[The role of transesophageal echocardiography (TEE): case study conducted at the Dax Hospital Center]. / Evaluation de la pratique de l'échocardiographie transœsophagienne (ETO): cas du Centre Hospitalier de Dax.

The purpose of this study is to assess the role of transesophageal echocardiography at the Dax Hospital Center based on indications, patients´ profile, results, cost-effectiveness and consistency with prescribers´ expectations. We conducted a retrospective, cross-sectional, descriptive and analytical study at the Cardiovascular Laboratory of the Dax Hospital Center from January 2016 to December 2018. The study included 434 exams out of 460 requested. The variables of interest were: demographic profile of the study population, indications, results, cost-effectiveness and consistency with prescribers´ expectations. The average age of patients undergoing the 434 exams included was 64.37 years, male patients accounted for 64.29%, with a sex ratio of 1.8. Stroke assessment (63.59%), the search for infective endocarditis (16.12%) and the assessment of the treatment of intracavitary thrombi (11.75%) were the main indications. Prescribers were mainly neurologists (60.83%). The examination was normal in 58.99% of cases. The pathological results (40,78%) were dominated by thrombi in the auricle (27.65%), altered auricle emptying (9.45%), the presence of foramen oval permeable (5.07%), interatrial septal aneurysm (2.53%) and infective endocarditis (2.76%). The exam was cost-effective in 40.78% of cases and the results were consistent with prescribers´ expectations in 39.86% of cases. Our study transesophageal echocardiography showed that the indications were dominated by stroke assessment. TEE is a cost-effective diagnostic test with a low rate of complications, and whose results are in line with practitioners' expectations.

Appropriate selection of echocardiographic guidance for transcatheter atrial septal defect closure.

Transesophageal echocardiography (TEE) under general anesthesia (GA) or intracardiac echocardiography (ICE) under sedation is usually used for echocardiographic guidance during transcatheter atrial septal defect (ASD) closure. However, appropriate selection of guidance has not been fully established. Our study aimed to evaluate whether selection of guidance depending on anatomic ASD features and TEE tolerability under sedation contributes to procedure success. On the basis of anatomic ASD characteristics and TEE tolerability under sedation during the pre-procedural TEE, we selected either TEE, ICE, or combined TEE and ICE under moderate-to-deep sedation or TEE under GA for guidance. Anatomic characteristics of the defect, medical costs, complications, and primary outcomes for these four different types of guidance were analyzed. A total of 154 patients were classified into four guidance groups depending on the results of diagnostic TEE under sedation; 11 patients were scheduled for the procedure under GA in advance. Procedures were successfully completed in all but two patients in whom closure guided by TEE under sedation was attempted for an extremely large defect or extensive superior rim deficiency. Two patients who underwent TEE or combined TEE and ICE guidance under sedation were converted to ICE-only guidance due to desaturation or excessive body movement. Device dislodgement was not observed during the procedure or during median follow-up of 1188 days [interquartile range 577-1831]. Appropriate selection of guidance might contribute to successful transcatheter ASD closure.

Cost-effectiveness analysis of 3D versus 2D transesophageal echocardiography for the evaluation of patients with primary mitral regurgitation with indication of surgical treatment

OBJECTIVES: To perform the cost-effectiveness analysis of three-dimensional transesophageal echocardiography (3DTEE) in comparison to two-dimensional transesophageal echocardiography (2DTEE) for the anatomic-functional evaluation and surgical planning of severe primary mitral regurgitation. METHODS: a complete economic study was based on a systematic review of 3DTEE and 2DTEE accuracy and private health system costs of two different surgical interventions: mitral valve plasty and mitral valve replacement. The prevalence of common postoperative complications was also predicted for elective procedures: atrial fibrillation (8.6%); acute myocardial infarction (1.4%); thrombosis (3.5%); bleeding (1.5%); endocarditis (6.3%). The decision tree method was adopted as a data analysis model. The Bayes" theorem was used based on sensitivity and specificity measurements. The costs, considering literature and professional tables, were: 3DTEE = US$ 349; 2DTEE = US$ 204; diagnostic evaluation = US$ 597; surgical procedure = US$ 3,643; surgical treatment = US$ 374. RESULTS: The deterministic analysis of the diagnostic test shows that 3DTEE (non-dominated) is superior to 2DTEE (absolutely dominated). The 3DTEE presents a cost reduction of US$ 1,147 and incremental effectiveness (true identification) of 22% when compared to 2DTEE. The multivariate probabilistic sensitivity analysis showed that after 100,000 iterations, the diagnosis based on the 3DTEE becomes the first choice regardless of the willingness to pay threshold. CONCLUSIONS: 3DTEE was cost-effective compared to 2DTEE. Thus, 3DTEE is a potential device to promote health compared to 2DTEE for surgical planning of severe primary mitral regurgitation. (AU)

Cost-effectiveness of routine transoesophageal echocardiography during cardiac surgery: a discrete-event simulation study.

BACKGROUND: The aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used. METHODS: The impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost-effectiveness ratio of €30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness. RESULTS: Routine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation. CONCLUSIONS: Routine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events.

Intraoperative Transesophageal Echocardiography During Cardiovascular Surgery in China.

OBJECTIVE: To perform a comprehensive nationwide survey of more than 90% of all cardiovascular hospitals in China to assess the current 2018 status of transesophageal echocardiography (TEE) equipment, operating physicians, education, impact on surgery, and reimbursement. DESIGN: In this nationwide survey, 716 cardiovascular hospitals in mainland China were included. A 15-question electronic survey was sent to these hospitals and the data were received directly from the questionnaire website for analysis. SETTING: Cardiovascular hospitals in mainland China. PARTICIPANTS: Departments of anesthesiology in cardiovascular hospitals in mainland China. INTERVENTIONS: Answer a 15-question survey. MEASUREMENTS AND MAIN RESULTS: About 90% of hospitals have acquired machines to perform TEEs with most of the machines controlled by the ultrasound department. Anesthesiologists performed intraoperative TEEs in 45% of the hospitals, but only 15% of the hospitals have anesthesiologists who have met the basic TEE training requirements. Most anesthesiologists (68%) believed TEE significantly contributed to patient care during cardiovascular surgeries. The overwhelming majority of surveyed hospital staff (93%) stated that they were planning to continue or start intraoperative TEE examinations in the future. CONCLUSION: Many hospitals in China have acquired equipment to perform intraoperative TEE examinations during cardiovascular surgeries. However, the number of anesthesiologists who can perform TEEs independently still is not adequate. Standardized trainings, a formal certification process, and governmental payment model changes must be provided to ensure high-quality TEE services and better surgical outcomes in China.

The cost effectiveness of transesophageal echocardiography for pediatric cardiac surgery: a systematic review.

BACKGROUND: Intraoperative transesophageal echocardiography (ITEE) for pediatric cardiac surgery has been described as clinically efficacious and cost-effective. There are a small number of publications supporting these claims. AIMS: The objectives were to assess the quality of the research, the variability of results across studies and, if possible, to make a consensus statement based on the results. METHODS: In March 2015, a systematic search of MEDLINE and MEDLINE In-Process, EMBASE, and the National Health Service Economic Evaluation Database was performed. The search was supplemented with a review of Health Technology Assessment reports through the Centre for Reviews and Dissemination database. English language articles including any quantitative economic evaluation were included. The quality of each study was assessed using the British Medical Journal economic evaluation quality checklist. Data extracted included the main outcomes from each study, study methodologies, itemized costs, sensitivity ranges, biases, and delayed reoperation prevented with ITEE. When possible, a cost-savings per ITEE was calculated to facilitate comparison across studies and used to create a synthesis of the results. RESULTS: Seven studies met the inclusion criteria; of these, five were included in the synthesis of results. The cost-savings per ITEE ranged from $194 to $4910 with a mean of $1930 (95%CI: $845 to $3015) (2015 USD). Prevented delayed reoperation rates using ITEE ranged from 2.8% to 10%. Earlier studies were of poorer quality (scores 8-17) and more recent studies were of higher quality (scores 22-25). Methodologies used were either retrospective chart reviews (57%) or prospective observational studies (43%) with a range of approaches to estimate costs. CONCLUSION: ITEE for pediatric cardiac surgery is effective and cost-saving. This is a validation of the current practice patterns. These finding may influence the expansion of the use of this technology.

Single-Center Experience With Adjustable Annuloplasty Ring in Degenerative Mitral Regurgitation.

OBJECTIVE: Owing to the complex anatomy of the mitral valve, successful surgical repair of degenerative regurgitation remains a challenging procedure in cardiac surgery. METHODS: This paper aimed to report on our single-center experience with 20 patients who received an adjustable annuloplasty ring (Cardinal ring, ValtechCardio Ltd, Or Yehuda, Israel) as part of their mitral valve repair procedure. The device allows for intraoperative echocardiography-guided ring size adjustments under beating-heart conditions. RESULTS: All of the 20 patients left the operating room without any residual mitral regurgitation. There was no risk of systolic anterior movement (SAM) because of image-guided fine tuning of the ring before weaning the patient from bypass. CONCLUSIONS: Further multicenter data are required to prove the concept of adjustable annuloplasty devices.

Comparison of transfemoral transcatheter aortic valve replacement performed in the catheterization laboratory (minimalist approach) versus hybrid operating room (standard approach): outcomes and cost analysis.

OBJECTIVES: The aim of this study was to compare transfemoral transcatheter aortic valve replacement (TF TAVR) performed in a catheterization laboratory (minimalist approach [MA]) with TF TAVR performed in a hybrid operating room (standard approach [SA]). BACKGROUND: A MA-TF TAVR can be performed without general anesthesia, transesophageal echocardiography, or a surgical hybrid room. The outcomes and cost of MA-TF TAVR compared with those of the SA have not been described. METHODS: Patients who underwent elective, percutaneous TF TAVR using the Edwards Sapien valve (Edwards Lifesciences, Irvine, California) were studied. Baseline characteristics, outcomes, and hospital costs of MA-TF TAVR and SA-TF TAVR were compared. RESULTS: A total of 142 patients were studied (MA-TF TAVR, n = 70 and SA-TF TAVR, n = 72). There were no differences in baseline comorbidities (Society of Thoracic Surgeons score, 10.6 ± 4.3 vs. 11.4 ± 5.8; p = 0.35). All procedures in the MA-TF TAVR group were successful; 1 patient was intubated. Three patients in the SA-TF TAVR group had procedure-related death. Procedure room time (150 ± 48 min vs. 218 ± 56 min, p < 0.001), total intensive care unit time (22 h vs. 28 h, p < 0.001), length of stay from procedure to discharge (3 days vs. 5 days, p < 0.001), and cost ($45,485 ± 14,397 vs. $55,377 ± 22,587, p < 0.001) were significantly less in the MA-TF TAVR group. Mortality at 30 days was not significantly different in the MA-TF TAVR group (0 vs. 6%, p = 0.12) and 30-day stroke/transient ischemic attack was similar (4.3% vs. 1.4%, p = 0.35). Moderate or severe paravalvular leak and device success were similar in the MA-TF TAVR and SA-TF TAVR groups (3% vs. 5.8%, p = 0.4 and 90% vs. 88%, p = 0.79, respectively) at 30 days. At a median follow-up of 435 days, there was no significant difference in survival (MA-TF TAVR, 83% vs. SA-TF TAVR, 82%; p = 0.639). CONCLUSIONS: MA-TF TAVR can be performed with minimal morbidity and mortality and equivalent effectiveness compared with SA-TF TAVR. The shorter length of stay and lower resource use with MA-TF TAVR significantly lowers hospital costs.

How I do it: judging appropriateness for TTE and TEE.

The increasing cost of healthcare is a widespread international problem to which the cost of imaging has been an important contributor. Some imaging tests are ordered inappropriately and contribute to wasted use of resources. Appropriate use criteria have been developed in the USA in order to guide test selection, but there are a number of problems, including the evidence base for these criteria and the steps that can be taken to change physician practice. A restrictive approach to test ordering is difficult to fit to the nuances of clinical presentation and may compromise patient care. We propose an alternative approach to physician guidance based on the most common markers of inappropriate testing.

From accuracy to patient outcome and cost-effectiveness evaluations of diagnostic tests and biomarkers: an exemplary modelling study.

BACKGROUND: Proper evaluation of new diagnostic tests is required to reduce overutilization and to limit potential negative health effects and costs related to testing. A decision analytic modelling approach may be worthwhile when a diagnostic randomized controlled trial is not feasible. We demonstrate this by assessing the cost-effectiveness of modified transesophageal echocardiography (TEE) compared with manual palpation for the detection of atherosclerosis in the ascending aorta. METHODS: Based on a previous diagnostic accuracy study, actual Dutch reimbursement data, and evidence from literature we developed a Markov decision analytic model. Cost-effectiveness of modified TEE was assessed for a life time horizon and a health care perspective. Prevalence rates of atherosclerosis were age-dependent and low as well as high rates were applied. Probabilistic sensitivity analysis was applied. RESULTS: The model synthesized all available evidence on the risk of stroke in cardiac surgery patients. The modified TEE strategy consistently resulted in more adapted surgical procedures and, hence, a lower risk of stroke and a slightly higher number of life-years. With 10% prevalence of atherosclerosis the incremental cost-effectiveness ratio was € 4,651 and € 481 per quality-adjusted life year in 55-year-old men and women, respectively. In all patients aged 65 years or older the modified TEE strategy was cost saving and resulted in additional health benefits. CONCLUSIONS: Decision analytic modelling to assess the cost-effectiveness of a new diagnostic test based on characteristics, costs and effects of the test itself and of the subsequent treatment options is both feasible and valuable. Our case study on modified TEE suggests that it may reduce the risk of stroke in cardiac surgery patients older than 55 years at acceptable cost-effectiveness levels.

Impact of routine transoesophageal echocardiography on safety, outcomes, and cost of pulmonary vein ablation: inferences drawn from a decision analysis model.

AIMS: The practice of routine vs. selective transoesophageal echocardiography (TEE) surveillance for left atrial appendage or intracavitary thrombus prior to pulmonary vein isolation (PVI) varies widely as evidence to guide this decision in terms of important clinical outcomes is lacking. METHODS AND RESULTS: We constructed a decision analysis model to compare the cost-effectiveness of routine TEE for detection of left atrial thrombus vs. no TEE. The model incorporated health outcomes and costs. Markov methodology was used to follow patients as they transition through varying health states. We examined a hypothetical cohort of patients with symptomatic atrial fibrillation suitable for PVI, and expected outcomes were modelled over a period of 2 years. Simulated patients (SPs) undergoing a strategy of a routine TEE experienced significantly fewer transient ischemic attacks (TIAs) [OR 0.28 (0.22-0.37)], and debilitating strokes [OR 0.23 (0.15-0.33)]. Routine TEE led to an absolute risk reduction for stroke of 1.2% [number needed to treat (NNT) 84 (79-100)] and 1.9% for TIA [NNT 53 (48-59)]. The incremental cost-effectiveness ratio (ICER) for TEE was $226,608 per quality-adjusted life year (QALY). The ICER for TEE among high-risk SPs, with pre-existing clot in the left atrium, was $2232 per QALY. CONCLUSION: Decision analysis and microsimulation suggest that routine use of TEE in an unselected population prior to PVI lowers the incidence of cerebral thrombo-embolic events but with considerable cost per QALY.

Intra-cardiac echocardiography in atrial septal interventions: impact on hospitalization costs.

OBJECTIVE: Intra-cardiac echocardiography (ICE) is used to guide percutaneous interventions on the atrial septum. However, ICE catheters are expensive. We questioned the impact of the use of ICE catheters on hospitalization costs for patent foramen ovale (PFO) or atrial septal defect (ASD) closure. METHODS AND RESULTS: Patients, scheduled for atrial septal closure, were randomly selected to use the AcuNav catheter (Biosense Webster Inc, Diamond Bar, CA, US) on top of the standard procedure (three or two days of hospitalization, procedure with transoesophageal echocardiography (TEE) and general anaesthesia). The AcuNav catheter was provided for free and the total hospitalization cost for each patient was calculated by verification of the bills, sent to the patient and the national health insurance. This was compared with a fictive hospitalization cost when ICE alone would have been used (three or two days of hospitalization, procedure without TEE, and local anaesthesia). Feasibility and safety were also evaluated. Three PFOs and two ASDs were successfully closed (3F/2M, age 55 +/- 12 years). The total hospitalization cost for a standard closing procedure was EUR 9345 +/- 132 and EUR 9303 +/- 132 for three and two days of hospitalization, respectively. With a free ICE catheter and no general anaesthesia, hospitalization cost lowered to EUR 8464 +/- 131 and EUR 8422 +/-131, respectively. Cost saving would be EUR 881 +/- 3, but the price of a single-use ICE catheter varies between EUR 2000 and 2500. In all patients, adequate images were obtained and no complications related to the ICE catheter occurred. CONCLUSIONS: Single-use ICE catheters remain expensive in percutaneous ASD or PFO closure. However, general anaesthesia might be avoided, which could open a discussion on cost savings.

Eco tridimensional: um grande avanço / Echocardiography, three - dimensional: a great advance

O autor apresenta um artigo de revisão sobre o eco tridimensional, desde um histórico do seu desenvolvimento até os diferentes modos de obtenção das imagens. Também fornece vários exemplos práticos que demosntram a utilidade, na pratica diária, dessa nova tecnologia.

Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients.

OBJECTIVES: To assess the effectiveness and cost-effectiveness of oesophageal Doppler monitoring (ODM) compared with conventional clinical assessment and other methods of monitoring cardiovascular function. DATA SOURCES: Electronic databases and relevant websites from 1990 to May 2007 were searched. REVIEW METHODS: This review was based on a systematic review conducted by the US Agency for Healthcare Research and Quality (AHRQ), supplemented by evidence from any additional studies identified. Comparator interventions for effectiveness were standard care, pulmonary artery catheters (PACs), pulse contour analysis monitoring and lithium or thermodilution cardiac monitoring. Data were extracted on mortality, length of stay overall and in critical care, complications and quality of life. The economic assessment evaluated strategies involving ODM compared with standard care, PACs, pulse contour analysis monitoring and lithium or thermodilution cardiac monitoring. RESULTS: The AHRQ report contained eight RCTs and was judged to be of high quality overall. Four comparisons were reported: ODM plus central venous pressure (CVP) monitoring plus conventional assessment vs CVP monitoring plus conventional assessment during surgery; ODM plus conventional assessment vs CVP monitoring plus conventional assessment during surgery; ODM plus conventional assessment vs conventional assessment during surgery; and ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment postoperatively. Five studies compared ODM plus CVP monitoring plus conventional assessment with CVP monitoring plus conventional assessment during surgery. There were fewer deaths [Peto odds ratio (OR) 0.13, 95% CI 0.02-0.96], fewer major complications (Peto OR 0.12, 95% CI 0.04-0.31), fewer total complications (fixed-effects OR 0.43, 95% CI 0.26-0.71) and shorter length of stay (pooled estimate not presented, 95% CI -2.21 to -0.57) in the ODM group. The results of the meta-analysis of mortality should be treated with caution owing to the low number of events and low overall number of patients in the combined totals. Three studies compared ODM plus conventional assessment with conventional assessment during surgery. There was no evidence of a difference in mortality (fixed-effects OR 0.81, 95% CI 0.23-2.77). Length of hospital stay was shorter in all three studies in the ODM group. Two studies compared ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment in critically ill patients. The patient groups were quite different (cardiac surgery and major trauma) and neither study, nor a meta-analysis, showed a statistically significant difference in mortality (fixed-effects OR 0.84, 95% CI 0.41-1.70). Fewer patients in the ODM group experienced complications (OR 0.49, 95% CI 0.30-0.81) and both studies reported a statistically significant shorter median length of hospital stay in that group. No economic evaluations that met the inclusion criteria were identified from the existing literature so a series of balance sheets was constructed. The results show that ODM strategies are likely to be cost-effective. CONCLUSIONS: More formal economic evaluation would allow better use of the available data. All identified studies were conducted in unconscious patients. However, further research is needed to evaluate new ODM probes that may be tolerated by awake patients. Given the paucity of the existing economic evidence base, any further primary research should include an economic evaluation or should provide data suitable for use in an economic model.

Impact of contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort.

OBJECTIVES: The aim of this study was to evaluate the impact of echocardiographic contrast utilization on patient diagnosis and management. BACKGROUND: Contrast echocardiography (CE) has improved visualization of endocardial borders. However, its impact on patient management has not been evaluated previously. METHODS: We prospectively enrolled 632 consecutive patients with technically difficult echocardiographic studies who received intravenous contrast (Definity, Lantheus Medical Imaging, Billerica, Massachusetts). Quality of studies, number of left ventricular (LV) segments visualized, estimated ejection fraction, presence of apical thrombus, and management decisions were compared before and after contrast. RESULTS: After CE, the percent of uninterpretable studies decreased from 11.7% to 0.3% and technically difficult studies decreased from 86.7% to 9.8% (p < 0.0001). Before contrast, 11.6 +/- 3.3 of 17 LV segments were seen, which improved after CE to 16.8 +/- 1.1 (p < 0.0001). An LV thrombus was suspected in 35 patients and was definite in 3 patients before CE. After contrast, only 1 patient had a suspected thrombus, and 5 additional patients with thrombus were identified (p < 0.0001). A significant impact of CE on management was observed: additional diagnostic procedures were avoided in 32.8% of patients and drug management was altered in 10.4%, with a total impact (procedures avoided, change in drugs, or both) observed in 35.6% of patients. The impact of contrast increased with worsening quality of nonenhanced study, the highest being in intensive care units. A cost-benefit analysis showed a significant savings using contrast ($122/patient). CONCLUSIONS: The utilization of CE in technically difficult cases improves endocardial visualization and impacts cardiac diagnosis, resource utilization, and patient management.