic RV and into the aorta (Fig. 1B). Over time, the Mustard procedure can lead to dysfunction of the morphologic RV because it lacks sufficient contractile reserve and atrioventricular valve function to generate systemic pressures long-term. For many individuals with either congenital or acquired forms of heart disease that result in decreased cardiac function, cardiac transplantation is the final treatment option for those who cannot recover with other therapies. RV failure continues to have significant morbidity for patients undergoing cardiac transplantation, especially those with high pulmonary vascular resistance preoperatively. RV failure after transplantation has been caused by preexisting pulmonary hypertension, poor RV myocardial protection, air embolism, or rare anatomic/anastomotic complications. Such causes of postoperative RV dysfunction secondary to outflow tract obstruction have been reported after anastomotic stricture after lung transplantation and kinking of the PA after heart transplantation. Pretransplant heart catheterization on our patient demonstrated PA pressures of 40/25 mm Hg (mean 35 mm Hg) and pulmonary vascular resistance of 2.56 Woods units, which was appropriate to attempt cardiac transplantation. Postoperative treatment with a VAD has been used after heart transplantation and for individuals with heart failure after acute myocardial infarction. VAD therapy allows recovery of ventricular function over time and eventual removal of the device, as it occurred in this patient. Examination after the RVAD was paused demonstrated improved RV function and normal tricuspid annulus plane systolic excursion before RVAD extraction on posttransplant day 27. Regarding the intraoperative findings, a normal diameter of the PA at the level of the stricture is 1.5 to 2.1 cm and normal flow through the PA and pulmonic valve should be 100 cm/second. Because the diameter of stricture on 2D imaging was 1.14 cm, it was a smaller than expected diameter for the PA. A focused evaluation using 2D echo in 2 orthogonal planes, midesophageal ascending aorta shortaxis view and midesophageal ascending aorta long-axis view, was important for confirmation that a stenotic area was present and not artifact. Manipulation of the TEE probe depth in these 2 views allowed visualization of the PA in long-axis and short-axis, respectively, though visualization of the PA with these views is not always available. The use of CFD to demonstrate flow acceleration at the From the Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.

Free-floating intracardiac mass after cardiopulmonary bypass for aortic valve replacement.

A 58-year-old woman presented for aortic valve (AV) replacement (AVR) because of a severely calcified bicuspid AV with a peak gradient of 99 mm Hg and an AV area of 0.58 cm on preoperative transthoracic echocardiogram. Consent for publication of this case has been obtained from the patient. Intraoperative transesophageal echocardiography (TEE) demonstrated a severely calcified AV (valve area 0.56 cm) measured by continuity equation and peak and mean gradients were verified using continuous-wave Doppler through the AV in the deep transgastric view. Moderate aortic regurgitation was also observed. The left ventricle (LV) was moderately depressed and hypertrophied; LV septal and posterior wall thickness equaled 15 mm. The mitral valve revealed trace regurgitation with moderate mitral annular calcification, including calcification of the leaflets but sparing of the subvalvular apparatus (Video 1, see Supplemental Digital Content 1,

Heart Failure With Preserved Ejection Fraction: A Perioperative Review

HEART FAILURE (HF) with preserved ejection fraction (HFpEF) presents significant challenges for anesthesiologists. Nearly 50% of patients presenting with HF have HFpEF, defined as having clinical HF with a left ventricular ejection fraction (LVEF) 450% and abnormal left ventricular diastolic dysfunction (LVDD). Even though HFpEF is a strong predictor of negative postoperative outcomes, it often is difficult to diagnose and the management strategies are unclear. Although there have been specific articles published with regard to the echocardiography descriptors, diagnosis, and relationship of LVDD with HF, the authors believed it was timely to present a review article for clinicians on the subject of perioperative HFpEF. This article reviews what is known about the pathogenesis, diagnosis, management options, and implications of HFpEF in the perioperative arena.

The Implementation of a Preoperative Transthoracic Echocardiography Consult Service by Anesthesiologists

We describe a preoperative transthoracic echocardiography consult service led by anesthesiologists. The implementation process and the patient cohort are described. Preoperative transthoracic echocardiographic examinations were mostly performed in patients undergoing intermediate- or high-risk noncardiac surgery and in patients with a higher calculated mortality risk. All transthoracic echocardiographic examinations were interpreted by anesthesiologists.