Overview of the Interatrial Septum: Review of Cardiac Nomenclature for Transseptal Puncture.

Transseptal puncture is an increasingly common procedure undertaken to gain access to the left side of the heart during structural heart disease interventions. Precision guidance during this procedure is paramount to ensure success and patient safety. As such, multimodality imaging, such as echocardiography, fluoroscopy, and fusion imaging, is routinely used to guide safe transseptal puncture. Despite the use of multimodal imaging, there is currently no uniform nomenclature of cardiac anatomy between the various imaging modes and proceduralists, and echocardiographers tend to use imaging modality-specific terminology when communicating among the various imaging modes. This variability in nomenclature among imaging modes stems from differing anatomic descriptions of cardiac anatomy. Given the required level of precision in performing transseptal puncture, a clearer understanding of the basis of cardiac anatomic nomenclature is required by both echocardiographers as well as proceduralists; enhanced understanding can help facilitate communication across specialties and possibly improve communication and safety. In this review, the authors highlight the variation in cardiac anatomy nomenclature among various imaging modes.

Curriculum for Subspecialty Anesthesia Training in Adult Structural Heart Disease Imaging: A Single-Center Experience.

Intraprocedural transesophageal echocardiography imaging is an integral part of percutaneous structural heart disease (SHD) interventions. The rapid growth in the number, scope, and complexity of SHD interventions has outpaced the efforts to develop training and proficiency standards in periprocedural imaging. At the Beth Israel Deaconess Medical Center in Boston, Massachusetts, the authors have developed a 6-month duration fellowship in interventional echocardiography for SHD to address this issue. The purpose of this fellowship is to train cardiac anesthesiologists to address the unique challenges of interventional echocardiography. In this paper, the authors describe the rationale for and specific features of this training program. Their fellowship curriculum follows a multimodal integrative approach to training in SHD imaging, which includes simulation sessions, online modules, deliberate practice in the clinical setting, and interdisciplinary team-based training. In the next several years, there will be an increased need for echocardiographers who are proficient in intraprocedural SHD imaging. In this article, the authors describe their experience with a competency-based curriculum for subspecialty anesthesia training in SHD imaging.

Training Surgical Residents for Ultrasound-Guided Assessment and Management of Unstable Patients.

OBJECTIVE: Proficiency in the use of ultrasound is presently not an ACGME required core competency for accredited surgical training. There should be a basic unified ultrasound curriculum for surgical trainees. We developed a multimodal ultrasound-training program to ensure baseline proficiency and readiness for clinical performance without impacting trainee duty hours. DESIGN: We developed and implemented a multimodal curriculum for ultrasound education and its use as a supplement to clinical evaluation of unstable patients. SETTING: A single-center study was completed in a hospital setting. PARTICIPANTS: Post-graduate year-1 surgical residents at our institution were invited to participate in a multimodal perioperative course. RESULTS: 51 residents attended the course over the three sessions. The vignette exam as a whole demonstrated a Cronbach's alpha of 0.819 indicating good internal reliability of the entire test. There was significant improvement in their knowledge in clinical vignettes (55% ±â€¯12.4 on pre-test vs. 83% ±â€¯13.2% on post-test, p<0.001). CONCLUSION: It is feasible to incorporate a focused ultrasound curriculum to assess clinically unstable patients. The multimodal nature of the course aid in the development of preclinical proficiency and decreased the orientation phase of ultrasound use.

Low-cost three-dimensional printed phantom for neuraxial anesthesia training: Development and comparison to a commercial model.

METHODS: Anonymized CT DICOM data was segmented to create a 3D model of the lumbar spine. The 3D model was modified, placed inside a digitally designed housing unit and fabricated on a desktop 3D printer using polylactic acid (PLA) filament. The model was filled with an echogenic solution of gelatin with psyllium fiber. Twenty-two staff anesthesiologists performed a spinal and epidural on the 3D printed simulator and a commercially available Simulab phantom. Participants evaluated the tactile and ultrasound imaging fidelity of both phantoms via Likert-scale questionnaire. RESULTS: The 3D printed neuraxial phantom cost $13 to print and required 25 hours of non-supervised printing and 2 hours of assembly time. The 3D printed phantom was found to be less realistic to surface palpation than the Simulab phantom due to fragility of the silicone but had significantly better fidelity for loss of resistance, dural puncture and ultrasound imaging than the Simulab phantom. CONCLUSION: Low-cost neuraxial phantoms with fidelity comparable to commercial models can be produced using CT data and low-cost infrastructure consisting of FLOS software and desktop 3D printers.

Summative Objective Structured Clinical Examination Assessment at the End of Anesthesia Residency for Perioperative Ultrasound.

While standardized examinations and data from simulators and phantom models can assess knowledge and manual skills for ultrasound, an Objective Structured Clinical Examination (OSCE) could assess workflow understanding. We recruited 8 experts to develop an OSCE to assess workflow understanding in perioperative ultrasound. The experts used a binary grading system to score 19 graduating anesthesia residents at 6 stations. Overall average performance was 86.2%, and 3 stations had an acceptable internal reliability (Kuder-Richardson formula 20 coefficient >0.5). After refinement, this OSCE can be combined with standardized examinations and data from simulators and phantom models to assess proficiency in ultrasound.

Multifactorial risk index for prediction of intraoperative blood transfusion in endovascular aneurysm repair.

BACKGROUND: In some institutions, the current blood ordering practice does not discriminate minimally invasive endovascular aneurysm repair (EVAR) from open procedures, with consequent increasing costs and likelihood of blood product wastage for EVARs. This limitation in practice can possibly be addressed with the development of a reliable prediction model for transfusion risk in EVAR patients. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to create a model for prediction of intraoperative blood transfusion occurrence in patients undergoing EVAR. Afterward, we tested our predictive model on the Vascular Study Group of New England (VSGNE) database. METHODS: We used the ACS NSQIP database for patients who underwent EVAR from 2011 to 2013 (N = 4709) as our derivation set for identifying a risk index for predicting intraoperative blood transfusion. We then developed a clinical risk score and validated this model using patients who underwent EVAR from 2003 to 2014 in the VSGNE database (N = 4478). RESULTS: The transfusion rates were 8.4% and 6.1% for the ACS NSQIP (derivation set) and VSGNE (validation) databases, respectively. Hemoglobin concentration, American Society of Anesthesiologists class, age, and aneurysm diameter predicted blood transfusion in the derivation set. When it was applied on the validation set, our risk index demonstrated good discrimination in both the derivation and validation set (C statistic = 0.73 and 0.70, respectively) and calibration using the Hosmer-Lemeshow test (P = .27 and 0.31) for both data sets. CONCLUSIONS: We developed and validated a risk index for predicting the likelihood of intraoperative blood transfusion in EVAR patients. Implementation of this index may facilitate the blood management strategies specific for EVAR.

Assessment of Perioperative Ultrasound Workflow Understanding: A Consensus.

OBJECTIVES: Understanding of the workflow of perioperative ultrasound (US) examination is an integral component of proficiency. Workflow consists of the practical steps prior to executing an US examination (eg, equipment operation). Whereas other proficiency components (ie, cognitive knowledge and manual dexterity) can be tested, workflow understanding is difficult to define and assess due to its contextual and institution-specific nature. The objective was to define the workflow components of specific perioperative US applications using an iterative process to reach a consensus opinion. DESIGN: Expert consensus, survey study. SETTING: Tertiary university hospital. PARTICIPANTS: This study sought expert consensus among a focus group of 9 members of an anesthesia department with experience in perioperative US. Afterward, 257 anesthesia faculty members from 133 academic centers across the United States were surveyed. INTERVENTIONS: A preliminary list of tasks was designed to establish the expectations of workflow understanding by an anesthesiology resident prior to clinical exposure to perioperative US. This list was modified by a focus group through an iterative process. Afterwards, a survey was sent to faculty members nationwide, and Likert scale ratings for each task were obtained and reviewed during a second round. MEASUREMENTS AND MAIN RESULTS: Consensus among members of the focus group was reached after 2 iterations. 72 participants responded to the nationwide survey (28%), and consensus was reached after the second round (Cronbach's α = 0.99, ICC = 0.99) on a final list of 46 workflow-related tasks. CONCLUSIONS: Specific components of perioperative US workflow were identified. Evaluation of workflow understanding may be combined with cognitive knowledge and manual dexterity testing for assessing proficiency in perioperative US.

Making three-dimensional echocardiography more tangible: a workflow for three-dimensional printing with echocardiographic data.

Three-dimensional (3D) printing is a rapidly evolving technology with several potential applications in the diagnosis and management of cardiac disease. Recently, 3D printing (i.e. rapid prototyping) derived from 3D transesophageal echocardiography (TEE) has become possible. Due to the multiple steps involved and the specific equipment required for each step, it might be difficult to start implementing echocardiography-derived 3D printing in a clinical setting. In this review, we provide an overview of this process, including its logistics and organization of tools and materials, 3D TEE image acquisition strategies, data export, format conversion, segmentation, and printing. Generation of patient-specific models of cardiac anatomy from echocardiographic data is a feasible, practical application of 3D printing technology.

Intrapleural placement of a thoracic epidural catheter in a patient with spinal stenosis.

Due to the close proximity of the thoracic epidural space and parietal pleura, pleural puncture with intrapleural catheter placement is a potential complication of thoracic epidural anesthesia. The authors present a case of an obese patient with a history of spinal stenosis that underwent thoracotomy. Repeated failed attempts at epidural anesthesia were complicated by intrapleural placement of the catheter. The patient subsequently developed clinical signs of pneumothorax and required urgent thoracostomy.

Tricuspid annulus: A spatial and temporal analysis.

BACKGROUND: Traditional two-dimensional (2D) echocardiographic evaluation of tricuspid annulus (TA) dilation is based on single-frame measurements of the septolateral (S-L) dimension. This may not represent either the axis or the extent of dynamism through the entire cardiac cycle. In this study, we used real-time 3D transesophageal echocardiography (TEE) to analyze geometric changes in multiple axes of the TA throughout the cardiac cycle in patients without right ventricular abnormalities. MATERIALS AND METHODS: R-wave-gated 3D TEE images of the TA were acquired in 39 patients undergoing cardiovascular surgery. The patients with abnormal right ventricular/tricuspid structure or function were excluded from the study. For each patient, eight points along the TA were traced in the 3D dataset and used to reconstruct the TA at four stages of the cardiac cycle (end- and mid-systole, end- and mid-diastole). Statistical analyses were applied to determine whether TA area, perimeter, axes, and planarity changed significantly over each stage of the cardiac cycle. RESULTS: TA area (P = 0.012) and perimeter (P = 0.024) both changed significantly over the cardiac cycle. Of all the axes, only the posterolateral-anteroseptal demonstrated significant dynamism (P < 0.001). There was also a significant displacement in the vertical axis between the points and the regression plane in end-systole (P < 0.001), mid-diastole (P = 0.014), and mid-systole (P < 0.001). CONCLUSIONS: The TA demonstrates selective dynamism over the cardiac cycle, and its axis of maximal dynamism is different from the axis (S-L) that is routinely measured with 2D TEE.

Valve-in-valve-in homograft: A case of a repeat transcatheter aortic valve replacement in a patient with an aortic homograft.

In recent years, the use of transcatheter aortic valve replacement (TAVR) has extended beyond the treatment of native aortic valve stenosis in patients with high surgical risk. TAVR is increasingly being performed for bioprosthetic aortic valve failure, i.e., the valve-in-valve (VIV) procedure. Establishing the success of a VIV procedure can be challenging in these cases. Furthermore, the limited availability of prostheses sizes further complicates the management of these patients. We present an unusual case of a repeat TAVR in a patient who previously had a VIV procedure in an aortic homograft.

Combined Epidural-General Anesthesia vs General Anesthesia Alone for Elective Abdominal Aortic Aneurysm Repair.

Importance: Epidural analgesia (EA) is used as an adjunct procedure for postoperative pain control during elective abdominal aortic aneurysm (AAA) surgery. In addition to analgesia, modulatory effects of EA on spinal sympathetic outflow result in improved organ perfusion with reduced complications. Reductions in postoperative complications lead to shorter convalescence and possibly improved 30-day survival. However, the effect of EA on long-term survival when used as an adjunct to general anesthesia (GA) during elective AAA surgery is unknown. Objective: To evaluate the association between combined EA-GA vs GA alone and long-term survival and postoperative complications in patients undergoing elective, open AAA repair. Design, Setting, and Participants: A retrospective analysis of prospectively collected data was performed. Patients undergoing elective AAA repair between January 1, 2003, and December 31, 2011, were identified within the Vascular Society Group of New England (VSGNE) database. Kaplan-Meier curves were used to estimate survival. Cox proportional hazards regression models and multivariable logistic regression models assessed the independent association of EA-GA use with postoperative mortality and morbidity, respectively. Data analysis was conducted from March 15, 2015, to September 2, 2015. Interventions: Combined EA-GA. Main Outcomes and Measures: The primary outcome measure was all-cause mortality. Secondary end points included postoperative bowel ischemia, respiratory complications, myocardial infarction, dialysis requirement, wound complications, and need for surgical reintervention within 30 days of surgery. Results: A total of 1540 patients underwent elective AAA repair during the study period. Of these, 410 patients (26.6%) were women and the median (interquartile range) age was 71 (64-76) years; 980 individuals (63.6%) received EA-GA. Patients in the 2 groups were comparable in terms of age, comorbidities, and suprarenal clamp location. At 5 years, the Kaplan-Meier-estimated overall survival rates were 74% (95% CI, 72%-76%) and 65% (95% CI, 62%-68%) in the EA-GA and GA-alone groups, respectively (P < .01). In adjusted analyses, EA-GA use was associated with significantly lower hazards of mortality compared with GA alone (hazard ratio, 0.73; 95% CI, 0.57-0.92; P = .01). Patients receiving EA-GA also had lower odds of 30-day surgical reintervention (odds ratio [OR], 0.65; 95% CI, 0.44-0.94; P = .02) as well as postoperative bowel ischemia (OR, 0.54; 95% CI, 0.31-0.94; P = .03), pulmonary complications (OR, 0.62; 95% CI, 0.41-0.95; P = .03), and dialysis requirements (OR, 0.44; 95% CI, 0.23-0.88; P = .02). No significant differences were noted for the odds of wound (OR, 0.88; 95% CI, 0.38-1.44; P = .51) and cardiac (OR, 1.08; 95% CI, 0.59-1.78; P = .82) complications. Conclusions and Relevance: Combined EA-GA was associated with improved survival and significantly lower HRs and ORs for mortality and morbidity in patients undergoing elective AAA repair. The survival benefit may be attributable to reduced immediate postoperative adverse events. Based on these findings, EA-GA should be strongly considered in suitable patients.