The Year in Perioperative Echocardiography: Selected Highlights from 2018.

This article is the third of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

The use of the Doppler pulmonary artery velocity time integral to optimize placement of a ventricular pacing lead in a patient with Ebstein's anomaly.

Ebstein's anomaly is a rare congenital heart defect. Patients with severe symptomatic tricuspid regurgitation requiring surgical correction often have conduction system disease. We present a case of a 14 year-old girl with Ebstein's malformation and bioprosthetic tricuspid valve who required permanent pacing for symptomatic bradycardia. The placement of the right ventricular pacing lead was facilitated by the use of the Doppler pulmonary artery velocity time integral as a surrogate for stroke volume. This case demonstrates the importance of site-specific pacing and the utility of Doppler echocardiography to optimize lead placement and cardiac performance in patients with Ebstein's anomaly and advanced conduction system disease.

AIDS associated with severe cor pulmonale and large pericardial effusion with cardiac tamponade.

Cardiac involvement in patients with advanced HIV/AIDS is common, including pericardial effusion and pulmonary hypertension. Although there is an increased incidence of pericardial effusion in patients with AIDS, most are small and asymptomatic. The presence of a pericardial effusion and/or pulmonary hypertension is associated with shortened survival. We present a case of a 43-year-old man with AIDS and advanced cardiovascular involvement who developed severe cor pulmonale and a large pericardial effusion with cardiac tamponade.

Remote second-hand tobacco exposure in flight attendants is associated with systemic but not pulmonary hypertension.

BACKGROUND: Second-hand tobacco smoke has been associated with cardiopulmonary dysfunction. We sought to examine the residual effects of remote second-hand smoke exposure on resting and exercise cardiopulmonary hemodynamics. We hypothesized that remote secondhand smoke exposure results in persistent cardiopulmonary hemodynamic abnormalities. METHODS: Participants were non-smoking flight attendants who worked in airline cabins prior to the in-flight tobacco ban. Participants underwent clinical evaluations and completed smoke exposure questionnaires. We used Doppler echocardiography to measure pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance (PVR) at rest and during supine bicycle ergometer exercise, using the validated formula TRV/VTIRVOT x 10 + 0.16, where VTIRVOT is the velocity time integral at the right ventricular outflow tract and TRV is the tricuspid regurgitation velocity. The group was divided into quartiles according to the degree of smoke exposure. Analysis of variance was used to determine the differences in hemodynamic outcomes. RESULTS: Seventy-nine flight attendants were included in our analysis. Baseline characteristics among participants in each quartile of smoke exposure were similar except for history of systemic hypertension, which was more prevalent in the highest quartile. Peak exercise PASP rose to the same degree in all test groups (mean PASP 44 mm Hg, p = 0.25), and PVR increased by approximately 27% in all quartiles. There was no significant difference in pulmonary artery systolic pressure or pulmonary vascular resistance among quartiles of smoke exposure. CONCLUSIONS: We found that remote heavy second-hand smoke exposure from in-flight tobacco is associated with systemic hypertension but does not have demonstrable pulmonary hemodynamic consequences.

Peripheral Bronchial Carcinoid Tumor Presenting as a Right Cardiophrenic Angle Mass.

A 50-year-old woman presented for evaluation of an enlarging right cardiophrenic angle mass. Two years prior she complained of intermittent nausea, diarrhea, and flushing. Initial chest radiography and computed tomography (CT) suggested a pericardial cyst. Due to the onset of increasing dyspnea on exertion, lower extremity edema, and weight gain repeat CT was performed revealing a solid tumor. An Indium-111 octreotide scan showed somatostatin activity limited to the pericardiac mass. Histology after resection confirmed the diagnosis of peripheral bronchial carcinoid. The traditional differential diagnosis for a right cardiophrenic angle mass was misleading in this patient.

Use of intracardiac echocardiography in guiding radiofrequency catheter ablation of atrial tachycardia in a patient after the senning operation.

A patient with D-transposition of the great arteries developed drug refractory atrial tachycardia 12 years after a Senning operation. Electrophysiological study confirmed the presence of atrial baffle-tricuspid valve isthmus dependent reentrant intraatrial tachycardia. Intracardiac echocardiography facilitated initial identification of structures, catheter positioning, and identification of the atrial baffle-tricuspid valve isthmus.