Intraoperative and Intraprocedural Use of 3-Dimensional Transesophageal Echocardiography: An International European Association of Cardiothoracic Anesthesia and Intensive Care Survey of Cardiac Surgical Centers.

OBJECTIVE: To assess the intraoperative use of 3-dimensional transesophageal echocardiography (3D TEE) in cardiac surgical centers, the authors created a survey aimed at evaluating the availability of equipment and the use of 3D TEE for specific surgical and interventional procedures and single-image modalities. The respondents were asked to identify the perceived impact on patient management and current limitations to its routine use. DESIGN: A multiple choice 25-question online survey submitted to the members of the European Association of Cardiothoracic Anesthesia and Intensive Care (EACTAIC) on December 6, 2021, and closed on January 31, 2022. SETTING: An online survey. PARTICIPANTS: Registered EACTAIC members in 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 239 respondents from 44 different countries took part in the survey (27% of the total 903 EACTAIC members). Most respondents (59%) were TEE-certified by the National Board of Echocardiography, European Association of Cardiovascular Imaging (EACVI/EACTAIC), or had a national certificate. Of the respondents, 68% had no formal 3D TEE training. Eight percent of respondents had no 3D machines, whereas 40% had one for each operating room, and 33% had only one for the entire operating room block. 3D TEE was performed most frequently in more than 67% of cases for mitral valve surgery, and in more than 54% of cases for mitral and tricuspid clips, aortic valve, tricuspid valve, and aortic surgery. CONCLUSION: Current guidelines suggest integrating 3D TEE into all comprehensive examinations. The authors' survey reported that intraoperative 3D TEE was used in the majority of mitral valve surgery and only one-half of the other valve surgeries and transcatheter procedures. Its use may be explained by the availability of 3D machines, trained personnel, and limited time to perform TEE in the operating room. Educational initiatives for training in 3D TEE may further increase its routine use.

Mortality in patients with normal left ventricular function requiring emergency VA-ECMO for postcardiotomy cardiogenic shock due to coronary malperfusion.

OBJECTIVES: To analyze outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to postcardiotomy cardiogenic shock (PCCS) related to coronary malperfusion. METHODS: Retrospective single-center analysis in patients with normal preoperative LVEF treated with VA-ECMO for coronary malperfusion-related PCCS between May 1998 and May 2018. The primary outcome was 30-day mortality, which was compared using the Kaplan-Meier method and the log-rank test. Multivariable logistic regression was performed to identify predictors of mortality. RESULTS: During the study period, a total of 62,125 patients underwent cardiac surgery at our institution. Amongst them, 59 patients (0.1%) with normal preoperative LVEF required VA-ECMO support due to coronary malperfusion-related PCCS. The mean duration of VA-ECMO support was 6 days (interquartile range 4-7 days). The 30-day mortality was 50.8%. Under VA-ECMO therapy, a complication composite outcome of bleeding, re-exploration for bleeding, acute renal failure, acute liver failure, and sepsis occurred in 51 (86.4%) patients. Independent predictors of 30-day mortality were lactate levels > 9.9 mmol/l before VA-ECMO implantation (odds ratio [OR]: 3.3; 95% confidence interval [CI] 1.5-7.0; p = 0.002), delay until revascularization > 278 minutes (OR: 2.9; 95% CI 1.3-6.4; p = 0.008) and peripheral arterial artery disease (OR: 3.3; 95% 1.6-7.5; p = 0.001). CONCLUSIONS: Mortality rates are high in patients with normal preoperative LVEF who develop PCCS due to coronary malperfusion. The early implantation of VA-ECMO before the development of profound tissue hypoxia and early coronary revascularization increases the likelihood of survival. Lactate levels are useful to define optimal timing for the VA-ECMO initiation.

Postoperative Weight Gain within Enhanced Recovery after Cardiac Surgery.

Optimal fluid therapy during perioperative care as part of enhanced recovery after cardiac surgery (ERACS) should improve the outcome. Our objective was finding out the effects of fluid overload on outcome and mortality within a well-established ERACS program. All consecutive patients undergoing cardiac surgery between January 2020 and December 2021 were enrolled. According to ROC curve analysis, a cut-off of ≥7 kg (group M, n = 1198) and <7 kg (group L, n = 1015) was defined. A moderate correlation was shown between weight gain and fluid balance r = 0.4, and a simple linear regression was significant p < 0.0001, R2 = 0.16. Propensity score matching showed that increased weight gain was associated with a longer hospital length of stay (LOS) (L 8 [3] d vs. M 9 [6] d, p < 0.0001), an increased number of patients who received pRBCs (L 311 (36%) vs. M 429 (50%), p < 0.0001), and a higher incidence of postoperative acute kidney injury (AKI) (L 84 (9.8%) vs. M 165 (19.2%), p < 0.0001). Weight gain can easily represent fluid overload. Fluid overload after cardiac surgery is common and is associated with prolonged hospital LOS and increases the incidence of AKI.

Incidence and outcomes of emergency intraprocedural surgical conversion during transcatheter aortic valve implantation: Insights from a large tertiary care centre.

OBJECTIVE: During a transcatheter aortic valve implant (TAVI) procedure, intraprocedural complications that are manageable only by conversion to emergency open-heart surgery (E-OHS) occasionally occur. Contemporary data on the incidence and outcome of TAVI patients undergoing E-OHS are scarce. This study aimed to evaluate early and midterm outcomes following E-OHS of patients undergoing TAVI in a large tertiary care centre with immediate surgical backup availability for all TAVI procedures over a 15-year period. METHODS: Data from all patients undergoing transfemoral TAVI between 2006 and 2020 at the Heart Centre Leipzig were analysed. The study time was divided into 3 periods: 2006-2010 (P1), 2011-2015 (P2) and 2016-2020 (P3). Patients were grouped according to their surgical risk (high risk: EuroSCORE II ≥ 6%; low/intermediate risk: EuroSCORE II <6%). Primary outcomes were intraprocedural and in-hospital death and 1-year survival. RESULTS: During the study period, a total of 6903 patients underwent transfemoral TAVI. Among them, 74 (1.1%) required E-OHS [high risk, n = 66 (89.2%); low/intermediate risk, n = 8 (10.8%)]. The rate of patients requiring E-OHS was 3.5% (20/577 patients), 1.8% (35/1967 patients) and 0.4% (19/4359 patients) in study periods P1 to P3, respectively (P < 0.001). The proportion of patients who had E-OHS who were low/intermediate risk increased considerably over time (P1:0%; P28.6%; P3:26.3%; P = 0.077). Intraprocedural deaths occurred in 10 patients (13.5%), all of whom were high-risk. In-hospital mortality was 62.1% in high-risk patients and 12.5% in low/intermediate risk patients (P = 0.007). One-year survival was 37.8% in all patients undergoing E-OHS, 31.8% in high-risk patients and 87.5% in low/intermediate risk patients (log-rank P = 0.002). CONCLUSIONS: In-hospital and 1-year survival rates following E-OHS are higher in low/intermediate risk than in high-risk patients undergoing TAVI. An on-site cardiac surgical department with immediately available E-OHS capabilities is an important component of the TAVI team.

Impact of a one-day three-dimensional transesophageal echocardiography workshop on clinical practice at a single academic centre.

Background: Transesophageal echocardiography (TEE) is a powerful diagnostic tool which has become an integral part in the management of cardiac surgery patients. We developed a one-day 3D TEE workshop specifically designed to meet the needs of perioperative cardiac anaesthesiologists. We hypothesized that participation in the workshop would increase the uptake of 3D TEE in routine perioperative practice. Aims: To examine the impact of one-day 3D TEE workshop on 3D TEE image acquisition and incorporation into routine perioperative practice. Setting: Tertiary care hospital. Design: Prospective observational monocentric study. Subjects and Methods: A convenience sample of 20 cardiac anesthesiologists (with an option to attend the one- day workshop midway through the study) from a single center consented to have their intraoperative TEE images collected during the course of the study reviewed for research purposes. Images acquired 6 months before, immediately after, and 6 months following the workshop and images were examined by a blinded, expert echocardiographer. Results: Data collected for 16 participants (8 workshop attendees, 8 non-attendees) indicate that the TEE workshop increased the number of 3D TEE images, but not x images acquired immediately following the workshop (P=0.006). No difference was observed in number of 3D images at six months' post workshop. Workshop participants obtained more 3D and multi-plane images after the workshop and more 3D images at 6 months compared to those who did not attend the workshop. Conclusion: Our study suggests that a single day hands-on 3D TEE workshop may have had an impact on the implementation of intraoperative 3D TEE in experienced echocardiographers.

Preintervention imaging and intraoperative management care of the hypertrophic obstructive cardiomyopathy patient.

With an estimated overall mortality of less than 1 percent per year, hypertrophic cardiomyopathy, is the most common genetic cardiomyopathy. Intraoperative transesophageal echocardiography is the standard of care for assessing patients with hypertrophic obstructive cardiomyopathy undergoing surgical septal myectomy, allowing surgical planning, intraoperative hemodynamic monitoring, and postprocedural assessment of the repair, including detection of immediate complications. At various phases during surgical septal myectomy, the changing hemodynamic conditions may lead to worsening or improvement in left ventricle outflow tract obstruction by change in preload or afterload, systolic anterior motion of the mitral valve, or sympathetic stimulation. These characteristics represent unique challenges in the management of these patients, requiring a comprehensive understanding of the management of all the conditions required to decrease the left ventricle outflow tract gradient avoiding obstruction, which include the maintenance of sinus rhythm, adequate rate avoiding tachycardia and bradycardia, and avoidance of systemic hypotension preserving preload and afterload, with adequate vasoactive agents. The aim of this review is to summarize the perioperative assessment and management of patients undergoing hypertrophic obstructive myopathy surgery.

Interventions Triggered During Routine Use of NIRS Cerebral Oxygenation Monitoring in Cardiac Surgical Patients.

OBJECTIVE: The purpose of this study was to determine the incidence and types of interventions triggered during a drop of baseline near-infraredspectroscopy (NIRS) values in consecutive cardiac surgical patients. DESIGN: A single-center, retrospective observational study. SETTING: A university-affiliated tertiary care center. PARTICIPANTS: Three thousand three hundred two consecutive cardiac surgical patients from October 2016 to August 2017 Interventions: None. MEASUREMENTS AND MAIN RESULTS: Of the 1,972 patients who met the inclusion criteria, 576 (29.2%) patients showed NIRS deviation of -20% from baseline. Interventions performed during the drop of baseline NIRS values were documented in 285 (14.4%) patients, with a total of 391 interventions. Three hundred fifteen (80%) interventions were triggered by a deviation in NIRS and concomitant changes in standard monitoring parameters. Seventy-six (20%) interventions were triggered by NIRS deviation alone, with no concomitant pathologic deviation in standard monitoring. A total of 279 (71%) interventions were performed on patients who had no recommendation for NIRS monitoring by current national guidelines. Out of these, 30 (7.7%) interventions (1.3% of all patients) were performed based on NIRS monitoring alone. The higher risk deviation group had longer intensive care unit and hospital lengths of stays (one and 15 days) and postoperative delirium when compared with the no-deviation group (zero and 13 days) Conclusions: The authors' data suggested that most interventions triggered during the drop of baseline values during routine use of NIRS would have also been triggered by the concomitant changes in standard monitoring parameters. Routine use of NIRS for all cardiac surgical patients still is debatable and needs to be evaluated in a large prospective trial.

Persistent and acute postoperative pain after cardiac surgery with anterolateral thoracotomy or median sternotomy: A prospective observational study.

OBJECTIVE: The primary objective of this study was to compare the association between cardiac surgical approach (thoracotomy vs. sternotomy) and incidence of persistent postoperative pain at 3 months. Secondary objectives were the incidence and intensity of persistent pain at 6 and 12 months, acute postoperative pain, analgesic requirement and its side effects. DESIGN: Single-center, prospective, observational study. Recruitment between December 2017 and August 2018. SETTING: Perioperative care at university-affiliated tertiary care centre. PATIENTS: 202 adults scheduled for cardiac surgery. Patients with chronic pain or behavioural disorder were excluded. INTERVENTIONS: Thoracotomy (n = 106) and sternotomy (n = 96). MEASUREMENTS: Pain scores and pain medication requirements from extubation until hospital discharge. Persistent postoperative pain was assessed using a telephone questionnaire. MAIN RESULTS: Incidence and intensity of pain was not significantly different between thoracotomy or sternotomy either in the short- or in the long-term follow-up. Incidence of persistent postoperative pain showed no differences between groups (30.2 vs 22.9% at 3 months (p = 0.297), 10.4 vs 7.3% at 6 months (p = 0.364) and 7.5 vs 7.3% at 12 months (p = 0.518) in thoracotomy and sternotomy group). A significant decrease of pain incidence was observed between 3 and 6 months (p < 0.001) but not between 6 and 12 months (p = 0.259) in both groups. ANOVA of repeated measures adjusted for confounding variable showed a decrease of acute pain intensity over time (p = 0.001) with no difference between groups (p = 0.145). Acute pain medication requirements were not different between the groups (p = 0.237 for piritramide and p = 0.743 for oxycodone) with no difference in their side effects. CONCLUSIONS: Our study showed no difference in short- or long-term pain in patients undergoing anterolateral thoracotomy or median sternotomy. Both groups showed a decrease in persistent postoperative pain incidence between 3 and 6 months without any significant changes at 12 months.

A Comparison of Patients Undergoing On- vs. Off-Pump Coronary Artery Bypass Surgery Managed with a Fast-Track Protocol.

The purpose of this study was to compare patients who underwent on- vs. off-pump coronary artery bypass surgery managed with a fast-track protocol. Between September 2012 and December 2018, n = 3505 coronary artery bypass surgeries were managed with a fast-track protocol in our specialized post-anesthesia care unit. Propensity score matching was applied and resulted in two equal groups of n = 926. There was no significant difference in ventilation time (on-pump 75 (55-120) min vs. off-pump 80 (55-120) min, p = 0.973). We found no statistically significant difference in primary fast-track failure in on-pump (8.2% (76)) vs. off-pump (6% (56)) groups (p = 0.702). The secondary fast-track failure rate was comparable (on-pump 12.9% (110) vs. off-pump 12.3% (107), p = 0.702). There were no significant differences between groups in regard to the post-anesthesia care unit, the intermediate care unit, and the hospital length of stay. Postoperative outcome and complications were also comparable, except for a statistically significant difference in PACU postoperative blood loss in on-pump (234 mL) vs. off-pump (323 mL, p < 0.0001) and red blood cell transfusion (11%) and (5%, p < 0.001), respectively. Our results suggest that on- and off-pump coronary artery bypass surgery in fast-track settings are comparable in terms of ventilation time, fast-track failure rate, and postoperative complications rate.

Preoperative management of anticoagulation in the surgical patient: Highlights of the latest guidelines.

Oral anticoagulants (OACs) are a class of medications commonly used in the long-term management of patients at risk of thrombosis. They include warfarin and direct oral anticoagulants (DOACs). The aging of the population and improvements in perioperative care have led to an increase in the number of patients on OACs and presenting for different types of elective and emergency surgery. Perioperative management of OACs constitutes a unique challenge. It is based on the quantification of a patient's individual hemorrhagic and thrombotic risk together with the intrinsic surgical bleeding risk. We reviewed current guidelines to define effective discontinuation of OACs, the need for bridging with different anticoagulants, and post-surgery OACs re-initiation. We also discussed the option for acute reversal of anticoagulation.

Immediate Impact of Prosthetic Graft Replacement of the Ascending Aorta on Circumferential Strain in the Descending Aorta.

OBJECTIVES: Prosthetic replacement of the ascending aorta (AA) can potentially modify energy propagation to the distal aorta and contribute to adverse aortic remodelling. This preliminary study employed intra-operative transoesophageal echocardiography (TOE) to assess the immediate impact of prosthetic graft replacement of the AA on circumferential strain in the descending aorta. METHODS: Intra-operative TOEs in patients undergoing AA graft replacement were analysed for circumferential strain, fractional area change (FAC), dimensions (end diastolic area [EDA], and end systolic area [ESA]) in the descending aorta immediately before and after graft replacement. Deformation was assessed via global peak circumferential aortic strain (CAS), together with pulse pressure corrected strain, time to peak strain (TTP), and aortic distensibility. RESULTS: Forty-five patients undergoing AA replacement with prosthetic graft (91% elective) were studied. Following grafting, descending thoracic aortic circumferential strain increased (6.3 ± 2.8% vs. 8.9 ± 3.4%, p = .001) paralleling distensibility (5.7 [3.7-8.6] 10-3 mmHg vs. 8.5 [6.4-12.4] 10-3 mmHg, p < .001). Despite slight increments in post graft left ventricular ejection fraction (LVEF) (52.3 ± 10.8% vs. 55.0 ± 11.9, p < .001), stroke volume was similar (p = .41), and magnitude of increased strain did not correlate with change in stroke volume (r = -.03, p = .86), LVEF (r = .18, p = .28), or pulse pressure (r = .28, p = .06). Descending aortic size (EDA 4 [2.7-4.6] cm2vs. 3.7 [2.5-5] cm2, p = .89; ESA 4.3 [3.2-5.3] cm2vs. 4.5 [3.3-5.8] cm2, p = .14) was similar pre- and post graft. In subgroup analysis, patients with cystic medial necrosis had a significantly higher post procedure CAS than patients with atherosclerotic aneurysms (9.7 ± 3.5% vs. 7.0 ± 2.3%, p = .03). CONCLUSIONS: Prosthetic graft replacement of the AA increases immediate aortic circumferential strain of the descending aorta, particularly in patients with cystic medial necrosis. Our findings suggest that grafts augment energy transfer to the distal aorta, a potential mechanism for progressive distal aortic dilation and/or dissection.

Eye Drops: Must-Knows for Anesthesiology and Perioperative Care.

Eye drops such as topical ß-blockers are widely used to treat glaucoma and other ocular diseases. We provide an overview of ophthalmic solutions, including ß-adrenergic receptor antagonists, for anesthesiologists and others involved in perioperative care. We summarize current evidence about systemic effects of topical ß-blockers and other commonly used ophthalmic agents such as parasympathomimetic eye drops, carbonic anhydrase inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), and emerging products such as combinations of multiple substances. We call for careful preoperative assessment and perioperative management of individuals using eye drops, especially critically ill patients, children, or those undergoing major surgery.

Validation of Quantitative 3-Dimensional Transesophageal Echocardiography Mitral Valve Analysis Using Stereoscopic Display.

OBJECTIVE: The use of 3-dimensional (3D) transesophageal echocardiography (TEE) in perioperative evaluation of the mitral valve (MV) is increasing progressively, including the use of 3D MV models for quantitative analysis. However, the use of 3D MV models in clinical practice still is limited by the need for specific training and the long time required for analysis. A new stereoscopic visualization tool (EchoPixel True 3D) allows virtual examination of anatomic structures in the clinical setting, but its accuracy and feasibility for intraoperative use is unknown. The aim of this study was to assess the feasibility of 3D holographic display and evaluate 3D quantitative measurements on a volumetric MV image using the EchoPixel system compared with the 3D MV model generated by QLAB Mitral Valve Navigation (MVN) software. DESIGN: This was a retrospective comparative study. SETTING: The study took place in a tertiary care center. PARTICIPANTS: A total of 40 patients, 20 with severe mitral regurgitation who underwent mitral valve repair and 20 controls with normal MV, were enrolled retrospectively. INTERVENTIONS: The 3D-TEE datasets of the MV were analyzed using a 3D MV model and stereoscopic display. The agreement of measurements, intraobserver and interobserver variability, and time for analysis were assessed. MEASUREMENTS AND MAIN RESULTS: Fair agreement between the 2 software systems was found for annular circumference and area in pathologic valves, but good agreement was reported for prolapse height and linear annular diameters. A higher agreement for all annular parameters and prolapse height was seen in normal valves. Excellent intraobserver and interobserver reliability was proved for the same parameters; time for analysis between the 2 methods in pathologic valves was substantially equivalent, although longer in pathologic valves when compared with normal MV using both tools. CONCLUSION: EchoPixel proved to be reliable to display 3D TEE datasets and accurate for direct linear measurement of both MV annular sizes and prolapse height compared to QLAB MVN software; it also carries a low interobserver and intraobserver variability for most measurements.

Aortic root changes before and after surgery for chronic aortic dilatation: A 3D echocardiographic study.

BACKGROUND: Quantitative 3D assessment of the aortic root may improve planning and success of aortic valve (AV)-sparing operations. AIMS: To use 3D transesophageal echocardiography (TEE) to assess the effect of chronic aortic dilatation on aortic root shape and aortic regurgitation (AR) severity and to examine the effects of AV-sparing operations. METHODS AND RESULTS: To determine the changes with chronic aortic dilatation, we studied 48 patients, 23 with aortic dilatation (Group 1 ≤ mild AR, n = 13; Group 2 ≥ moderate AR, n = 10) and 25 Controls. To determine the changes in AV-sparing operations, a subgroup of 15 patients were examined pre- and post surgery. 3D-TEE images were analyzed using multiplanar reconstruction (QLAB, Philips, Philips Medical Systems, Andover, MA, USA) to obtain aortic root areas, diameters, and lengths. We also calculated a novel parameter called total coaptation surface area (TCoapSA), which sums the contact surface area of all the AV cusps. Compared to Controls, Groups 1 and 2 had significantly larger aortic root areas, inter-commissural distances, and cusp heights. Compared to Group 1 and Controls, Group 2 had significantly smaller TCoapSA when adjusted for aortic annular area (P = 0.001) with shorter coaptation height (P < 0.001). In patients undergoing AV-sparing surgery, TCoapSA was significantly larger post surgery (P = 0.001) with greater coaptation height (P < 0.001) and smaller inter-commissural distances (P < 0.001). CONCLUSIONS: The aortic valve is a dynamic structure that remodels in response to aortic dilatation. Successful valve-sparing surgery corrects these changes. Quantitative modeling of the aortic valve and root could potentially improve the repair to the individual patients and modify outcomes.

In Situ Cold Perfusion of the Liver on Cardiopulmonary Bypass: Coagulopathy and Its Correction: A Case Report.

We report a case of profound coagulopathy after the dual insult of cold in-situ perfusion of the liver and cardiopulmonary bypass in a patient undergoing complex hepatobiliary and cardiovascular surgery. Management of this coagulopathy with conventional blood products was hindered by elevated venous pressures, thought to contribute to persistent bleeding and risked liver and right ventricular dysfunction, necessitating a change in strategy. Anesthesiologists should consider fluid-restrictive strategies to correct coagulopathy in combined liver and cardiac surgery.