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.

European association of cardiothoracic anesthesiology and intensive care (EACTAIC) fellowship curriculum: second edition

Abstract Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

European association of cardiothoracic anesthesiology and intensive care pediatric cardiac anesthesia fellowship curriculum: first edition

ABSTRACT: Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

European Association of Cardiothoracic Anesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum: First Edition.

Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee.

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

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.

Current Anesthetic Care of Patients Undergoing Transcatheter Aortic Valve Replacement in Europe: Results of an Online Survey.

OBJECTIVES: Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe. DESIGN: Structured web-based, anonymized, voluntary survey. SETTING: Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018. PARTICIPANTS: Physicians. MEASUREMENTS AND MAIN RESULTS: The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only ≤30%. Postprocedurally, patients were transferred to an intensive care unit by 51.43% of the respondents with a reported nurse-to-patient ratio of 1:2 or 1:3, to a post-anesthesia care unit by 27.14%, to a postoperative recovery room by 11.43%, and to a peripheral ward by 10%. CONCLUSION: The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe.

Thoracic Anesthesia of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee.

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.

European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia Fellowship Curriculum: First Edition.

This special article summarizes the design and certification process of the European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia (CTVA) Fellowship Program. The CTVA fellowship training includes a two-year curriculum at an EACTA-accredited educational facility. Before fellows are accepted into the program, they must meet a number of requirements, including evidence of a valid license to practice medicine, a specialist degree examination in anesthesiology, and appropriate language skills as required in the host centers. The CVTA Fellowship Program has 2 sequential and complementary levels of training-both with a modular structure that allows for individual planning and also takes into account the differing national healthcare needs and requirements of the 36 countries represented in EACTA. The basic training period focuses on the anesthetic management of patients undergoing cardiac, thoracic, and vascular surgery and related procedures. The advanced training period is intended to deepen and to extend the clinical and nontechnical skills that fellows have acquired during the basic training. The goal of the EACTA fellowship is to produce highly trained and competent perioperative physicians who are able to care for patients undergoing cardiac, thoracic, and vascular anesthesia.

Perspectives on the Fellowship Training in Cardiac, Thoracic, and Vascular Anesthesia and Critical Care in Europe From Program Directors and Educational Leads Around Europe.

This article reviews fellowship training in adult cardiac, thoracic, and vascular anesthesia and critical care from the perspective of European program initiators and educational leaders in these subspecialties together with current training fellows. Currently, the European Association of Cardiothoracic Anaesthesiology (EACTA) network has 20 certified fellowship positions each year in 10 hosting centers within 7 European countries, with 2 positions outside Europe (São Paulo, Brazil). Since 2009, 42 fellows have completed the fellowship training. The aim of this article is to provide an overview of the rationale, requirements, and contributions of the fellows, in the context of the developmental progression of the EACTA fellowship in adult cardiac, thoracic, and vascular anesthesia and critical care from inception to present. A summary of the program structure, accreditation of host centers, requirements to join the program, teaching and assessment tools, certification, and training requirements in transesophageal electrocardiography is outlined. In addition, a description of the current state of EACTA fellowships across Europe, and a perspective for future steps and challenges to the educational program, is provided.

Feasibility of transcatheter aortic valve implantation in patients with coronary heights ≤7 mm: insights from the transcatheter aortic valve implantation Karlsruhe (TAVIK) registry.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) in patients with low coronary heights is generally denied but is not impossible. Information about these high-risk procedures is sparse. METHODS: Since May 2008, data of more than 3000 patients who had TAVI were prospectively collected in the institutional TAVI Karlsruhe registry. Characteristics, peri- and postoperative outcome of patients with low coronary heights of ≤7 mm were analysed according to the Valve Academic Research Consortium-2. RESULTS: Eighty-six patients with an average coronary height of 6.4 ± 1.1 mm (mean age 81.0 ± 5.3 years, logistic EuroSCORE I 19.6 ± 13.3%) were treated. TAVI was performed in 72 transfemoral (83.7%) and 14 transapical (16.3%) cases using 44 CoreValve/Evolut R (51.2%), 21 Sapien XT/S3 (24.4%), 14 ACURATE (16.3%), 5 Lotus (5.8%) and 2 Portico (2.3%) prostheses. Ten procedures were valve-in-valve (VinV) TAVI (VinV, 11.6%). The 72-h, 30-day, 1-year and follow-up (3.0 ± 1.6 years) mortality rates were 2.3%, 8.0%, 10.5% and 26.7%, respectively. Within 30 days, 4 cardiac deaths and 3 non-cardiac deaths occurred (4.7% and 3.5%). Three coronary obstructions (3.5%) occurred-2 during VinV TAVI. One patient was connected to extracorporeal circulation that could not be weaned later due to an unsuccessful percutaneous coronary intervention. Another patient, the only conversion (1.2%), required delayed surgical valve replacement. The third patient died of right heart failure after aortic dissection. The procedural success rate was 95.3%. VinV procedures were associated with increased follow-up deaths (P < 0.001; hazard ratio 7.96). CONCLUSIONS: Coronary-related complications in TAVI procedures in patients with coronary heights ≤7 mm occurred less frequently, but once they occurred, they were serious. These TAVI procedures are feasible, with a high procedural success rate, but meticulous preoperative planning should be mandatory. In VinV procedures, the follow-up mortality rate is increased; therefore, we do not recommend these procedures.

Feasibility of measurements of valve dimensions in en-face-3D transesophageal echocardiography.

Newest 3D software allows measurements directly in the en-face-3D TEE mode. Aim of the study was to ascertain whether measurements performed in the en-face-3D TEE mode are comparable with conventional measurement methods based on 2D TEE and 3D using the multiple plane reconstruction mode with the Qlab® software. En-face-3D TEE is used more frequently in daily clinical routine during cardiac operations. So far measurements could only be done based on 2D images or with the use of multi planar reconstruction mode with additional software. Measurement directly in the 3D image (en-face-3D TEE) would make measurements faster and easier to use in clinical practice. After approval by the local ethic committee and written informed consent from the patients additionally to a comprehensive perioperative 2D TEE examination a real time (RT) 3D zoom- dataset was recorded. Routine measurements of the length of anterior and posterior mitral valve leaflets as well as mitral valve and aortic valve areas were performed in en-face-3D TEE, multiplanar reconstruction mode using Qlab®-software (Philips, Netherlands) and 2D TEE standard views. Twenty nine patients with a mean age of 67 years undergoing elective cardiac surgery/interventions were enrolled in this study. Direct measurements in en-face-3D TEE mode lead to non significant underestimation of all parameters as compared to Qlab® and 2D TEE measurements. Measurements in en-face-3D TEE are feasible but lead to non significant underestimation compared to measurements performed with Qlab® or in 2D TEE views.

Analysis of circumflex artery anatomy by real time 3D transesophageal echocardiography compared to cardiac computed tomography.

Iatrogenic injury to the circumflex artery (Cx) due to its close proximity to the mitral annulus is a rare but dreadful complication that can occur during mitral valve repair. The aim of our study was to compare multiple measurements of the Cx datasets, obtained by real time three-dimensional transesophageal echocardiography (RT3D TEE) and corresponding measurements assessed in multi-planar three-dimensional images acquired by multidetector computed tomography (MDCT). Preoperative RT3D TEE and MDCT datasets of 25 patients who had previously undergone minimally invasive mitral valve surgery were retrospectively analyzed. The vessel diameter and the horizontal as well as vertical distances from the center of the Cx to the mitral valve annulus were measured. Horizontal as well as vertical Cx distances showed a strong correlation between measurements of RT3D TEE and MDCT whereas the measurements of the Cx diameter showed no correlation. Measurements of horizontal and vertical distances of the Cx to the mitral annulus can be performed using RT3D TEE and show good correlation with MDCT-based measurements.

Guidelines of the Indian Association of Cardiovascular and Thoracic Anaesthesiologists and Indian College of Cardiac Anaesthesia for perioperative transesophageal echocardiography fellowship examination.

During current medical care, perioperative transesophageal echocardiography (TEE) has become a vital component of patient management, especially in cardiac operating rooms and in critical care medicine. Information derived from echocardiography has an important bearing on the patient's outcome. The Indian Association of Cardiovascular and Thoracic Anaesthesiologists (IACTA) has promoted the use of TEE during routine clinical care of patients undergoing cardiac surgery. An important mission of IACTA is to oversee training and certify anesthesiologists in the perioperative and intensive care use of TEE. The provision of "Fellowship" is by way of conducting IACTA - TEE fellowship (F-TEE) examination. This has been done annually for the past 7 years using well-established curriculums by accredited national and international societies. Now, with the transformation and reconstitution of IACTA education and research cell into the newly formed Indian College of Cardiac Anaesthesia, F-TEE is bound to meet international standards. To ensure that the examinations are conducted in a transparent and foolproof manner, the guideline committee (formulated in 2010) of IACTA has taken the onus of formulating the guidelines for the same. These guidelines have been formally reviewed and updated since 2010 and are detailed here to serve as a guide to both the examinee and examiner ensuring standardization, efficiency, and competency of the IACTA F-TEE certification process.

Aortic valve calcium score for paravalvular aortic insufficiency (AVCS II) study in transapical aortic valve implantation.

BACKGROUND: Transapical aortic valve implantation (TAAVI) has evolved into a routine procedure for select high-risk patients. The aim was to study the impact of native aortic valve calcification on paravalvular leaks in cardiac contrast-enhanced computed tomography (CT). METHODS: The degree and distribution of valve calcification were quantified using an Aortic Valve Calcium Score (AVCS) for each cusp separately (3mensio Valves). To reduce an artificial increase of the AVCS due to the presence of contrast material, we used thresholds for density [mean aortic density + 2*SD] and volume [0, 3, 5, 25, and 50 mm3] of calcification. RESULTS: 111 consecutive patients prior to TAAVI with preoperative CT aged 79.8 ± 5.8 years were included using the Edwards Sapien prosthesis. Paravalvular leaks were significantly associated with eccentric calcified plaques (r [Spearman] = 0.37; χ2-statistic = 15.4; P = .002), presence of LVOT calcium (r [Spearman] = 0.28; χ2-statistic = 11.3; P = .009), and the commissural gap at the anatomic ventriculo-arterial junction (r [Spearman] = 0.41-0.63; χ2-statistic = 50.8-53.0; P = .002-≤.001). There was no significant association between the total AVCS and PV leaks (r [Spearman] = 0.076; χ2-statistic = 1.471; P = .240, 120 kV, 850 hounsfield units) with no additional use of a volume-based threshold. CONCLUSION: Asymmetry of leaflet calcium distribution, LVOT calcium, and the commissural gap between leaflets were significantly associated with paravalvular leaks. Moreover, quantification of aortic valve calcification in contrast enhanced CTs shows only a weak correlation with paravalvular leakage and is therefore not reliable as a predictor, respectively.

Initial Experience With a Percutaneous Approach to Redo Mitral Valve Surgery: Management and Procedural Success.

OBJECTIVE: The purpose of the study was to report the anesthetic management and immediate procedural success in the initial 20 patients undergoing percutaneous transapical mitral valve replacement. DESIGN: Retrospective review of collected data. SETTING: University-affiliated heart center. PARTICIPANTS: Twenty patients with mitral regurgitation or stenosis due to a degenerated valve or ring in the mitral position. INTERVENTIONS: TEE-guided transapical mitral valve replacement under general anesthesia and early extubation by means of an established fast-track protocol. MEASUREMENTS AND MAIN METHODS: Twenty patients underwent transapical mitral valve replacement by a beating heart procedure, avoiding cardiopulmonary bypass. The valve was either deployed due to a previously implanted bioprosthetic valve (valve-in-valve group), which degenerated, or a ring (valve-in-ring group), which predominantly showed regurgitation. There was a significant increase in the mitral valve opening area in stenosed valve pathology from 1.3-1.9 sq. cm (p = 0.004), and an increase in ejection fraction from 40% to 45% (p = 0.52). In the valve-in-ring group, valve area increased from 2.0 sq. cm to 2.6 sq. cm (p = 0.21), with an increase in ejection fraction from 30% to 35% (p = 0.18). Eighteen patients underwent successful deployment of the valve. The anesthesia duration for the procedure lasted 185.5 ± 25.4 minutes. CONCLUSIONS: There was a significant increase in opening area of the valve and improvement in ejection fraction in this patient group. TEE and fluoroscopy-guided imaging is necessary for the procedure's success and is an evolving alternative treatment for high-risk mitral valve patients who would otherwise be considered inoperable for routine surgery using sternotomy.

Four-dimensional modelling of the mitral valve by real-time 3D transoesophageal echocardiography: proof of concept.

OBJECTIVES: The complexity of the mitral valve (MV) anatomy and function is not yet fully understood. Assessing the dynamic movement and interaction of MV components to define MV physiology during the complete cardiac cycle remains a challenge. We herein describe a novel semi-automated 4D MV model. METHODS: The model applies quantitative analysis of the MV over a complete cardiac cycle based on real-time 3D transoesophageal echocardiography (RT3DE) data. RT3DE data of MVs were acquired for 18 patients. The MV annulus and leaflets were semi-automatically reconstructed. Dimensions of the mitral annulus (anteroposterior and anterolateral-posteromedial diameter, annular circumference, annular area) and leaflets (MV orifice area, intercommissural distance) were acquired. Variability and reproducibility (intraclass correlation coefficient, ICC) for interobserver and intraobserver comparison were quantified at 4 time points during the cardiac cycle (mid-systole, end-systole, mid-diastole and end-diastole). RESULTS: Mitral annular dimensions provided highly reliable and reproducible measurements throughout the cardiac cycle for interobserver (variability range, 0.5-1.5%; ICC range, 0.895-0.987) and intraobserver (variability range, 0.5-1.6%; ICC range, 0.827-0.980) comparison, respectively. MV leaflet parameters showed a high reliability in the diastolic phase (variability range, 0.6-9.1%; ICC range, 0.750-0.986), whereas MV leaflet dimensions showed a high variability and lower correlation in the systolic phase (variability range, 0.6-22.4%; ICC range, 0.446-0.915) compared with the diastolic phase. CONCLUSIONS: This 4D model provides detailed morphological reconstruction as well as sophisticated quantification of the complex MV structure and dynamics throughout the cardiac cycle with a precision not yet described.

Rare complication of circumflex artery occlusion during transfemoral aortic valve replacement (TAVR).

Circumflex artery occlusion is an unusual but grave complication that can be intra-operatively challenging to identify. Various modalities of imaging are possible during transfemoral aortic valve replacement (TAVR). Fluoroscopy and/or transesophageal echocardiography maybe used for assessment during and after TAVR. Imaging dilemma can cause delay or alter diagnosis. We report a case of an imaging complication during TAVR which might have modified the outcome of the procedure.