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1.
Anaesthesia ; 75(1): 21-26, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31236918

RESUMO

Previous studies on the safety of peri-operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. That said, there has been a paucity of prospective multicentre studies in this important area of clinical practice. We carried out a one-year prospective study in 2017, co-ordinated by the Association of Cardiothoracic Anaesthesia and Critical Care, to determine the rate and severity of complications associated with peri-operative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients. With the help of clinicians from 28 centres across the UK and Ireland, we recorded the total number of examinations conducted in anaesthetised patients during the study period. All major complications at each centre were prospectively reported and recorded. Of the 22,314 examinations, there were 17 patients diagnosed with a major complication which caused either palatal injury or gastro-oesophageal disruption. This corresponds to an incidence of 0.08% (95%CI 0.05-0.13%) or approximately 1:1300 examinations. There were seven deaths reported during the study period which were directly attributed to these complications, corresponding to an incidence of 0.03% (95%CI 0.01-0.07%) or approximately 1:3000. These figures are higher than previously reported and suggest a high probability of death following the development of a complication (~40%). Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro-oesophageal injury. We suggest clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.


Assuntos
Anestesia em Procedimentos Cardíacos , Procedimentos Cirúrgicos Cardíacos , Ecocardiografia Transesofagiana/efeitos adversos , Auditoria Médica/estatística & dados numéricos , Assistência Perioperatória/efeitos adversos , Idoso , Ecocardiografia Transesofagiana/estatística & dados numéricos , Feminino , Humanos , Irlanda , Masculino , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Sociedades Médicas , Reino Unido
2.
Zhonghua Nei Ke Za Zhi ; 58(12): 869-882, 2019 Dec 01.
Artigo em Chinês | MEDLINE | ID: mdl-31775449

RESUMO

Transesophageal echocardiography(TEE) is valuable in intensive care unit (ICU) because its application meets the requirements of diagnosis and treatment of critically ill patients.However, the current application has not fully adapted to the specialty of critical care. TEE could be more valuablein ICU when used with a new way that under the guidance of the theory of critical care and embedded into the treatment workflow. We have expanded and improved the application of traditional TEE and integrated the concept of critical care, established the concept of transesophageal echocardiography for critical care (TEECC). Chinese Critical Ultrasound Study Group (CCUSG) organized experts in the area to form the consensus based the previous studiesand the long term practice of critical care ultrasound and TEE, aiming at clarifying the nature and characteristics of TEECC, promoting the rational and standardized clinical application and the coming researches.The consensus of Chinese experts on clinical application of TEECC (2019) were 33 in total, of whichthe main items were as follows: (1) TEECC is a significant means, which is expanded and improved from the traditional transesophageal echocardiography according to characteristics of critically ill patients and is applied in ICU based on critically clinical scenarios and requirements by the critical care physician, to promote visualized, refined and precisely management of critically ill patients.(2) TEE possesses distinctive superiority in implementation in ICU. It has characteristics of images with good quality, operations with good stability and low-dependent of operators, monitoring with continuity, and visualization with all-dimensional and detail of heart and blood vessels.(3)As a means of refined monitoring that could resulted in precise diagnosis and treatment, TEECC expands the dimension of intensive monitoring and improves the performance of critical care. (4) Indications of TEECC application include clinical etiological searching and invasive procedures guiding when it acted as a traditional role; and also refined hemodynamic monitoring based on critical care rationale and over-all management under specific critical clinical scenarios. (5) TEE and TTE assessments are complementary; they are not alternative. Integrated assessment of TTE and TEE is required under many critical clinical scenarios.(6) TEE should be a necessary configuration in ICU. (7) All-round and significant information regarding to the mechanism of acute circulatory disorders can be provided by TEECC; it is a non-substitutable means of identifying the causes of shock under some special clinical scenarios. (8) Focal extracardiac hematoma can be accurately and rapidly detected by TEE in patients with open-thoracic cardiac surgery or severe chest trauma when highly suspected pericardial tamponade.(9) The priority of pathophysiologic mechanism of septic shock can be rapidly and accurately identified by TEE; even if its pathophysiological changes are complex, including hypovolemia and/or vasospasm and/or left and right heart dysfunction. (10) Causes of hemodynamic disorders can be rapidly and qualitatively evaluated so that the orientation of treatment can be clarified by TEECC. (11) A full range of quantitative indicators for refined hemodynamic management in critically ill patients can be provided by TEECC. (12) TEECC helps to accurately assess volume status and predict fluid responsiveness.(13) TEECC is specially suitable for accurate quantitative assessment of cardiac function.(14) Mini TEE provides long-term continuous hemodynamic monitoring. (15) Standard views are easy to be acquired by TEECC, which is a premise for accurate and repeatable measurements, and a guarantee for assessment of effect and risk of therapy. (16) Compared with invasive hemodynamic monitoring, TEECC is minimally invasive, with low infection risk and high safety.(17) In patients with acute cor pulmonale (ACP) under condition of right ventricular dysfunction and low cardiac output, TEECC is a key tool for assessment. (18) TEECC should be implemented actively when suspicious of left to right shunt in critically ill patients who occurred hypotension that hard to explain the cause. (19) TEECC should be implemented actively when suspicious of right to left shunt in critically ill patients who occurred hypoxemia that hard to explain the cause. (20) TEECC is preferred in hemodynamics monitoring under prone position of ventilated patients.(21) TEECC is an imperative means to achieve over-all management of extracorporeal membrane oxygenation (ECMO) therapy, especially for all-round hemodynamic monitoring. (22) Three basic views is recommended to be used to simplify TEE assessment during cardiac arrest so that reversible causes could be identified, and resuscitation could be guided. (23) The flow related echodynamic evaluation (TEECC-FREE) workflow is preferred in refined hemodynamics monitoring and therapy. (24) Simple workflow of TEECC could be implemented in special critical clinical scenarios. (25) Application of TEECC is highly secure; however, impairments of procedure should also be alert by operators. (26) Pitfalls in application of TEE should be paid attention to by the critical care physician. (27) Timely and rationally application of TEECC is in favor of diagnosis and treatment of critically ill patients and may improve the prognosis.


Assuntos
Consenso , Cuidados Críticos , Ecocardiografia Transesofagiana , China , Estado Terminal , Ecocardiografia Transesofagiana/efeitos adversos , Ecocardiografia Transesofagiana/métodos , Coração/fisiologia , Coração/fisiopatologia , Humanos , Unidades de Terapia Intensiva
3.
Med. infant ; 26(2): 139-141, Junio 2019. ilus
Artigo em Espanhol | LILACS | ID: biblio-1015939

RESUMO

El control ecocardiográfico al momento de la reparación de las cardiopatías congénitas es una estrategia cardiológica para mejorar los resultados quirúrgicos de nuestros pacientes. En este artículo les contamos cómo es el método, qué información nos brinda y cómo influye en la toma de decisiones en el quirófano y en el manejo posoperatorio (AU)


Echocardiographic monitoring at the time of congenital heart defects repair is a strategy to improve the surgical outcomes of our patients. In this article we discuss the method, what information it provides, and how it influences decision-making in the operating room and postoperative management (AU)


Assuntos
Humanos , Recém-Nascido , Lactente , Pré-Escolar , Criança , Monitorização Intraoperatória/métodos , Ecocardiografia Transesofagiana/efeitos adversos , Ecocardiografia Transesofagiana/métodos , Cardiopatias Congênitas/cirurgia , Cardiopatias Congênitas/diagnóstico por imagem , Circulação Extracorpórea , Cuidados Intraoperatórios
6.
J Hosp Infect ; 102(1): 54-60, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30630000

RESUMO

BACKGROUND: Enterobacteriaceae are recognized as leading pathogens of healthcare-associated infections. AIM: To report the investigation of a nosocomial outbreak of extended-spectrum ß-lactamase-producing Enterobacter cloacae affecting cardiothoracic surgery patients in a Belgian academic hospital. METHODS: Cases were defined based on epidemiological and microbiological investigations, including molecular typing using repetitive element-based polymerase chain reaction and multi-locus sequence typing. Case-control studies followed by field evaluations allowed the identification of a possible reservoir, and the retrospective assessment of human and financial consequences. FINDINGS: Over a three-month period, 42 patients were infected or colonized by CTX-M-15-producing E. cloacae strains that belonged to the same clonal lineage. Acquisition mainly occurred in the intensive care unit (N = 23) and in the cardiothoracic surgery ward (N = 16). All but one patient had, prior to acquisition, undergone a cardiothoracic surgical procedure, monitored by the same transoesophageal echocardiography (TOE) probe in the operating room. Despite negative microbiological culture results, the exclusion of the suspected probe resulted in rapid termination of the outbreak. Overall, the outbreak was associated with a high mortality rate among infected patients (40%) as well as significant costs (€266,550). CONCLUSION: The outbreak was indirectly shown to be associated with the contamination of a manually disinfected TOE probe used per-operatively during cardiothoracic surgery procedures, because withdrawal of the putative device led to rapid termination of the outbreak.


Assuntos
Infecção Hospitalar/epidemiologia , Surtos de Doenças , Enterobacter cloacae/isolamento & purificação , Infecções por Enterobacteriaceae/epidemiologia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Bélgica/epidemiologia , Estudos de Casos e Controles , Infecção Hospitalar/microbiologia , Ecocardiografia Transesofagiana/efeitos adversos , Enterobacter cloacae/classificação , Enterobacter cloacae/enzimologia , Enterobacter cloacae/genética , Infecções por Enterobacteriaceae/microbiologia , Feminino , Técnicas de Genotipagem , Humanos , Masculino , Pessoa de Meia-Idade , Tipagem de Sequências Multilocus , Estudos Retrospectivos , beta-Lactamases/metabolismo
12.
Arch Cardiovasc Dis ; 111(12): 730-738, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30539734

RESUMO

BACKGROUND: Few data are available on the application of transoesophageal echocardiography (TOE) recommendations in daily practice. AIMS: To evaluate TOE practice based on echocardiography societies' guidelines, and to determine complication rates and factors associated with patient feelings. METHODS: Between April and June 2017, we prospectively included all consecutive patients referred to 14 French hospitals for a transoesophageal echocardiogram (TOE). A survey was taken just after the examination, which included questions about pre-procedural anxiety, and any pain, unpleasant feeling or breathing difficulties experienced during the examination. RESULTS: Overall, 1718 TOEs were performed, mainly for stroke evaluation. A standardized operating procedure checklist was completed in half of the patients before the examination. TOE was unpleasant for 62.4% of patients, but was stopped for agitation or intolerance in 3.5 and 1.4% of cases, respectively. We observed one severe complication (pulmonary oedema). The mean TOE duration was short (9.2±4.6minutes), but was longer with residents than with more experienced physicians (11±4.7 vs. 8.8±4.7minutes for junior physicians [P=0.0027]; vs. 8.9±4.8minutes for senior physicians [P=0.0013]; and vs. 7.5±4.1minutes for associate professors/professors [P<0.0001]). The visual analogue scale (VAS) score after TOE was good (8.3±1.7 out of 10), and was better in patients with general anaesthesia (GA) than in those without GA (9.3±0.9 vs. 8.1±1.7; P<0.0001). In patients without GA, the VAS score was similar with and without local anaesthesia (8.1±1.7 vs. 8.2±1.6; P=0.19). After multivariable adjustment, absence of anxiety before TOE and greater operator experience were consistently associated with a higher VAS score. CONCLUSIONS: TOE is safe, with a low rate of complications and few stops for intolerance. A shorter TOE duration and better patient feelings were observed for experienced operators, highlighting the importance of the learning curve, and paving the way for teaching on a TOE simulator.


Assuntos
Ecocardiografia Transesofagiana/tendências , Cardiopatias/diagnóstico por imagem , Padrões de Prática Médica/tendências , Idoso , Idoso de 80 Anos ou mais , Competência Clínica , Ecocardiografia Transesofagiana/efeitos adversos , Ecocardiografia Transesofagiana/normas , Feminino , França , Fidelidade a Diretrizes/tendências , Humanos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Valor Preditivo dos Testes , Estudos Prospectivos
13.
Am J Cardiol ; 122(12): 2142-2146, 2018 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-30477726

RESUMO

The objective was to study the utility of transesophageal echocardiography (TEE) in affecting acute ischemic stroke treatment of older adults (age ≥80 years). Patients hospitalized in January 2010 and February 2015 were included who had TEE ordered as part of their diagnostic workup at a tertiary medical center. We studied 515 hospitalized patients with acute stroke or transient ischemic attack who underwent TEE. The proportion of patients with important TEE findings was 35%. However, TEE changed management in only 2.5% of cases. When anticoagulation for proximal mobile aorta atheroma was excluded, no change in management resulted from TEE for patients older than 80 years. In conclusion, TEE has a low likelihood of a pathologic finding that resulted in a change in treatment strategy, especially in patients ≥80 years of age.


Assuntos
Isquemia Encefálica/etiologia , Ecocardiografia Transesofagiana/efeitos adversos , Ataque Isquêmico Transitório/etiologia , Sistema de Registros , Medição de Risco/métodos , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Arizona/epidemiologia , Isquemia Encefálica/epidemiologia , Ecocardiografia Transesofagiana/tendências , Feminino , Seguimentos , Humanos , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
14.
Rev Port Cardiol ; 37(9): 763-772, 2018 09.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30219202

RESUMO

INTRODUCTION: Percutaneous closure of the left atrial appendage (LAA) is a promising therapy in patients with atrial fibrillation with high risk for stroke and contraindication for oral anticoagulation (OAC). Intracardiac echocardiography (ICE) may make this percutaneous procedure feasible in patients in whom transesophageal echocardiography (TEE) is inadvisable. Our aim was to assess the efficacy and safety of LAA closure and the feasibility of ICE compared to TEE to guide the procedure. METHODS: In this cohort study of patients who underwent LAA closure between May 2010 and January 2017, clinical and imaging assessment was performed before and after the procedure. RESULTS: In 82 patients (mean age 74±8 years, 64.4% male) the contraindications for OAC were severe bleeding or anemia (65%), high bleeding risk (14%), labile INR (16%), or recurrent embolic events (5%). The procedural success rate was 96.3%. The procedure was guided by TEE or ICE, and no statistically significant differences were observed between the two techniques. During follow-up, one patient had an ischemic stroke at 12 months, two had bleeding complications at six months, and there were four non-cardiovascular deaths. Embolic and bleeding events were less frequent than expected from the observed CHA2DS2VASc (0.6% vs. 6.3%; p<0.001) and HAS-BLED (1.2% vs. 4.1%; p<0.001) risk scores. CONCLUSIONS: In this population percutaneous LAA closure was shown to be safe and effective given the lower frequency of events than estimated by the CHA2DS2VASc and HAS-BLED scores. The clinical and imaging results of procedures guided by ICE in the left atrium were not inferior to those guided by TEE.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/diagnóstico por imagem , Ecocardiografia , Ultrassonografia de Intervenção , Idoso , Idoso de 80 Anos ou mais , Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Estudos de Coortes , Ecocardiografia/efeitos adversos , Ecocardiografia/métodos , Ecocardiografia/estatística & dados numéricos , Ecocardiografia Transesofagiana/efeitos adversos , Ecocardiografia Transesofagiana/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Complicações Pós-Operatórias , Acidente Vascular Cerebral , Ultrassonografia de Intervenção/efeitos adversos , Ultrassonografia de Intervenção/métodos , Ultrassonografia de Intervenção/estatística & dados numéricos
15.
JACC Cardiovasc Interv ; 11(11): 1086-1092, 2018 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-29880104

RESUMO

OBJECTIVES: This study sought to evaluate the feasibility, safety, and efficacy of intracardiac echocardiography (ICE)-guided versus transesophageal echocardiography (TEE)-guided left atrial appendage occlusion (LAAO) by the use of Amplatzer Cardiac Plug or Amulet devices included in a large Italian registry. BACKGROUND: TEE is widely used for LAAO procedure guidance. ICE may be a potential alternative imaging modality in LAAO. METHODS: Data from 604 LAAO procedures performed in 16 Italian centers were reviewed. ICE-guided LAAO was performed in 187 patients, whereas TEE was used in 417 patients. Procedural success was defined as LAAO without occurrence of pericardial tamponade, stroke, systemic embolism with end organ damage, major bleeding, and device embolization. Stroke, transient ischemic attack, major bleeding, overall and cardiovascular death were analyzed. RESULTS: CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65 to 74 years, sex category) and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) scores were similar between the ICE and TEE groups. TEE implied lower procedural (delta 12 min) and fluoroscopy time (delta 5 min) when compared with ICE. Procedural success was similarly high (≥94%) between the TEE and ICE groups with a complication rate of 6.5% for TEE versus 4.2% for ICE (odds ratio: 1.468; 95% confidence interval: 0.681 to 3.166; p = 0.327). At median follow-up of 451 days (interquartile range: 162 to 899 days), the rate of cerebral ischemic events was similar between TEE-guided and ICE-guided procedures. CONCLUSIONS: ICE-guided LAAO by means of Amplatzer devices may represent a second alternative imaging modality after an appropriate learning curve and bearing in mind that pre-procedural computed tomography imaging is mandatory. When comparing ICE with TEE, TEE remains the gold standard.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/terapia , Cateterismo Cardíaco/métodos , Ecocardiografia Transesofagiana , Ultrassonografia de Intervenção/métodos , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico por imagem , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Ecocardiografia Transesofagiana/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Itália , Masculino , Valor Preditivo dos Testes , Sistema de Registros , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos
17.
J Am Coll Cardiol ; 71(11): 1246-1254, 2018 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-29544609

RESUMO

BACKGROUND: Transesophageal echocardiography operators (TEEOP) provide critical imaging support for percutaneous structural cardiac intervention procedures. They stand close to the patient and the associated scattered radiation. OBJECTIVES: This study sought to investigate TEEOP radiation dose during percutaneous structural cardiac intervention. METHODS: Key personnel (TEEOP, anesthetist, primary operator [OP1], and secondary operator) wore instantly downloadable personal dosimeters during procedures requiring TEE support. TEEOP effective dose (E) and E per unit Kerma area product (E/KAP) were calculated. E/KAP was compared with C-arm projections. Additional shielding for TEEOP was implemented, and doses were measured for a further 50 procedures. Multivariate linear regression was performed to investigate independent predictors of radiation dose reduction. RESULTS: In the initial 98 procedures, median TEEOP E was 2.62 µSv (interquartile range [IQR]: 0.95 to 4.76 µSv), similar to OP1 E: 1.91 µSv (IQR: 0.48 to 3.81 µSv) (p = 0.101), but significantly higher than secondary operator E: 0.48 µSv (IQR: 0.00 to 1.91 µSv) (p < 0.001) and anesthetist E: 0.48 µSv (IQR: 0.00 to 1.43 µSv) (p < 0.001). Procedures using predominantly right anterior oblique (RAO) and steep RAO projections were associated with high TEEOP E/KAP (p = 0.041). In a further 50 procedures, with additional TEEOP shielding, TEEOP E was reduced by 82% (2.62 µSv [IQR: 0.95 to 4.76] to 0.48 µSv [IQR: 0.00 to 1.43 µSv] [p < 0.001]). Multivariate regression demonstrated shielding, procedure type, and KAP as independent predictors of TEEOP dose. CONCLUSION: TEE operators are exposed to a radiation dose that is at least as high as that of OP1 during percutaneous cardiac intervention. Doses were higher with procedures using predominantly RAO projections. Radiation doses can be significantly reduced with the use of an additional ceiling-suspended lead shield.


Assuntos
Ecocardiografia Transesofagiana , Exposição Ocupacional , Intervenção Coronária Percutânea/métodos , Exposição à Radiação , Proteção Radiológica/métodos , Austrália , Ecocardiografia Transesofagiana/efeitos adversos , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Masculino , Exposição Ocupacional/análise , Exposição Ocupacional/prevenção & controle , Doses de Radiação , Exposição à Radiação/análise , Exposição à Radiação/prevenção & controle
18.
Clin Microbiol Infect ; 24(12): 1251-1256, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29581048

RESUMO

BACKGROUND: Recent criteria which can identify patients with Staphylococcus aureus bacteraemia (SAB) who are at very low risk of endocarditis raise the question of whether transoesophageal echocardiography (TOE) is appropriate for these patients. AIMS: To estimate the probability of occult endocarditis complicating SAB below which a TOE-guided treatment strategy no longer offers the best 180-day survival, and to examine the key uncertainties affecting this result. SOURCES: Estimates of the parameters required to calculate the Pauker-Kassirer testing threshold were identified from studies published prior to 1 June 2017 using a composite search strategy that involved a systematic search for relevant controlled trials and guidelines, followed by a non-systematic iterative search of the observational literature. CONTENT: Estimates of the necessary parameters were generally consistent across the literature with the exception of the procedural mortality of TOE. In our base-case scenario (TOE mortality 0.1%), the testing threshold for TOE in apparently uncomplicated SAB was a 1.1% probability of occult endocarditis. Sensitivity analyses revealed that the procedural mortality of TOE was a key uncertainty affecting estimates of the testing threshold. IMPLICATIONS: None of the available clinical tools can place patients with SAB below this probability of endocarditis with 95% confidence. Future work in this area should concentrate on improving the precision of these tools and on exploring the value of alternative echocardiography strategies. In addition, a better understanding of the harms of TOE is required to ensure that recommendations regarding the role of this investigation in the management of patients with SAB are appropriate.


Assuntos
Bacteriemia/complicações , Ecocardiografia Transesofagiana/efeitos adversos , Endocardite Bacteriana/diagnóstico , Infecções Estafilocócicas/complicações , Adulto , Pré-Escolar , Endocardite Bacteriana/etiologia , Endocardite Bacteriana/microbiologia , Humanos , Mortalidade , Fatores de Risco , Infecções Estafilocócicas/sangue , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus/isolamento & purificação
19.
Catheter Cardiovasc Interv ; 92(2): 401-407, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-29388306

RESUMO

BACKGROUND: Preliminary data comparing 3-dimensional computed tomography (3D-CT) to transesophageal echocardiography (TEE) for left atrial appendage occlusion (LAAO) indicates that 3D-CT provides more accurate measurements and improves case planning. Therefore, we conducted a pilot study comparing 3D-CT to TEE in occluder selection accuracy and procedural efficiency. METHODS: From May 2016 to February 2017, 24 patients were prospectively randomized to undergo LAAO using either TEE or 3D-CT. The primary endpoint was device accuracy while the secondary endpoints included # devices per case, # guide catheters used per case, # fluoroscopy angles used, procedure time, fluoroscopy time, radiation dose, and major adverse events (stroke, MI, device embolization, perforation, death). RESULTS: Procedure success was 100% and 92% for the 3D-CT and 2D-TEE cohorts respectively. Accuracy for 1st device selection 92% and 27% (P = .01) for 3D-CT and 2D-TEE respectively but with intra-procedural upsizing in the 2D-TEE cohort, the 2D-TEE cohort accuracy increased to 64% while the 3D-CT groups 92% was accurate (P = .33). Case planning using 3D-CT was significantly more efficient with respect to device utilization (CT 1.33 ± 0.7 vs. 2D-TEE 2.5 ± 1.2 P = .01), guide catheters (CT 1 vs. 2D-TEE 1.7 ± 0.8 P = .01) and procedure time (3D-CT 55 ± 17 min vs. 2D-TEE 73 ± 24 min P < .05). One major adverse event, a stroke occurred in the 2D-TEE group. CONCLUSION: In this single-center pilot study, CT guided LAAO case planning was associated with improved device selection accuracy and procedural efficiency. This study data supports the notion that comprehensive 3D assessment significantly simplifies LAAO, minimizing the time and number of steps needed.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/terapia , Cateterismo Cardíaco/métodos , Ecocardiografia Transesofagiana , Imagem Tridimensional , Radiografia Intervencionista/métodos , Tomografia Computadorizada por Raios X , Ultrassonografia de Intervenção/métodos , Idoso , Idoso de 80 Anos ou mais , Apêndice Atrial/fisiopatologia , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Ecocardiografia Transesofagiana/efeitos adversos , Feminino , Humanos , Imagem Tridimensional/efeitos adversos , Masculino , Michigan , Projetos Piloto , Valor Preditivo dos Testes , Impressão Tridimensional , Estudos Prospectivos , Doses de Radiação , Exposição à Radiação , Interpretação de Imagem Radiográfica Assistida por Computador , Radiografia Intervencionista/efeitos adversos , Reprodutibilidade dos Testes , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X/efeitos adversos , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos
20.
Semin Cardiothorac Vasc Anesth ; 22(2): 122-136, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29441818

RESUMO

Intraoperative use of transesophageal echocardiography (TEE) has become commonplace in high-risk noncardiac surgeries but the balance of benefits and harms remains unclear. This systematic review investigated the comparative effectiveness and harms of intraoperative TEE in noncardiac surgery. We searched Ovid MEDLINE, PubMed, EMBASE, and the Cochrane Library from 1946 to March 2017. Two reviewers independently screened the literature for eligibility. Studies were assessed for the risk of selection bias, confounding, measurement bias, and reporting bias. Three comparative and 13 noncomparative studies were included. Intraoperative TEE was employed in a total of 1912 of 3837 patients. Studies had important design limitations. Data were not amenable to quantitative synthesis due to clinical and methodological diversity. Reported incidence of TEE complications ranged from 0% to 1.7% in patients undergoing various procedures (5 studies, 540 patients). No serious adverse events were observed for mixed surgeries (2 studies, 197 patients). Changes in surgical or medical management attributable to the use of TEE were noted in 17% to 81% of patients (7 studies, 558 patients). The only randomized trial of intraoperative TEE was grossly underpowered to detect meaningful differences in 30-day postoperative outcomes. There is lack of high-quality evidence of effectiveness and harms of intraoperative TEE in the management of non-cardiac surgeries. Evidence, however, indicates timely evaluation of cardiac function and structure, and hemodynamics. Future studies should be comparative evaluating confounder-adjusted impact on both intraoperative and 30-day postoperative clinical outcomes.


Assuntos
Ecocardiografia Transesofagiana , Monitorização Intraoperatória , Ecocardiografia Transesofagiana/efeitos adversos , Hemodinâmica , Humanos
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