Preoperative Tricuspid Regurgitation Is Associated With Long-Term Mortality and Is Graded More Severe Than Intraoperative Tricuspid Regurgitation.

OBJECTIVES: To determine whether preoperative (preop) tricuspid regurgitation (TR) severity grade was associated with postoperative mortality, to examine the correlation between pre-op and intraoperative (intraop) TR grades, and to understand which TR grade had better prognostic predictability in cardiac surgery patients. DESIGN: Retrospective. SETTING: Single institution. PARTICIPANTS: Patients. INTERVENTIONS: Preop and intraop echocardiography TR grades of 4,232 patients who had undergone cardiac surgeries between 2004 and 2014 were examined. MEASUREMENTS AND MAIN RESULTS: Kaplan-Meier curves and Cox proportional hazard models were used to determine the association between TR grades and the primary endpoint of all-cause mortality. The Wilcoxon signed-rank test and Spearman's rank correlation were analyzed to assess the similarity and correlation between preop and intraop-grade pairs. Multivariate logistic regression models of the area under the curve characteristics were compared for prognostic implications. Kaplan-Meier curves demonstrated a strong relationship between preop grades and survival. Multivariate models showed significantly increased mortality starting at mild preop TR (mild TR: hazard ratio [HR] 1.24; 95% CI 1.05-1.46, p = 0.013; moderate TR: HR 1.60; 95% CI 1.05-1.97, p < 0.001; severe TR: HR 2.50; 95% CI 1.74-3.58, p < 0.001). Preop TR grades were mostly higher than intraop grades. Spearman's correlation was 0.55 (p < 0.001). The area under the curves of preop and intraop TR-based models were almost identical (0.704 v 0.702 1-year mortality and 0.704 v 0.700 2-year mortality). CONCLUSIONS: The authors found that echocardiographically-determined preop TR grade at the time of surgical planning was associated with long-term mortality, starting even at a mild grade. Preop grades were higher than intraop grades, with a moderate correlation. Preop and intraop grades exhibited similar prognostic implications.

EACTA/SCA Recommendations for the Cardiac Anesthesia Management of Patients With Suspected or Confirmed COVID-19 Infection: An Expert Consensus From the European Association of Cardiothoracic Anesthesiology and Society of Cardiovascular Anesthesiologists With Endorsement From the Chinese Society of Cardiothoracic and Vascular Anesthesiology.

The European Association of Cardiothoracic Anaesthesiology (EACTA) and the Society of Cardiovascular Anesthesiologists (SCA) aimed to create joint recommendations for the perioperative management of patients with suspected or proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection undergoing cardiac surgery or invasive cardiac procedures. To produce appropriate recommendations, the authors combined the evidence from the literature review, reevaluating the clinical experience of routine cardiac surgery in similar cases during the Middle East Respiratory Syndrome (MERS-CoV) outbreak and the current pandemic with suspected coronavirus disease 2019 (COVID-19) patients, and the expert opinions through broad discussions within the EACTA and SCA. The authors took into consideration the balance between established procedures and the feasibility during the present outbreak. The authors present an agreement between the European and US practices in managing patients during the COVID-19 pandemic. The recommendations take into consideration a broad spectrum of issues, with a focus on preoperative testing, safety concerns, overall approaches to general and specific aspects of preparation for anesthesia, airway management, transesophageal echocardiography, perioperative ventilation, coagulation, hemodynamic control, and postoperative care. As the COVID-19 pandemic is spreading, it will continue to present a challenge for the worldwide anesthesiology community. To allow these recommendations to be updated as long as possible, the authors provided weblinks to international public and academic sources providing timely updated data. This document should be the basis of future task forces to develop a more comprehensive consensus considering new evidence uncovered during the COVID-19 pandemic.

A Novel 3-Dimensional Approach for the Echocardiographic Evaluation of Mitral Valve Area After Repair for Degenerative Disease.

BACKGROUND: Currently available 2-dimensional (2D) echocardiographic methods for accurately assessing the mitral valve orifice area (MVA) after mitral valve repair (MVr) are limited due to its complex 3-dimensional (3D) geometry. We compared repaired MVAs obtained with commonly used 2D and 3D echocardiographic methods to a 3D orifice area (3DOA), which is a novel echocardiographic measurement and independent of geometric assumptions. METHODS: Intraoperative 2D and 3D transesophageal echocardiography (TEE) images from 20 adult cardiac surgery patients who underwent MVr for mitral regurgitation obtained immediately after repair were retrospectively reviewed. MVAs obtained by pressure half-time (PHT), 2D planimetry (2DP), and 3D planimetry (3DP) were compared to those derived by 3DOA. RESULTS: MVAs (mean value ± standard deviation [SD]) after MVr were obtained by PHT (3 ± 0.6 cm), 2DP (3.58 ± 0.75 cm), 3D planimetry (3DP; 2.78 ± 0.74 cm), and 3DOA (2.32 ± 0.76 cm). MVAs obtained by the 3DOA method were significantly smaller compared to those obtained by PHT (mean difference, 0.68 cm; P = .0003), 2DP (mean difference, 1.26 cm; P < .0001), and 3DP (mean difference, 0.46 cm; P = .003). In addition, MVA defined as an area ≤1.5 cm was identified by 3DOA in 2 patients and by 3DP in 1 patient. CONCLUSIONS: Post-MVr MVAs obtained using the novel 3DOA method were significantly smaller than those obtained by conventional echocardiographic methods and may be consistent with a higher incidence of MVA reduction when compared to 2D techniques. Further studies are still needed to establish the clinical significance of 3D echocardiographic techniques used to measure MVA after MVr.

Intraoperative Hemodynamic and Echocardiographic Measurements Associated With Severe Right Ventricular Failure After Left Ventricular Assist Device Implantation.

BACKGROUND: Severe right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation increases morbidity and mortality. We investigated the association between intraoperative right heart hemodynamic data, echocardiographic parameters, and severe versus nonsevere RVF. METHODS: A review of LVAD patients between March 2013 and March 2016 was performed. Severe RVF was defined by the need for a right ventricular mechanical support device, inotropic, and/or inhaled pulmonary vasodilator requirements for >14 days. From a chart review, the right ventricular failure risk score was calculated and right heart hemodynamic data were collected. Pulmonary artery pulsatility index (PAPi) [(pulmonary artery systolic pressure - pulmonary artery diastolic pressure)/central venous pressure (CVP)] was calculated for 2 periods: (1) 30 minutes before cardiopulmonary bypass (CPB) and (2) after chest closure. Echocardiographic data were recorded pre-CPB and post-CPB by a blinded reviewer. Univariate logistic regression models were used to examine the performance of hemodynamic and echocardiographic metrics. RESULTS: A total of 110 LVAD patients were identified. Twenty-five did not meet criteria for RVF. Of the remaining 85 patients, 28 (33%) met criteria for severe RVF. Hemodynamic factors associated with severe RVF included: higher CVP values after chest closure (18 ± 9 vs 13 ± 5 mm Hg; P = .0008) in addition to lower PAPi pre-CPB (1.2 ± 0.6 vs 1.7 ± 1.0; P = .04) and after chest closure (0.9 ± 0.5 vs 1.5 ± 0.8; P = .0008). Post-CPB echocardiographic findings associated with severe RVF included: larger right atrial diameter major axis (5.4 ± 0.9 vs 4.9 ± 1.0 cm; P = .03), larger right ventricle end-systolic area (22.6 ± 8.4 vs 18.5 ± 7.9 cm; P = .03), lower fractional area of change (20.2 ± 10.8 vs 25.9 ± 12.6; P = .04), and lower tricuspid annular plane systolic excursion (0.9 ± 0.2 vs 1.1 ± 0.3 cm; P = .008). Right ventricular failure risk score was not a significant predictor of severe RVF. Post-chest closure CVP and post-chest closure PAPi discriminated severe from nonsevere RVF better than other variables measured, each with an area under the curve of 0.75 (95% CI, 0.64-0.86). CONCLUSIONS: Post-chest closure values of CVP and PAPi were significantly associated with severe RVF. Echocardiographic assessment of RV function post-CPB was weakly associated with severe RVF.

Joint analysis of left ventricular expression and circulating plasma levels of Omentin after myocardial ischemia.

BACKGROUND: Omentin-1, also known as Intelectin-1 (ITLN1), is an adipokine with plasma levels associated with diabetes, obesity, and coronary artery disease. Recent studies suggest that ITLN1 can mitigate myocardial ischemic injury but the expression of ITLN1 in the heart itself has not been well characterized. The purpose of this study is to discern the relationship between the expression pattern of ITLN1 RNA in the human heart and the level of circulating ITLN1 protein in plasma from the same patients following myocardial ischemia. METHODS: A large cohort of patients (n = 140) undergoing elective cardiac surgery for aortic valve replacement were enrolled in this study. Plasma and left ventricular biopsy samples were taken at the beginning of cardiopulmonary bypass and after an average of 82 min of ischemic cross clamp time. The localization of ITLN1 in epicardial adipose tissue (EAT) was also further characterized with immunoassays and cell fate transition studies. RESULTS: mRNA expression of ITLN1 decreases in left ventricular tissue after acute ischemia in human patients (mean difference 280.48, p = 0.001) whereas plasma protein levels of ITLN1 increase (mean difference 5.24, p < 0.001). Immunohistochemistry localized ITLN1 to the mesothelium or visceral pericardium of EAT. Epithelial to mesenchymal transition in mesothelial cells leads to a downregulation of ITLN1 expression. CONCLUSIONS: Myocardial injury leads to a decrease in ITLN1 expression in the heart and a corresponding increase in plasma levels. These changes may in part be due to an epithelial to mesenchymal transition of the cells that express ITLN1 following ischemia. Trial Registration Clinicaltrials.gov ID: NCT00985049.

Echocardiographic Assessment of Mitral Stenosis Orifice Area: A Comparison of a Novel Three-Dimensional Method Versus Conventional Techniques.

BACKGROUND: A comprehensive evaluation of mitral stenosis (MS) severity commonly utilizes two-dimensional (2D) echocardiography techniques. However, the complex three-dimensional (3D) structure of the mitral valve (MV) poses challenges to accurate measurements of its orifice area by 2D imaging modalities. We aimed to assess MS severity by comparing measurements of the MV orifice area using conventional echocardiography methods to 3D orifice area (3DOA), a novel echocardiographic technique which minimizes geometric assumptions. METHODS: Routine 2D and 3D intraoperative transesophageal echocardiographic images from 26 adult cardiac surgery patients with at least moderate rheumatic MS were retrospectively reviewed. Measurements of the MV orifice area obtained by pressure half-time (PHT), proximal isovelocity surface area (PISA), continuity equation, and 3D planimetry were compared to those acquired using 3DOA. RESULTS: MV areas derived by PHT, PISA, continuity equation, 3D planimetry, and 3DOA (mean value ± standard deviation) were 1.12 ± 0.27, 1.03 ± 0.27, 1.16 ± 0.35, 0.97 ± 0.25, and 0.76 ± 0.21 cm, respectively. Areas obtained from the 3DOA method were significantly smaller than areas derived from PHT (mean difference 0.35 cm, P < .0001), PISA (mean difference: 0.28 cm, P = .0002), continuity equation (mean difference: 0.43 cm, P = .0015), and 3D planimetry (mean difference: 0.19 cm, P < .0001). MV 3DOAs also identified a significantly greater percentage of patients with severe MS (88%) compared to PHT (31%, P = .006), PISA (42%, P = .01), and continuity equation (39%, P = .017) but not in comparison to 3D planimetry (62%, P = .165). CONCLUSIONS: Novel measures of the stenotic MV 3DOA in patients with rheumatic heart disease are significantly smaller than calculated values obtained by conventional methods and may be consistent with a higher incidence of severe MS compared to 2D techniques. Further investigation is warranted to determine the clinical relevance of 3D echocardiographic techniques used to measure MV area.

Length Polymorphisms in Heme Oxygenase-1 and AKI after Cardiac Surgery.

Heme oxygenase-1 (HO-1) catalyzes the degradation of heme, which may be involved in the pathogenesis of AKI. Length polymorphisms in the number of GT dinucleotide repeats in the HO-1 gene (HMOX1) promoter inversely associate with HMOX1 mRNA expression. We analyzed the association between allelic frequencies of GT repeats in the HMOX1 gene promoter and postoperative AKI in 2377 white patients who underwent cardiac surgery with cardiopulmonary bypass. We categorized patients as having the short allele (S; <27 GT repeats) or long allele (L; ≥27 GT repeats), and defined AKI as an increase in serum creatinine ≥0.3 mg/dl within 48 hours or ≥50% within 5 days, or the need for RRT. Compared with patients with the SS genotype, patients with the LL genotype had 1.58-fold (95% confidence interval, 1.06 to 2.34; P=0.02) higher odds of AKI. After adjusting for baseline and operative characteristics, the odds ratio for AKI per L allele was 1.26 (95% confidence interval, 1.05 to 1.50; P=0.01). In conclusion, longer GT repeats in the HMOX1 gene promoter associate with increased risk of AKI after cardiac surgery, consistent with heme toxicity as a pathogenic feature of cardiac surgery-associated AKI, and with HO-1 as a potential therapeutic target.

The Mechanism of Mitral Regurgitation Influences the Temporal Dynamics of the Vena Contracta Area as Measured with Color Flow Doppler.

BACKGROUND: In patients with mitral regurgitation (MR), the effective regurgitant orifice area can be estimated by measuring the vena contracta area (VCA). We hypothesize that the VCA has characteristic temporal dynamics related to the underlying mechanism of functional mitral regurgitation (FMR) versus degenerative mitral valve disease (DMVD). METHODS: VCA measurements obtained by planimetry of the proximal jet from 3D transesophageal echocardiographic (TEE) color flow Doppler data sets were acquired in 42 cardiac surgical patients, including 22 with FMR and 20 with DMVD. Serial VCAs were measured throughout systole for each patient to evaluate variation in the effective regurgitant orifice area. Tercile averages were compared within and between the FMR and DMVD groups using repeated measures analysis of variance. Pairwise tests were Bonferroni-corrected for the number of comparisons. RESULTS: Normalized average VCA values in patients with FMR revealed a biphasic pattern compared with a monophasic pattern in patients with DMVD. Among FMR patients, normalized average VCA values in early (1.10 ± 0.32 cm2) and late systole (1.11 ± 0.33 cm2) were similar but were both significantly greater compared with mid-systole (0.79 ± 0.22 cm; P = 0.0144 and P = 0.0106, respectively). Among DMVD patients, normalized average VCA values in mid-systole (1.37 ± 0.15 cm2) were significantly greater than those in early (0.53 ± 0.14 cm2) and late systole (1.09 ± 0.18 cm2; P < 0.0001 for both). An analysis of normalized average VCAs also revealed significant differences between the FMR and the DMVD groups during early (1.10 ± 0.32 cm vs 0.53 ± 0.14 cm2) and mid-systole (0.79 ± 0.22 cm2 vs 1.37 ± 0.15 cm2; P < 0.0001 for both). CONCLUSIONS: VCA dynamics are governed by the mechanism of MR and are observed in FMR patients primarily as a biphasic temporal pattern compared with a monophasic temporal pattern in patients with DMVD.

Integrated microRNA and mRNA responses to acute human left ventricular ischemia.

MicroRNAs (miRNAs) play a significant role in ischemic heart disease. Animal models of left ventricular (LV) ischemia demonstrate a unique miRNA profile; however, these models have limitations in describing human disease. In this study, we performed next-generation miRNA and mRNA sequencing on LV tissue from nine patients undergoing cardiac surgery with cardiopulmonary bypass and cardioplegic arrest. Samples were obtained immediately after aortic cross clamping (baseline) and before aortic cross clamp removal (postischemic). Of 1,237 identified miRNAs, 21 were differentially expressed between baseline and postischemic LV samples including the upregulated miRNAs miR-339-5p and miR-483-3p and the downregulated miRNA miR-139-5p. Target prediction analysis of these miRNAs was integrated with mRNA expression from the same LV samples to identify anticorrelated miRNA-mRNA pairs. Gene enrichment studies of candidate mRNA targets demonstrated an association with cardiovascular disease, cell death, and metabolism. Therapeutics that intervene on these miRNAs and their downstream targets may lead to novel mechanisms of mitigating the damage caused by ischemic insults on the human heart.

Using next-generation RNA sequencing to examine ischemic changes induced by cold blood cardioplegia on the human left ventricular myocardium transcriptome.

BACKGROUND: The exact mechanisms that underlie the pathological processes of myocardial ischemia in humans are unclear. Cardiopulmonary bypass with cardioplegic arrest allows the authors to examine the whole transcriptional profile of human left ventricular myocardium at baseline and after exposure to cold cardioplegia-induced ischemia as a human ischemia model. METHODS: The authors obtained biopsies from 45 patients undergoing aortic valve replacement surgery at baseline and after an average of 79 min of cold cardioplegic arrest. Samples were RNA sequenced and analyzed with the Partek Genomics Suite (Partek Inc., St. Louis, MO) for differential expression. Ingenuity Pathway Analysis (Ingenuity Systems, Redwood City, CA) and Biobase ExPlain (Biobase GmbH, Wolfenbuettel, Germany) systems were used for functional and pathway analyses. RESULTS: Of the 4,098 genes with a mean expression value greater than 5, 90% were down-regulated and 9.1% were up-regulated. Of those, 1,241 were significantly differentially expressed. Gene ontology analysis revealed significant down-regulation in immune inflammatory response and complement activation categories and highly consistent was the down-regulation of intelectin 1, proteoglycan, and secretory leukocyte peptidase inhibitor. Up-regulated genes of interest were FBJ murine osteosarcoma viral oncogene homolog and the hemoglobin genes hemoglobin α1 (HBA1) and hemoglobin ß. In addition, analysis of transcription factor-binding sites revealed interesting targets in factors regulating reactive oxygen species production, apoptosis, immunity, cytokine production, and inflammatory response. CONCLUSIONS: The authors have shown that the human left ventricle exhibits significant changes in gene expression in response to cold cardioplegia-induced ischemia during cardiopulmonary bypass, which provides great insight into the pathophysiology of ventricular ischemia, and thus, may help guide efforts to reduce myocardial damage during surgery.

Genetic Variants Associated With Atrial Fibrillation and PR Interval Following Cardiac Surgery.

OBJECTIVE: The authors hypothesized that genetic association between atrial fibrillation (AF)-associated and PR-associated genetic loci was biologically mediated through slower conduction velocities for some or all of these loci. DESIGN: Prospectively collected cohort study. SETTING: Single tertiary care university hospital. PARTICIPANTS: A total of 1227 Caucasian patients who underwent coronary artery bypass grafting (CABG). INTERVENTIONS: A total of 677 single nucleotide polymorphisms previously associated with ambulatory AF or PR interval were tested for association with postoperative atrial fibrillation (poAF) and preoperative PR interval, maximum PR interval, maximum change in PR interval, and maximum change in PR interval from preoperative PR interval. MEASUREMENTS AND MAIN RESULTS: The incidence of new-onset poAF was 31%. All of the PR interval variables were longer in the poAF cohort. Two variants on 1q21 and 12 on 4q25 were associated with poAF after adjustment for false discovery rate (FDR), but no variants were associated with PR interval variables after adjustment for FDR. Several variants were associated with both poAF and PR interval variables at p<0.05, but none of them remained significant after adjusting for FDR. CONCLUSION: It was found that patients with poAF have significantly longer PR interval. Genetic variants in both the 1q21 and 4q25 regions associate with poAF after CABG surgery, but the authors were unable to find association between these variants and PR interval after adjusting for FDR.

Plasma corin decreases after coronary artery bypass graft surgery and is associated with postoperative heart failure: a pilot study.

OBJECTIVE: Corin is a natriuretic peptide-converting enzyme that cleaves precursor pro-B-type natriuretic peptide to active B-type natriuretic peptide (BNP) (diuretic, natriuretic, and vasodilatory properties). Increased plasma BNP is a known diagnostic and prognostic heart failure (HF) biomarker in ambulatory and surgical patients. Recent studies indicate that plasma corin is decreased significantly in chronic HF patients, yet perioperative plasma corin concentrations have not been assessed in cardiac surgical patients. The objectives of this study were to determine the effect of coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) on plasma corin concentrations and to assess the association between change in perioperative plasma corin concentration and long-term postoperative HF hospitalization or death. It was hypothesized that plasma corin concentrations decrease significantly from preoperative baseline during postoperative days 1 to 4 and that hospitalization or death from HF during the 5 years after surgery is associated with higher relative difference (preoperative baseline to postoperative nadir) in plasma corin concentrations. DESIGN: Prospective observational pilot study. SETTING: Two institutions: Brigham and Women's Hospital, Boston, Massachusetts and the Texas Heart Institute, St. Luke's Hospital, Houston, Texas. PARTICIPANTS: 99 patients of European ancestry who underwent isolated primary CABG surgery with CPB. INTERVENTIONS: Nonemergency isolated primary CABG surgery with CPB. MEASUREMENTS AND MAIN RESULTS: Plasma corin concentration was assessed preoperatively and at 4 postoperative time points (postoperative days 1-4). HF hospitalization or HF death events during the 5 years after surgery were identified by review of hospital and death records. Postoperative plasma corin concentrations were significantly lower than preoperative baseline concentrations (p<0.0001). Perioperative corin concentrations were significantly higher in males than in females (p<0.0001). Fifteen patients experienced long-term postoperative HF events. Patients who experienced HF hospitalization or HF death during study follow-up had significantly higher relative difference in plasma corin concentration (preoperative baseline to postoperative nadir) than patients who did not experience HF events during study follow-up (p=0.03). CONCLUSIONS: Plasma corin concentrations decrease significantly from preoperative concentrations after CABG surgery. HF hospitalization or HF death during the 5 years after CABG surgery with CPB is associated with larger relative decrease in plasma corin concentration from preoperative baseline. Further investigation is warranted to determine the role of corin in postoperative HF biology.

GNAS gene variants affect ß-blocker-related survival after coronary artery bypass grafting.

BACKGROUND: Cardiac overexpression of the ß-adrenoreceptor (ßAR)-coupled stimulatory G-protein subunit Gαs enhances inotropic responses to adrenergic stimulation and improves survival in mice under ßAR blockade. The authors recently identified three common haplotypes in the GNAS gene encoding Gαs, with the greatest Gαs protein expression and signal transduction in haplotype *3 carriers and less in haplotype *2 and *1 carriers. The authors tested the hypothesis that these GNAS variants result in altered mortality in patients after coronary artery bypass graft surgery, particularly in those receiving ßAR blockade. METHODS: This prospective analysis included 1,627 European ancestry patients undergoing primary coronary artery bypass graft surgery. Patients were genotyped for two GNAS haplotype tagging single-nucleotide polymorphisms defining three major haplotypes. Up to 5-yr all-cause mortality was estimated using a Cox proportional hazard model; hazard ratios and 95% CIs were calculated while adjusting for demographics, clinical covariates, and the new EuroSCORE II. RESULTS: Univariate analysis revealed haplotype-dependent 5-yr mortality rates (*1/*1: 18.9%, *2/*1: 13.7%, *2/*2: 9.3%, *3/*1: 10.6%, *3/*2: 9.1%, and *3/*3: 9.6%; P = 0.0006). After adjustment for other predictors of death, homozygote haplotype *1 carriers showed a doubled risk for death (hazard ratio, 2.2; 95% CI, 1.2 to 3.8; P = 0.006). Considering only patients receiving ßAR blockers (n = 1,267), the adjusted risk of death even tripled (hazard ratio, 3.0; 95% CI, 1.5 to 6.1; P = 0.002). CONCLUSIONS: GNAS haplotypes independently associate with an increased risk of death after primary coronary artery bypass graft surgery. These results are most pronounced in patients receiving ßAR blockers, strengthening the rationale for personalized treatment, to decrease medication side effects and improve outcomes.

Echocardiographic evaluation of mitral inflow hemodynamics after asymmetric double-orifice repair.

BACKGROUND: A comprehensive transesophageal echocardiographic (TEE) examination is essential for the evaluation of a mitral valve (MV) repair. The edge-to-edge MV repair (i.e., Alfieri stitch) can pose a unique challenge in assessing iatrogenic mitral stenosis, especially when an asymmetric double-orifice is created. The reliability of the simplified Bernoulli equation for evaluating transvalvular pressure gradients across an asymmetric Alfieri MV repair remains controversial. We sought to evaluate the reliability of this principle further by comparing TEE-acquired pressure gradients across each orifice in patients undergoing asymmetric, double-orifice repair. METHODS: Routinely collected intraoperative, 2-dimensional and 3-dimensional TEE datasets acquired from 15 patients undergoing double-orifice MV repair were retrospectively reviewed and analyzed. Planimetered anterior lateral (AL) and posterior medial (PM) orifice areas were acquired from 3-dimensional TEE full volume datasets, by cropping the image to develop a short-axis view at the narrowest diastolic orifice cross-sectional area at the MV leaflet tips. Transmitral Doppler flow velocity values were measured through the AL and PM orifices. Peak and mean pressure gradients were calculated from the simplified Bernoulli equation at both orifices and were compared to each respective orifice for each patient. RESULTS: The mean difference between the AL and PM orifice areas for each patient was statistically significant (0.72 ± 0.40 cm(2), P < 0.0001). The mean differences between the AL and PM parameters were also significant for peak velocity: 0.15 m/s, SD: 0.08, P < 0.0001; peak pressure gradients: 1.76 mm Hg, SD: 1.42, P < 0.0001; and mean pressure gradient: 1.04 mm Hg, SD: 0.93, P < 0.0001. CONCLUSIONS: The echocardiographic assessment of MV dysfunction after an Alfieri repair is important. Although the differences that we demonstrated between orifice areas and maximum velocities across the asymmetric orifices after a double-orifice MV repair are statistically significant, the corresponding difference in mean transorifice pressure gradient is not clinically relevant. Thus, either orifice can be interrogated with Doppler echocardiography for the determination of pressure gradients after double-orifice MV repair.

Multinational institutional survey on patterns of intraoperative transesophageal echocardiography use in adult cardiac surgery.

OBJECTIVES: To assess institutional patterns of perioperative transesophageal echocardiography (TEE) usage. DESIGN: The authors hypothesized that TEE is performed more frequently and comprehensively in academic centers, mainly by anesthesiologists, and barriers to performing TEE are due to inadequate resources. A survey was deployed to selected participants. Collated responses were assessed for demographic patterns in TEE practice, and 2-category comparisons were made with Chi-squared association tests. SETTING: Web-based survey. PARTICIPANTS: Practitioners in cardiovascular anesthesia/surgery in 200 institutions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Surveys were completed by respondents representing 200 centers in 27 countries and 1,727 anesthesiologists with a mean annual institutional volume of 924 cases. Most centers were in the USA (53%) and were defined as academic (83%). Anesthesiologists performed (85%) and also read/reported TEEs (78%) in most centers. Three-dimensional TEE is performed routinely at 40% of centers. TEE is used routinely for valve surgery in 95% of institutions compared to 68% for coronary artery bypass graft surgery. Academic institutions assessed diastolic function more often than nonacademic centers (46% v 19%; p = 0.006). The most important reason cited for not using TEE in all cases was insufficient resource availability (47%). CONCLUSIONS: These results suggest that TEE is performed more comprehensively in academic centers, mainly by anesthesiologists, and that lack of resources is a significant barrier to routine TEE usage. TEE is used more often for valve surgery than for coronary artery bypass graft surgery, and many centers use 3D TEE. This survey describes international TEE practice patterns and identifies limitations to universal adoption of TEE in cardiac surgery.