Whose Voices Are Heard? Speaker Gender Representation at the Society of Cardiovascular Anesthesiologists Annual Meeting.

OBJECTIVE: Gender disparities in academic medicine continue to be prevalent despite significant advances in the number of women entering medicine over the last decades. The purpose of the present study was to investigate gender representation of speakers at Society of Cardiovascular Anesthesiologists (SCA) Annual Scientific Sessions meetings from 2015 to 2018. DESIGN: Observational study. SETTING: Internet analysis and cross-sectional survey. PARTICIPANTS: Speakers at the SCA Annual Scientific Sessions meetings from 2015 to 2018. INTERVENTIONS: Individual speakers in the main program, problem-based learning discussions, workshops, and fellow sessions were analyzed for speaker gender. Speakers' names, pronouns, institutional biographies, and accompanying images were matched with public online data and were used to identify gender. Gender data from the 2019 SCA Diversity Survey respondents were used to estimate gender of the SCA membership. MEASUREMENTS AND MAIN RESULTS: Between 2015 and 2018, the number of lectures given by women was 22% to 25%. A statistically significant difference was found in the expected versus observed proportion of women in speaking slots for all combined sessions (2015-2018; p = 0.0027, 0.0023, 0.0018, 0.025, respectively). There also was a statistically significant difference in the expected versus observed proportion of women in speaking slots in the main sessions (2015-2018; p ≤ 0.0001, 0.00069, 0.00019, 0.00019, respectively). For the workshops, problem-based learning discussions, and fellow sessions, no statistically significant difference was found in the observed versus expected proportion of women in speaker slots. CONCLUSIONS: Between 2015 and 2018, the majority of lectures at the SCA annual meetings were given by men, with women consistently giving 22% to 25% of individual lectures. When all sessions were combined, there was a statistically significant difference in the expected versus observed proportion of women in speaking slots.

Distinguished Service Awards in Anesthesiology Specialty Societies: Analysis of Gender Differences.

The authors queried 9 anesthesiology societies to examine Distinguished Service Award recipients over time by gender. Of the 211 total Distinguished Service Awards given by all 9 societies, women received 25 (11.8%). Comparing pre-2008 data to the most recent decade, there was no statistical difference in the number of women Distinguished Service Award recipients with 8.9% and 17.1% women Distinguished Service Award recipients, respectively (P = .076). Societies varied greatly in their women awardees, from 40% to 0% in the last decade. Low levels of awardees stand in contrast to the increasing number of women in the academic pipeline. The authors recommend that societies collect gender membership data and study their award processes from nomination to selection.

Right Atrial Inversion Mimicking Right Atrial Mass in the Setting of Cardiac Tamponade.

A 44-year-old woman was transferred to the authors' institution in cardiogenic shock secondary to a presumed viral myocarditis and subsequently was placed on venoarterial extracorporeal membrane oxygenation. Transthoracic echocardiography revealed a large right atrial mass of unknown etiology and moderate pericardial effusion. The patient was taken to the operating room for surgical removal of the right atrial mass. Intraoperative transesophageal echocardiography demonstrated cardiac tamponade with complete invagination of the right atrium. Surgical evacuation of the pericardial effusion reverted the right atrium, with no further evidence of the right atrial mass, and no mass was discovered after right atriotomy, indicating that the right atrial "mass" was likely the result of complete inversion of the right atrium in the setting of cardiac tamponade.

Perioperative transesophageal echocardiography for non-cardiac surgery.

PURPOSE: The use of transesophageal echocardiography (TEE) has evolved to include patients undergoing high-risk non-cardiac procedures and patients with significant cardiac disease undergoing non-cardiac surgery. Implementation of basic TEE education in training programs has increased across a broad spectrum of procedures in the perioperative arena. This paper describes the use of perioperative TEE in non-cardiac surgery and provides an overview of the basic TEE examination. PRINCIPAL FINDINGS: Perioperative TEE is used to monitor hemodynamic parameters in non-cardiac procedures where there is a high risk of hemodynamic instability. Its use extends to include moderate-risk procedures for patients with significant cardiac diseases such as low ejection fraction, hypertrophic cardiomyopathy, severe valve lesions, or congenital heart disease. Vascular procedures involving the aorta, blunt trauma, and liver transplantation are all examples of procedures that may benefit from TEE. Transesophageal echocardiography examination allows assessment of volume status, ventricular function, diagnosis of gross valvular pathology and pericardial tamponade, as well as close monitoring of cardiac output, response to therapy, and the impact of ongoing surgical manipulation. In patients with unexplained and unexpected hemodynamic instability, "rescue TEE" can be used to help identify the underlying cause. CONCLUSIONS: Perioperative TEE is emerging as a preferred tool to manage hemodynamics in high-risk procedures and in high-risk patients undergoing non-cardiac surgery. A rescue TEE examination protocol is a helpful approach for early identification of the etiology of hemodynamic instability.

Perioperative Care of the Obese Cardiac Surgical Patient.

Morbid obesity is associated with impairment of cardiovascular, pulmonary, gastrointestinal, and renal physiology with significant perioperative consequences and has been linked with higher morbidity and mortality after cardiac surgery. Cardiac surgery patients have a higher incidence of difficult airway and difficult laryngoscopy than general surgery patients do, and obesity is associated with difficult mask ventilation and direct laryngoscopy. Positioning injuries occur more frequently because obese patients are at greater risk of pressure injury, such as rhabdomyolysis and compartment syndrome. Despite the association between obesity and several chronic disease states, the effects of obesity on perioperative outcomes are conflicting. Studies examining outcomes of overweight and obese patients in cardiac surgery have reported varying results. An "obesity paradox" has been described, in which the mortality for overweight and obese patients is lower compared with patients of normal weight. This review describes the physiologic abnormalities and clinical implications of obesity in cardiac surgery and summarizes recommendations for anesthesiologists to optimize perioperative care of the obese cardiac surgical patient.

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.

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.

The safety of transesophageal echocardiography in patients undergoing orthotopic liver transplantation.

OBJECTIVE: To evaluate the safety of transesophageal echocardiography for the evaluation and intraoperative monitoring of patients during orthotopic liver transplantation. DESIGN: Retrospective observational study. SETTING: Tertiary care, university teaching hospital. PARTICIPANTS: Patients (n = 116) who underwent intraoperative transesophageal echocardiography during liver transplantation. INTERVENTIONS: Intraoperative transesophageal echocardiography during liver transplantation. MEASUREMENTS AND MAIN RESULTS: The authors evaluated the safety of intraoperative transesophageal echocardiography in patients undergoing liver transplantation through a retrospective chart review. Complications associated with transesophageal echocardiography use were divided into minor and major complications. Out of 116 patients who underwent intraoperative transesophageal echocardiography, there was one minor and one major complication. The major complication rate was 0.86% (1/116) and the overall complication rate was 1.7% (2/116). There was no statistically significant correlation between pre-transplant sclerotherapy for treatment of varices and intraoperative transesophageal echocardiography-related gastrointestinal bleeding. Although the reported complication rate is higher than what has been quoted in the cardiac literature, intraoperative transesophageal echocardiography during liver transplantation has a low complication rate. CONCLUSIONS: Intraoperative transesophageal echocardiography is a relatively safe method of monitoring cardiac performance in liver transplant patients.

Echocardiography-based hemodynamic management of left ventricular diastolic dysfunction: a feasibility and safety study.

BACKGROUND: 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. METHODS: Subjects were screened for LVDD by preoperative transthoracic echocardiography (TTE) and randomized to the conventional or EGHEM group. Subjects in EGHEM received hemodynamic management based on left ventricular filling patterns on transesophageal echocardiography (TEE). Primary outcomes measured were the feasibility to obtain TEE images and follow a TEE-based treatment algorithm. Safety outcomes also compared the following clinical differences between groups: length of hospitalization, incidence of atrial fibrillation, congestive heart failure (CHF), myocardial infarction, cerebrovascular accident, transient ischemic attack and renal failure measured 30 days postoperatively. RESULTS: Population consisted of 28 surgical subjects (14 in conventional group and 14 in EGHEM group). Mean subject age was 73.4 ± 6.7 years (36% male) in conventional group and 65.9 ± 14.4 years (36% male) in EGHEM group. Procedures included orthopedic (conventional = 29%, EGHEM 36%), general (conventional = 50%, EGHEM = 36%), vascular (conventional = 7%, EGHEM = 21%), and thoracic (conventional = 14%, EGHEM = 7%). There was no statistically significant difference in adverse clinical events between the 2 groups. The EGHEM group had less CHF, atrial fibrillation, and shorter length of stay. CONCLUSIONS: Echocardiography-guided hemodynamic management of patients with LVDD during surgery is feasible and may be a safe alternative to conventional management.

Use of rapid "rescue" perioperative echocardiography to improve outcomes after hemodynamic instability in noncardiac surgical patients.

OBJECTIVE: To investigate if modified "rescue" echocardiography enhanced management during perioperative hemodynamic instability in patients undergoing noncardiac surgery. DESIGN: A retrospective analysis of the medical data. SETTING: Perioperative setting at a single academic medical center. PARTICIPANTS: Thirty-one adult patients undergoing noncardiac surgery who experienced perioperative hemodynamic instability and were evaluated by either transthoracic echocardiography (TTE, n = 9) or transesophageal echocardiography (TEE, n = 22). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Rapid "rescue" echocardiography was performed on each patient looking for a specific cause for the patient's perioperative compromise. Echocardiography results, medical management, surgical management, and patient outcomes were all reviewed from the medical record and the department database. All patients were found to have an explainable diagnosis for the hemodynamic instability on the echocardiographic examination. The most common diagnoses were left-heart dysfunction (n = 16), right-heart dysfunction (n = 9), hypovolemia (n = 5), pulmonary embolus (n = 5), and myocardial ischemia (n = 4). Based on findings at echocardiography, 4 patients (13%) underwent and survived an emergent secondary procedure. All 31 patients recovered during their surgical procedure, and 25 (81%) progressed to hospital discharge. CONCLUSIONS: Both TTE and TEE can play a critical role in the diagnosis and management of perioperative hemodynamic instability.