Perioperative echocardiographic strain analysis: what anesthesiologists should know.

PURPOSE: Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined. CLINICAL FEATURES: This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period. CONCLUSION: Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

RéSUMé: OBJECTIF: L'analyse échocardiographique de la déformation cardiaque (strain analysis) par suivi des marqueurs acoustiques (speckle-tracking) permet d'évaluer la déformation du myocarde au cours du cycle cardiaque. Ses applications cliniques se sont considérablement développées au cours des deux dernières décennies en tant que marqueur sensible du dysfonctionnement myocardique, avec des valeurs diagnostiques et pronostiques importantes. L'analyse de la déformation cardiaque a le potentiel de devenir une partie intégrante de l'examen échocardiographique périopératoire de routine pour la plupart des anesthésiologistes-échocardiographes, mais son rôle exact dans le cadre périopératoire est encore en cours de définition. CARACTéRISTIQUES CLINIQUES: Ce rapport clinique passe en revue les principes qui sous-tendent l'analyse de la déformation cardiaque et décrit ses principales utilisations cliniques pertinentes dans le domaine de l'anesthésiologie et de la médecine périopératoire. L'analyse de la déformation cardique pour l'évaluation de la fonction ventriculaire gauche et droite ainsi que de la déformation auriculaire sont décrites. Nous discutons également du rôle potentiel de l'analyse de la déformation cardiaque pour aider à la stratification du risque périopératoire, à la sélection des patients en chirurgie cardiaque, à l'orientation du choix des moniteurs anesthésiques, et à la prise de décision clinique en période périopératoire. CONCLUSION: L'analyse échocardiographique de la déformation cardiaque est un outil puissant qui permet de voir ce que l'imagerie 2D conventionnelle ne parvient parfois pas à révéler. Elle fournit souvent un aperçu physiopathologique de diverses maladies cardiaques à un stade précoce. L'analyse de la déformation cardiaque est facilement réalisable et reproductible grâce à l'utilisation de plateformes logicielles hautement automatisées. Cette technique est potentiellement prometteuse et pourrait devenir un outil précieux dans l'arsenal de l'anesthésiologiste-échocardiographe et aider à la stratification du risque périopératoire et à la prise de décision clinique.

The Year in Perioperative Echocardiography: Selected Highlights from 2023.

This article is the eighth in 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 echocardiographic diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, the articles will target the use of perioperative echocardiography in general.

Comparison of visual estimation and quantitative measurement of left ventricular ejection fraction in untrained perioperative echocardiographers.

BACKGROUND: Perioperative evaluation of the left ventricular systolic function is essential information to help diagnose and manage life-threatening perioperative emergencies. Although quantifying the left ventricular ejection fraction (LVEF) is recommended to determine the left ventricular function, it may not always be feasible in emergency perioperative settings. This study compared the visual estimation of LVEF (eyeballing) by noncardiac anesthesiologists with the quantitative LVEF measured using a modified Simpson's biplane method. METHODS: Transesophageal echocardiographic (TEE) studies of 35 patients were selected and 3 different echocardiographic views (the mid-esophageal four chamber view, the mid-esophageal two chamber view, and the transgastric mid-papillary short axis view) were recovered from each study and displayed in random order. Two cardiac anesthesiologists certified in perioperative echocardiography independently measured LVEF using the modified Simpson method and categorized LVEF into five grades: hyperdynamic LVEF, normal, mildly reduced LVEF, moderately reduced LVEF and severely reduced LVEF. Seven noncardiac anesthesiologists with limited experience in echocardiography also reviewed the same TEE studies and estimated the LVEF and graded LV function. The precision of the LV function classification and the correlation between visual estimation of LVEF and quantitative LVEF were calculated. The agreement of measurements between the two methods was also assessed. RESULTS: Pearson's correlation between the LVEF estimated by the participants and the quantitative LVEF using the modified Simpson method was 0.818 (p < 0.001). Of a total of 245 responses, 120 (49.0%) responses were correct grading of the LV function. Participants were able to classify the LV function more accurately in the LV function grades 1 and 5 (65.3%). The 95% level of agreement of the Bland-Altman method was - 11.3-24.5. -21.9-22.6, - 23.1-26.5, - 20.5-22.0 and - 26.6-11.1 for LV grade 1 to 5, respectively. CONCLUSION: Visual estimation of LVEF in perioperative TEE has acceptable accuracy in untrained echocardiographers and can be used for rescue TEE.

The Year in Perioperative Echocardiography: Selected Highlights From 2022.

THIS SPECIAL article is part of an annual series 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, which focuses on the past year's research highlights that pertain to perioperative echocardiography in relation to cardiothoracic and vascular anesthesia. The major selected themes for 2022 include (1) updates on mitral valve assessments and interventions, (2) training and simulation updates, (3) outcomes and complications of transesophageal echocardiography, and (4) point-of-care cardiac ultrasound. The themes selected for this special article are just a sample of the advances in perioperative echocardiography during 2022. An appreciation and understanding of these highlights will help to ensure and improve the perioperative outcomes for patients with cardiovascular disease undergoing cardiac surgery.

Interobserver Variation in Echocardiographic Measurements and Grading of Tricuspid Regurgitation Based on a Novel Web-Based Assessment Environment.

OBJECTIVES: The primary aim of this study was to assess interobserver variability in grading tricuspid regurgitation (TR) severity. The authors' secondary goals were to delineate which transesophageal echocardiographic (TEE) parameters best correlate with severity and how consistent the participants were at grading severity. DESIGN: This was a prospective cohort study of how clinicians evaluated previously acquired TEE images and videos. SETTING: The 19 TEE studies of patients with TR were recorded by 4 senior echocardiographers across 4 US academic institutions. The participants evaluated these cases on a novel, web-based, assessment environment designed specifically for this study. PARTICIPANTS: Twenty-nine fellowship-trained and board-certified cardiologists and cardiothoracic anesthesiologists volunteered to participate in the study as observers from 19 different institutions. INTERVENTIONS: No interventions were performed on the participants. MEASUREMENTS AND MAIN RESULTS: For each case, participants measured the vena contracta (VC), proximal isovelocity surface area (PISA), and jet area before giving a final classification on the severity of TR. Variation was highest for effective regurgitant orifice area and lowest for VC and PISA. The coefficient of variation, defined as the standard deviation from the mean divided by the mean, for all cases of trace, mild, moderate and severe TR were as follows: Jet Area-111%, 46%, 48%, 76%; VC-67%, 44%, 43%, 36%; PISA-52%, 48%, 31%, 35%; and effective regurgitant orifice area-127%, 95%, 66%, 58%. CONCLUSIONS: The interobserver variation in quantifying TEE parameters for TR is high, suggesting these may be difficult to measure reliably in a busy perioperative setting. Of the parameters assessed, VC and PISA radius had the highest interobserver agreement and the highest correlation with severity.

The Year in Perioperative Echocardiography: Selected Highlights From 2021.

This article is the sixth 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 were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but, in some cases, these articles targeted the use of perioperative echocardiography in general.

Dynamic monitoring of cardiac foreign body by perioperative echocardiography: A case study.

Cardiac foreign bodies, especially those with sharp tips, may lead to unpredictable complications, such as penetrating cardiac injuries. Yet there have not been many reports of penetrating cardiac injuries caused by a needle that migrates from the neck to the heart. We herein present a review of such a case, focusing on the dynamic monitoring by perioperative echocardiography. The needle was represented on the monitor as a linear artifact that had penetrated through the ventricular wall and caused increasing pericardial effusion. Fortunately, the needle was successfully removed before it completely entered the right ventricular cavity. In this case, perioperative echocardiography played a significant role in clinical emergency decision making.

Femoral Vein Pulsatility: What Does It Mean?

In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.

The Year in Perioperative Echocardiography: Selected Highlights from 2020.

This article is the fifth 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 Editor-in-Chief Dr. Kaplan and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are 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 Year in Perioperative Echocardiography: Selected Highlights From 2019.

This article is the fourth 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 were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles targetted the use of perioperative echocardiography in general.

Surrogate indices of aortic peak systolic velocity variation to monitor fluid responsiveness in pediatric non-cardiac surgery: a prospective observational study.

Aortic peak systolic velocity variation (ΔVpeakAo) is a reliable dynamic indicator of preload in mechanically ventilated children. However, easily measurable alternative parameters like carotid peak systolic velocity variation (ΔVpeakCa) and suprasternal peak systolic velocity variation (ΔVpeakSs) are not well evaluated in children. The aim of the study was to find correlation between ΔVpeakCa and ΔVpeakSs to ΔVpeakAo, as potential surrogate markers of fluid responsiveness. 52 children, 1-12 years old, undergoing major non-cardiac surgeries under general endotracheal anaesthesia were recruited for this single-centre prospective observational study. ΔVpeakAo, ΔVpeakCa and ΔVpeakSs were measured by pulsed wave Doppler in appropriate windows, measuring maximum and minimum peak flow velocity over a single respiratory cycle. Calculated parameters were compared by a repeated measures study design. Correlation coefficients were 0.82 between ΔVpeakAo and ΔVpeakSs and 0.73 between ΔVpeakAo and ΔVpeakCa. Bland-Altman analysis showed minimal bias of 1.86 percentage points with limits of agreement of 11.21 to - 7.49 (ΔVpeakAo and ΔVpeakSs) and 3.93 percentage points with limits of agreement of 14.04 to - 6.18 (ΔVpeakAo and ΔVpeakCa). ΔVpeakSs and ΔVpeakCa also showed good discrimination to predict ΔVpeakAo (lying in previously validated fluid responsive zones) with sensitivities and specificities of 82.25% and 85% with cut-off of 11% for ΔVpeakSs, and 88.52% and 70% with cut-off of 8.6% for ΔVpeakCa. Carotid peak systolic velocity variation (ΔVpeakCa) and suprasternal peak systolic velocity variation (ΔVpeakCa) can be potential surrogate markers for Aortic peak systolic velocity variation (ΔVpeakAo) in assessing fluid responsiveness in mechanically ventilated children.Study registration: Clinicaltrials.gov ID NCT03155555.

The Use of Subcostal Echocardiographic Views to Guide the Insertion of a Right Ventricular Temporary Transvenous Pacemaker-Description of the Technique.

The need for temporary cardiac pacing may occur in emergency and elective situations and may require transvenous right ventricular lead placement. The treatment of bradyarrhythmias presents the most common perioperative emergency indication. Intraoperatively, temporary rapid right ventricular pacing is accepted as a safe, titratable, and highly reliable method to achieve deliberate hypotension, and it has become a routine practice in the anesthetic management of cardiovascular interventions. The navigation of the lead into the right ventricle often requires fluoroscopy to guide placement and to confirm position. Ultrasound guidance has been accepted widely by perioperative physicians as a safe technique for central venous access. Basic ultrasound and transthoracic echocardiographic skills rapidly are becoming integral to anesthesiologists' practice. When used to guide transvenous pacemaker wire insertion, subcostal echocardiographic imaging offers attractive advantages over blind or fluoroscopic placement, including rapid deployment, avoidance of radiation, real-time visualization of the lead in relation to the cardiac structures, and early detection of potential complications, such as tamponade. Although several articles on echocardiographic guidance for transvenous pacing have been published in other acute care specialty fields in the last decade, this is the first description of the technique and of the recommended echocardiographic views in a perioperative context. In addition, a review of the current literature is presented, and the specific advantages and disadvantages of the approach are discussed in this article.

Preparing for a Fellowship in Adult Cardiothoracic Anesthesiology: Resources and Approaches for the Anesthesiology Trainee.

Adult cardiothoracic anesthesiology (ACTA) is a competitive fellowship. Despite increases in both the number of programs offering cardiothoracic fellowships and the number of residents applying each year, there is little direction or advice for prospective candidates. This review aims to educate anesthesiology residents who are hoping to pursue cardiothoracic anesthesiology, by examining a brief history of the advanced perioperative echocardiography qualification, the credentialing goals of ACTA fellowships, and the current status of ACTA fellowships. The second part of the review covers the ACTA fellowship application and aims to assist the candidate in navigating this process. The review examines the qualifications that fellowship programs look for in a candidate, including a discussion on professional behavior, and what an applicant can look for in a program. Finally, there is a brief discussion on post-match preparation.

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 Year in Perioperative Echocardiography: Selected Highlights from 2017.

This article is the second 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 start this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; however, in some cases, these articles will target the use of perioperative echocardiography in general.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2013.

This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs that require a precise prescription with respect to type, dose, and duration. The final theme is patient safety in the cardiac perioperative environment. A recent expert scientific statement has focused attention on this issue because most perioperative errors are preventable. It is likely that clinical research in this area will blossom because this is a major opportunity for improvement in our specialty. The patient care processes identified in these research highlights will further improve perioperative outcomes for our patients.

A Multi-Country Survey on the Availability of Intraoperative Use of Echocardiography for Noncardiac Surgery.

BACKGROUND: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. METHODS: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. RESULTS: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. CONCLUSIONS: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

Challenges Regarding the Value of Routine Perioperative Transesophageal Echocardiography in Mitral Valve Surgery.

BACKGROUND AND OBJECTIVES: Transesophageal echocardiography (TEE) is considered an indispensable tool for perioperative evaluation in mitral valve (MV) surgery. TEE is routinely performed by anesthesiologists competent in TEE; however, in certain situations, the expertise of a senior cardiologist specializing in TEE is required, which incurs additional costs. The purpose of this study is to determine the indications for specialized perioperative TEE based on its utility and the correlation between intraoperative TEE diagnoses and surgical findings, compared with routine TEE performed by an anesthesiologist. MATERIALS AND METHODS: We conducted a three-year prospective study involving 499 patients with MV disease undergoing cardiac surgery. Patients underwent intraoperative and early postoperative TEE and at least one other perioperative echocardiographic evaluation. A computer application was dedicated to calculating the utility of each type of specialized TEE indication depending on the type of MV disease and surgical intervention. RESULTS: The indications for performing specialized perioperative TEE identified in our study can be categorized into three groups: standard, relative, and uncertain. Standard indications for specialized intraoperative TEE included establishing the mechanism and severity of MR (mitral regurgitation), guiding MV valvuloplasty, diagnosing associated valvular lesions post MVR (mitral valve replacement), routine evaluations in triple-valve replacements, and identifying the causes of acute, intraoperative, life-threatening hemodynamic dysfunction. Early postoperative specialized TEE in the intensive care unit (ICU) is indicated for the suspicion of pericardial or pleural effusions, establishing the etiology of acute hemodynamic dysfunction, and assessing the severity of residual MR post valvuloplasty. CONCLUSIONS: Perioperative TEE in MV surgery can generally be performed by a trained anesthesiologist for standard measurements and evaluations. In certain cases, however, a specialized TEE examination by a trained senior cardiologist is necessary, as it is indirectly associated with a decrease in postoperative complications and early postoperative mortality rates, as well as an improvement in immediate and long-term prognoses. Also, for standard indications, the correlation between surgical and TEE diagnoses was superior when specialized TEE was used.