Guidelines for Performing a Comprehensive Transesophageal Echocardiographic

Iatrogenic Aortic Regurgitation Caused by Arterial Cannula Tip Rotation During Cardiopulmonary Bypass: A Case Report

Iatrogenic aortic regurgitation (AR) after ventricular septal defect (VSD) closure occurs because of the distortion of the aortic valve or leaflet perforation. We presented a case of a 1-month-old child who had iatrogenic AR after VSD closure caused by the rotation of the arterial cannula tip toward the aortic valve during cardiopulmonary bypass. Transesophageal echocardiography (TEE) detected a retrograde jet flow from the arterial cannula to the aortic valve, causing eccentric AR. Our case shows a new differential diagnosis of iatrogenic AR after VSD closure and TEE's usefulness with color Doppler imaging to identify the direction of the arterial cannula tip.

Hemodynamic Effects of Altering Tidal Volume During Positive Pressure Ventilation in the Fontan Circulation: A Randomized Crossover Trial

BACKGROUND

Primary determinants of pulmonary blood flow in the Fontan circulation are low transpulmonary gradient and pulmonary vascular resistance (PVR). Changes in intrathoracic pressure during intermittent positive pressure ventilation can influence the transpulmonary gradient, PVR, pulmonary blood flow, and cardiac output. The aim of this study was to evaluate the effect of low (5 mL/kg) versus high (10 mL/kg) tidal volume (VT) ventilation on Fontan circulation hemodynamics.

METHOD

Postoperative patients with a Fontan circulation were enrolled in this single-center, randomized crossover trial. Patients, randomized to group 1 or 2, underwent a ventilation study sequence (baseline ventilation [7 mL/kg], then high VT [10 mL/kg] or low VT [5 mL/kg], then washout ventilation [7 mL/kg], followed by low [5 mL/kg] or high VT [10 mL/kg]) in the operating room at the end of the cardiac surgical procedure. Respiratory, hemodynamic, and transesophageal (TEE) measurements were recorded after 5 min in each ventilation condition. The primary aim of this study was to evaluate the effect of low VT ventilation (5 mL/kg) versus high VT ventilation (10 mL/kg) on transpulmonary gradient (Fontan pressure minus left atrial pressure). The secondary aim was to compare TEE measurements of pulmonary blood flow, stroke volume, and Fontan flow between low and high VT ventilation. We also compared standard hemodynamic and ventilation parameters for all ventilation conditions. Analysis was of paired data, calculating the between-treatment difference within participants across ventilation conditions.

RESULTS

Eleven patients were included in the final data analysis with a median [IQR] age of 5 [4, 11] years and weight of 16.3 [13.8, 31.6] kg. The mean (±SD) peak inspiratory pressure during low and high VT ventilation was 15.3 (±2.9) cmH2O and 22.2 (±3.7) cmH2O, respectively (difference -6.9, 95% CI -7.8, -5.9, p < 0.001). The mean airway pressure during low and high VT ventilation was 7.3 ± 0.8 and 8.7 ± 0.9 (difference -1.5, 95% CI -2.1, -0.8, p = 0.001) with a mean inspiratory time of 0.62 (±0.22) s and 1.21 (±0.55) s (difference -0.59, 95% CI -0.84, -0.34, p < 0.001), respectively. During low VT ventilation, the mean Fontan pressure was 13.3 (±1.8) mmHg compared to 12.3 (±2.5) mmHg for high VT ventilation (difference 0.8, 95% CI -0.5, 2.1, p = 0.18). The mean transpulmonary gradient was 7.0 ± 1.3 mmHg compared to 6.8 ± 1.2 mmHg during low and high VT ventilation, respectively (difference 0.2, 95% CI -0.2, 0.6, p = 0.21). We found no significant differences between low and high VT ventilation in TEE measures of pulmonary blood flow, stroke volume, and Fontan flow.

CONCLUSIONS

This randomized, crossover pilot trial of Fontan patients showed that a low VT ventilation (5 mL/kg) resulted in significantly lower peak and mean airway pressure compared with a high VT ventilation (10 mL/kg). However, there were no significant changes in transpulmonary gradient, mean Fontan pressure, or TEE parameters of stroke volume, pulmonary blood flow, or Fontan flow.

CLINICAL TRIALS REGISTRATION NUMBER

NCT04633343.

PRINCIPAL INVESTIGATOR

Manchula Navaratnam.

DATE OF REGISTRATION

November 11, 2020. Clinical Trials Registration Registry URL: https://clinicaltrials.gov/study/NCT04633343?term=Fontan%20ventilation&rank=3.

PRIOR PRESENTATIONS

Congenital Cardiac Anesthesia Society Annual Meeting Top Oral Abstract Presentation.

PRESENTER

Alexander R Schmidt, March 30th, 2023.

Multimodality Imaging Approach to Infective Endocarditis: Current Opinion in Patients with Congenital Heart Disease

Although advances in medical and surgical management have significantly improved clinical outcomes, infective endocarditis (IE) remains a significant threat to patients with congenital heart disease (CHD). The complexity of cardiac anatomy, the presence of prosthetic materials, and the emergence of novel pathogens pose unique diagnostic challenges in this specific population. However, the use of personalized imaging, integrating the strengths of each modality, has the potential to refine the diagnostic process, thereby optimizing diagnostic accuracy, guiding therapeutic decisions, and, ultimately, improving patient clinical outcomes. This review delves into the critical role of the multimodality imaging approach in the care of patients with IE and CHD, underscoring the importance of tailored and patient-centered management strategies in this vulnerable cohort.

Transesophageal Echocardiography-Related Complications During Mitral Valve Repair in Dogs

BACKGROUND

Transesophageal echocardiography (TEE) is an indispensable modality in cardiac surgery; however, the complications associated with its use in veterinary clinical settings remain unclear.

HYPOTHESIS/OBJECTIVES

To investigate the complications associated with TEE probe manipulation during mitral valve repair in dogs and identify the risk factors for new mucosal injuries.

ANIMALS

This prospective study evaluated 60 client-owned dogs that underwent TEE to support mitral valve repair.

METHODS

Esophageal endoscopy was performed twice-once after anesthesia induction and once before extubation-to assess esophageal mucosal injuries during the procedure. The type of injury was classified as 'complex' (intramural hematoma and mucosal laceration), 'minor' (petechiae and ecchymosis), or 'minute' (visible only on narrowband imaging) lesions. During the surgery, TEE was performed three times. Hemodynamics were evaluated before the initial TEE insertion and immediately after it was removed.

RESULTS

Of the 60 dogs, newly detected mucosal lesions were observed in 20 dogs and classified as 'minor' in four and 'minute' in 16 dogs. These 'minute' lesions were not visible with conventional endoscopy, and no 'complex' lesions were identified. No significant factors were associated with the presence of mucosal lesions. After TEE insertion, systolic blood pressure decreased from 95 ± 13 mmHg to 92 ± 11 mmHg (p = 0.008), and heart rate decreased from 128 ± 25 bpm to 123 ± 24 bpm (p < 0.001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Intraoperative TEE results in a low incidence of esophageal mucosal injuries. Hemodynamic changes could occur during TEE manipulation, underscoring the need for close monitoring.

Proposed Quality Metrics for Congenital Cardiac Anesthesia: A Scoping Review

Congenital cardiac anesthesiologists practice in a unique environment with high risk for morbidity and mortality. Quality metrics can be used to focus clinical initiatives on evidence-based care and provide a target for local quality improvement measures. However, there has been no comprehensive review on appropriate quality metrics for congenital cardiac anesthesia to date. Members of the Quality and Safety Committee for the Congenital Cardiac Anesthesia Society proposed 31 possible candidate topics for metrics. Using a scoping review strategy, 3649 abstracts were reviewed with 30 articles meeting final criteria. Of these, 5 candidate metrics were unanimously proposed for local collection and national benchmarking efforts: use of a structured handover in the intensive care unit, use of an infection prevention bundle, use of blood conservation strategies, early extubation of cardiopulmonary bypass cases, and cardiac arrest under the care of a cardiac anesthesiologist. Many metrics were excluded due to a lack of primary data and perceived complexity beyond the scope of cardiac anesthesia practice. There is a need to develop more primary data including linking process measures with outcomes, developing risk-stratification for our patients, and collecting national data for benchmarking purposes.

Application of Echocardiography in Anaesthesia: From Preoperative Risk Assessment to Postoperative Care

Echocardiography has carved out a fundamental niche in anaesthesiology, revolutionizing the monitoring and management of cardiac function during surgery. Clinical practice has changed from simple 2D and 3D echocardiography to more sophisticated applications such as incorporating artificial intelligence. Echocardiography provides detailed real-time information about cardiac anatomy and function, helping anaesthesiologists make better decisions regarding tailoring anesthetic interventions and optimizing patient outcomes. From optimizing hemodynamic management in patients with severe aortic stenosis to fine-tuning fluid and vasopressor therapy in patients with right heart dysfunction, echocardiography has improved the care provided in the perioperative period. These applications permit the demonstration of not only technical advantages that could accrue from echocardiography but are also a part of individualized care to improve the outcomes of patients. The challenges in integrating echocardiography with anaesthesia include operator dependency, a steep learning curve in acquiring echocardiographic skills, and limitations due to patient factors and technological limitations, which lead to poor echocardiographic performance. Additionally, transoesophageal echocardiography (TEE) is an invasive procedure with several potential risks that must be considered cautiously. Continuing education, certification recommendations, and skill development are prerequisites for this echocardiography tool to remain robust and reliable in anaesthesiology. Technological innovation, especially in improving 3D imaging and integration with artificial intelligence, is where a very bright future lies ahead for echocardiography. It would further accelerate the process of echocardiographic evaluation and improve diagnostic accuracy. All these would turn out to be more person-centered for each patient. Anaesthesiologists must, therefore, pace themselves with such developments so these can be appropriately applied in the clinics. In summary, echocardiography became so integrally ingrained into anaesthesia that it propelled the specialty with essential tools anaesthesiologists use to manage patients for optimum outcomes. Its application has difficulties and limitations, but continued professional development and development of echocardiographic technology will make sure that its benefits are maximized. Quickly, echocardiography is becoming central to anaesthesiology's role in optimizing patient care and surgical success as we move into the application of evermore sophisticated echocardiographic techniques.

Clinical Presentation and Management of the Cervical Aortic Arch in the Adult Population: A Review of Case Reports

The cervical aortic arch (CAA) is an uncommon congenital anomaly in aortic development, characterized by an elongated aortic arch extending at or above the medial ends of the clavicles. Our objective was to examine the clinical and surgical characteristics of this infrequent condition in the adult population. PubMed, ScienceDirect, SciELO, DOAJ, and Cochrane Library databases were searched until December 2023 for case reports describing the presence of a cervical aortic arch in patients aged ≥18 years. Case reports and series were included if the following criteria were met: (1) description of the cervical aortic arch, (2) age ≥18 years, and (3) English language. The literature search identified 2,325 potentially eligible articles, 61 of whom met our inclusion criteria and included a combined number of 71 patients. Mean age was 38.6 ± 15.4 years, with a female prevalence of 67.1% (47/70). Two-thirds of the CAA were left-sided (48/71, 67.6%), and 62.0% (44/71) of patients presented a concomitant arch aneurysm. Asymptomatic patients were 45.7% (32/70), while of those that were symptomatic, 60.5% (23/38) had symptoms related to vascular-induced compression of trachea and esophagus. Surgery was performed in 42 patients (62.7%) among 67 cases that reported the patient's treatment, and 5 patients (11.9%) among those surgically treated underwent the procedure through an endovascular approach. CAA is an uncommon congenital abnormality that presents challenges in diagnosis and treatment due to its high anatomical variability, diverse clinical manifestations, and presence of concomitant diseases. Surgery seems to be a safe and effective option for the resolution of symptoms.

Evaluation of responses to cardiac imaging questions by the artificial intelligence large language model ChatGPT

PURPOSE

To assess ChatGPT's ability as a resource for educating patients on various aspects of cardiac imaging, including diagnosis, imaging modalities, indications, interpretation of radiology reports, and management.

METHODS

30 questions were posed to ChatGPT-3.5 and ChatGPT-4 three times in three separate chat sessions. Responses were scored as correct, incorrect, or clinically misleading categories by three observers-two board certified cardiologists and one board certified radiologist with cardiac imaging subspecialization. Consistency of responses across the three sessions was also evaluated. Final categorization was based on majority vote between at least two of the three observers.

RESULTS

ChatGPT-3.5 answered seventeen of twenty eight questions correctly (61 %) by majority vote. Twenty one of twenty eight questions were answered correctly (75 %) by ChatGPT-4 by majority vote. Majority vote for correctness was not achieved for two questions. Twenty six of thirty questions were answered consistently by ChatGPT-3.5 (87 %). Twenty nine of thirty questions were answered consistently by ChatGPT-4 (97 %). ChatGPT-3.5 had both consistent and correct responses to seventeen of twenty eight questions (61 %). ChatGPT-4 had both consistent and correct responses to twenty of twenty eight questions (71 %).

CONCLUSION

ChatGPT-4 had overall better performance than ChatGTP-3.5 when answering cardiac imaging questions with regard to correctness and consistency of responses. While both ChatGPT-3.5 and ChatGPT-4 answers over half of cardiac imaging questions correctly, inaccurate, clinically misleading and inconsistent responses suggest the need for further refinement before its application for educating patients about cardiac imaging.

Wilms Tumor with Vena Caval Intravascular Extension: A Surgical Perspective

Wilms tumor (WT) is the most common kidney tumor in pediatric patients. Intravascular extension of WT above the level of the renal veins is a rare manifestation that complicates surgical management. Patients with intravascular extension are frequently asymptomatic at diagnosis, and tumor thrombus extension is usually diagnosed by imaging. Neoadjuvant chemotherapy is indicated for thrombus extension above the level of the hepatic veins and often leads to thrombus regression, obviating the need for cardiopulmonary bypass in cases of cardiac thrombus at diagnosis. In cases of tumor extension to the retrohepatic cava, neoadjuvant therapy is not strictly indicated, but it may facilitate the regression of tumor thrombi, making resection safer. Hepatic vascular isolation and cardiopulmonary bypass increase the risk of bleeding and other complications when utilized for tumor thrombectomy. Fortunately, WT patients with vena caval with or with intracardiac extension have similar overall and event-free survival when compared to patients with WT without intravascular extension when thrombectomy is successfully performed. Still, patients with metastatic disease at presentation or unfavorable histology suffer relatively poor outcomes. Dedicated pediatric surgical oncology and pediatric cardiothoracic surgery teams, in conjunction with multimodal therapy directed by a multidisciplinary team, are preferred for optimized outcomes in this patient population.

Contemporary transesophageal echocardiography practice patterns among paediatric cardiology centres in the United States and Canada

OBJECTIVE

To characterise transesophageal echocardiography practice patterns among paediatric cardiac surgical centres in the United States and Canada.

METHODS

A 42-question survey was sent to 80 echocardiography laboratory directors at paediatric cardiology centres with surgical programmes in the United States and Canada. Question domains included transesophageal echocardiography centre characteristics, performance and reporting, equipment use, trainee participation, and quality assurance.

RESULTS

Fifty of the 80 centres (62.5%) responded to the survey. Most settings were academic (86.0%) with 42.0% of centres performing > 350 surgical cases/year. The median number of transesophageal echocardiograms performed/cardiologist/year was 50 (26, 73). Pre-operative transesophageal echocardiography was performed in most surgical cases by 91.7% of centres. Transesophageal echocardiography was always performed by most centres following Norwood, Glenn, and Fontan procedures and by < 10% of centres following coarctation repair. Many centres with a written guideline allowed transesophageal echocardiography transducer use at weights below manufacturer recommendations (50.0 and 61.1% for neonatal and paediatric transducers, respectively). Most centres (36/37, 97.3%) with categorical fellowships had rotations which included transesophageal echocardiography participation. Large surgical centres (>350 cases/year) had higher median number of transesophageal echocardiograms/cardiologist/year (75.5 [53, 86] versus 35 [20, 52], p < 0.001) and more frequently used anaesthesia for diagnostic transesophageal echocardiography ≥ 67% of time (100.0 versus 62.1%, p = 0.001).

CONCLUSIONS

There is significant variability in transesophageal echocardiography practice patterns and training requirements among paediatric cardiology centres in the United States and Canada. Findings may help inform programmatic decisions regarding transesophageal echocardiography expectations, performance and reporting, equipment use, trainee involvement, and quality assurance.

Usefulness of perioperative transoesophageal echocardiography during paediatric cardiac surgery

BACKGROUND

Paediatric transoesophageal echocardiography probes allow perioperative evaluation during paediatric congenital heart disease surgery.

AIM

To assess the usefulness of perioperative transoesophageal echocardiography in evaluating the severity of residual lesions, based on the type of congenital heart disease repaired in paediatric patients.

METHODS

A retrospective analysis was conducted on paediatric patients who underwent open-heart surgery at our tertiary centre over a four-year period. Perioperative transoesophageal echocardiography studies were performed, and residual lesions were classified as mild, moderate or severe.

RESULTS

Overall, 323 procedures involving 310 patients with a median age of 13.8 (0.07-214.4) months and a median weight of 8.2 (2-96) kg at intervention were enrolled in the study. Twenty-one (6.5%) residual lesions led to immediate reintervention: severe right ventricular outflow tract obstruction (n=12); severe aortic regurgitation (n=3); superior vena cava stenosis (n=2); moderate residual ventricular septal defect (n=2); severe mitral regurgitation (n=1); and severe mitral stenosis (n=1). Three (0.9%) neonates had ventilation difficulties caused by the transoesophageal echocardiography probe having to be removed, but experienced no sequelae.

CONCLUSION

Perioperative transoesophageal echocardiography is a safe procedure, providing information on severe residual lesions, leading to the immediate revision of several paediatric congenital heart disease cases.

Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography

Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Advancing paediatric cardiac imaging: a comprehensive analysis of the feasibility and accuracy of a novel 3D paediatric transoesophageal probe

Aims

Pediatric transoesophageal echocardiography (TOE) probes have remained two-dimensional (2D) limiting their use compared to adults. While critical in pediatrics for interventions and post-surgery assessments, technological advancements introduced a three-dimensional (3D) pediatric TOE probe. This study assessed the new 3D pediatric TOE probe (GE 9VT-D) for feasibility, handling, and imaging quality.

Methods and results

At Children's Hospital of Toulouse, 2-month prospective study enrolled children undergoing TOE with the new probe. All imaging modalities were rated by 2 operators using a 5-point Likert-type scale from 1 (very poor) to 5 (very good) quality. Forty-five children, median age 3.7 (range: 2 months-14.7 years) median weight 7.8 kg (range: 4.3-48 kg) underwent 60 TOEs: 25% pre-surgery, 45% post-surgery, 28% during percutaneous procedures, and 2% in intensive care. Probe handling was "very easy" in all cases without adverse events. The median score of 2D, 2D colour, pulsed Doppler and 3D were noted 5 out of 5 and continuous Doppler and 3D colour 4 out of 5. The 3D image quality remained consistent irrespective of the patient weighing above or below 7.8 kg (p = 0.72). Postoperative TOEs identified two cases needing further interventions, emphasizing its value in evaluating surgical outcomes and also for guiding percutaneous interventions.

Conclusion

Our comprehensive evaluation demonstrates that the new 3D pediatric TOE probe is feasible and provides high-quality imaging in pediatric patients. The successful integration of this novel probe into clinical practice has the potential to enhance diagnostic accuracy and procedural planning, ultimately optimizing patient outcomes in pediatric cardiac care.

Recommendations for centers performing pediatric heart surgery in the United States

Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

Recommendations for Centers Performing Pediatric Heart Surgery in the United States

Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

Imaging and guiding intervention for tricuspid valve disorders using 3-dimensional transesophageal echocardiography in pediatric and congenital heart disease

In the pediatric and congenital heart disease (CHD) population, tricuspid valve (TV) disorders are complex due to the variable TV morphology, its sophisticated interaction with the right ventricle as well as associated congenital and acquired lesions. While surgery is the standard of care for TV dysfunction in this patient population, transcatheter treatment for bioprosthetic TV dysfunction has been performed successfully. Detailed and accurate anatomic assessment of the abnormal TV is essential in the preoperative/preprocedural planning. Three-dimensional transthoracic and 3D transesophageal echocardiography (3DTEE) provides added value to 2-dimensional imaging in the characterization of the TV to guide therapy and 3DTEE serves as an excellent tool for intraoperative assessment and procedural guidance of transcatheter treatment. Notwithstanding advances in imaging and therapy, the timing and indication for intervention for TV disorders in this population are not well defined. In this manuscript, we aim to review the available literature, provide our institutional experience with 3DTEE, and briefly discuss the perceived challenges and future directions in the assessment, surgical planning, and procedural guidance of (1) congenital TV malformations, (2) acquired TV dysfunction from transvenous pacing leads, or following cardiac surgeries, and (3) bioprosthetic TV dysfunction.

Performance of four cardiac output monitoring techniques vs. intermittent pulmonary artery thermodilution during a modified passive leg raise maneuver in isoflurane-anesthetized dogs

Objective

This study investigated the performance among four cardiac output (CO) monitoring techniques in comparison with the reference method intermittent pulmonary artery thermodilution (iPATD) and their ability to diagnose fluid responsiveness (FR) during a modified passive leg raise (PLRM) maneuver in isoflurane-anesthetized dogs undergoing acute blood volume manipulations. The study also examined the simultaneous effect of performing the PLRM on dynamic variables such as stroke distance variation (SDV), peak velocity variation (PVV), and stroke volume variation (SVV).

Study design

Prospective, nonrandomized, crossover design.

Study animals

Six healthy male Beagle dogs.

Methods

The dogs were anesthetized with propofol and isoflurane and mechanically ventilated under neuromuscular blockade. After instrumentation, they underwent a series of sequential, nonrandomized steps: Step 1: baseline data collection; Step 2: removal of 33 mL kg-1 of circulating blood volume; Step 3: blood re-transfusion; and Step 4: infusion of 20 mL kg-1 colloid solution. Following a 10-min stabilization period after each step, CO measurements were recorded using esophageal Doppler (EDCO), transesophageal echocardiography (TEECO), arterial pressure waveform analysis (APWACO), and electrical cardiometry (ECCO). Additionally, SDV, PVV, and SVV were recorded. Intermittent pulmonary artery thermodilution (iPATDCO) measurements were also recorded before, during, and after the PLRM maneuver. A successful FR diagnosis made using a specific test indicated that CO increased by more than 15% during the PLRM maneuver. Statistical analysis was performed using one-way analysis of variance for repeated measures with post hoc Tukey test, linear regression, Lin's concordance correlation coefficient (ρc), and Bland-Altman analysis. Statistical significance was set at p < 0.05.

Results

All techniques detected a reduction in CO (p < 0.001) during hemorrhage and an increase in CO after blood re-transfusion and colloid infusion (p < 0.001) compared with baseline. During hemorrhage, CO increases with the PLRM maneuver were as follows: 33% for iPATD (p < 0.001), 19% for EC (p = 0.03), 7% for APWA (p = 0.97), 39% for TEE (p < 0.001), and 17% for ED (p = 0.02). Concurrently, decreases in SVV, SDV, and PVV values (p < 0.001) were also observed. The percentage error for TEE, ED, and EC was less than 30% but exceeded 55% for APWA. While TEECO and ECCO slightly underestimated iPATDCO values, EDCO and APWACO significantly overestimated iPATDCO values. TEE and EC exhibited good and acceptable agreement with iPATD. However, CO measurements using all four techniques and iPATD did not differ before, during, and after PLRM at baseline, blood re-transfusion, and colloid infusion.

Conclusion and clinical relevance

iPATD, EC, TEE, and ED effectively assessed FR in hypovolemic dogs during the PLRM maneuver, while the performance of APWA was unacceptable and not recommended. SVV, SDV, and PVV could be used to monitor CO changes during PLRM and acute blood volume manipulations, suggesting their potential clinical utility.

Recommendations for Centers Performing Pediatric Heart Surgery in the United States

Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.

Infective Endocarditis among Pediatric Patients with Prosthetic Valves and Cardiac Devices: A Review and Update of Recent Emerging Diagnostic and Management Strategies

Infective endocarditis (IE) is a disease of the endocardium, which leads to the appearance of vegetation on the valves, cardiac structures, or, potentially, vascular endothelium of the heart. The risk of IE can be increased more than 140 times by congenital heart disease (50-59% of all IE), particularly if cyanotic. An increase in mortality may result from IE in patients with a complex cardiac pathology or patients with an implanted prosthetic material, most frequently conduits in a pulmonary position. Cardiac implantable electronic devices (CIED) infective endocarditis is a life-threatening complication representing 10% of all cases of endocarditis. Common signs of presentation are often fever and chills; redness and swelling at the pocket of the pacemaker, including the erosion and exteriorization of the device; and life-threatening sepsis. The use of intracardiac echocardiography for the diagnosis of IE is an innovative method. This may be needed, especially in older children undergoing complex cardiac surgery, when transthoracic echocardiography (TTE) and transesophageal echocardiography (TOE) failed to provide a reliable diagnosis. The 2018 European Heart Rhythm Association (EHRA) experts' consensus statement on transvenous lead extraction recommends complete device removal and antimicrobial therapy for any device-related infection, including CIED-IE. The most detected microorganism was Staphylococcus Aureus. In addition, cardiac surgery and interventional cardiology associated with the placement of prostheses or conduits may increase the risk of IE up to 1.6% for Melody valve implantation. Our manuscript presents a comprehensive review of infective endocarditis associated with cardiac devices and prostheses in the pediatric population, including recent advances in diagnosis and management.

Complications Associated With Transesophageal Echocardiography in Transcatheter Structural Cardiac Interventions

BACKGROUND

Transesophageal echocardiograms (TEEs) performed during transcatheter structural cardiac interventions may result in greater complications than those performed in the nonoperative setting or even those performed during cardiac surgery. However, there are limited data on complications associated with TEE during these procedures. We evaluated the prevalence of major complications among these patients in the United States.

METHODS

A retrospective cohort study was conducted using an electronic health record database (TriNetX Research Network) from large academic medical centers across the United States for patients undergoing TEE during transcatheter structural interventions from January 2012 to January 2022. Using the American Society of Echocardiography-endorsed International Statistical Classification of Diseases and Related Health Problems Clinical Modifications (10th edition) codes, patients undergoing TEE during a transcatheter structural cardiac intervention, including transaortic, mitral or tricuspid valve repair, left atrial appendage occlusion, atrial septal defect closure, patent foramen ovale closure, and paravalvular leak repair, were identified. The primary outcome was major complications within 72 hours of the procedure (composite of bleeding and esophageal and upper respiratory tract injury). The secondary aim was the frequency of major complications, death, or cardiac arrest within 72 hours in patients who completed intraoperative TEE during surgical valve replacement.

RESULTS

Among 12,043 adult patients (mean age, 74 years old; 42% female) undergoing TEE for transcatheter structural cardiac interventions, 429 (3.6%) patients had a major complication. Complication frequency was higher in patients on anticoagulation or antiplatelet therapy compared with those not on therapy (3.9% vs 0.5%; risk ratio [RR] = 8.09, P < .001). Compared with those patients <65 years of age, patients ≥65 years of age had a higher frequency of major complications (3.9% vs 2.2%; RR = 1.75, P < .001). Complication frequency was similar among male and female patients (3.5% vs 3.7%; RR = 0.96, P = .67). Among 28,848 patients who completed surgical valve replacement with TEE guidance, 728 (2.5%) experienced a major complication.

CONCLUSIONS

This study found that more than 3% of patients undergoing TEE during transcatheter structural cardiac interventions have a major complication, which is more common among those on anticoagulant or antiplatelet therapy or who are elderly. With a shift of poor surgical candidates to less invasive percutaneous procedures, the future of TEE-guided procedures relies on comprehensive risk discussion and updating practices beyond conventional methods to minimize risk for TEE-related complications.

Left Atrioventricular Transvalvular Pressure Gradients Derived from Intraoperative and Postoperative Echocardiograms following Atrioventricular Septal Defect Repair

BACKGROUND

Left atrioventricular valve (LAVV) stenosis following an atrioventricular septal defect (AVSD) repair is a rare but potentially life-threatening complication. While echocardiographic quantification of diastolic transvalvular pressure gradients is paramount in the evaluation of a newly corrected valve function, it is hypothesized that these measured gradients are overestimated immediately following a cardiopulmonary bypass (CPB) due to the altered hemodynamics when compared to postoperative valve assessments using awake transthoracic echocardiography (TTE) upon recovery after surgery.

METHODS

Out of the 72 patients screened for inclusion at a tertiary center, 39 patients undergoing an AVSD repair with both intraoperative transesophageal echocardiograms (TEE, performed immediately after a CPB) and an awake TTE (performed prior to hospital discharge) were retrospectively selected. The mean (MPGs) and peak pressure gradients (PPGs) were quantified using a Doppler echocardiography and other measures of interest were recorded (e.g., a non-invasive surrogate of the cardiac output and index (CI), left ventricular ejection fraction, blood pressures and airway pressures). The variables were analyzed using the paired Student's t-tests and Spearman's correlation coefficients.

RESULTS

The MPGs were significantly higher in the intraoperative measurements when compared to the awake TTE (3.0 ± 1.2 vs. 2.3 ± 1.1 mmHg; p < 0.01); however, the PPGs did not significantly differ (6.6 ± 2.7 vs. 5.7 ± 2.8 mmHg; p = 0.06). Although the assessed intraoperative heart rates (HRs) were also higher (132 ± 17 vs. 114 ± 21 bpm; p < 0.001), there was no correlation found between the MPG and the HR, or any other parameter of interest, at either time-point. In a further analysis, a moderate to strong correlation was observed in the linear relationship between the CI and the MPG (r = 0.60; p < 0.001). During the in-hospital follow-up period, no patients died or required an intervention due to LAVV stenosis.

CONCLUSIONS

The Doppler-based quantification of diastolic transvalvular LAVV mean pressure gradients using intraoperative transesophageal echocardiography seems to be prone to overestimation due to altered hemodynamics immediately after an AVSD repair. Thus, the current hemodynamic state should be taken into consideration during the intraoperative interpretation of these gradients.

Evaluation of two probes for transesophageal echocardiography in small dogs: imaging capabilities, image quality, and usability

INTRODUCTIONS

Patient size is a limiting factor for transesophageal echocardiography (TEE) in small dogs. The objective of this study was to describe imaging capabilities of two probes for TEE in small dogs.

ANIMALS, MATERIALS, AND METHODS

Prospective study in 10 client-owned dogs weighing <4 kg with congenital heart disease (CHD). Dogs had TEE performed with a microprobe (10T-D, GE Medical) and intracardiac echocardiography (ICE) catheter-based probe (AcuNav™, Biosense Webster) in the esophagus in alternating order. Ease of placement, ability to acquire images of the CHD, image quality, and probe limitations were recorded.

RESULTS

Median weight was 2.4 kg (range, 1.0-3.2). Congenital abnormalities included patent ductus arteriosus (n = 9) and pulmonary valve stenosis (n = 1). The 10T-D microprobe was easy to place (n = 8) or achievable with gentle manipulation (n = 2), and image quality of the CHD was optimal (n = 8), adequate (n = 1), or poor (n = 1). The ICE probe was difficult to place in the esophagus even with an external support system (n = 9) or could not be placed (n = 1), and image quality of the CHD was optimal (n = 2), adequate (n = 3), or poor (n = 5). Both probes provided images in a 1.0-kg dog. Probe limitations included lack of lateral motion (microprobe), the need for an external support system (ICE probe) and inability to consistently maintain contact with the esophagus (ICE probe).

CONCLUSION

The 10T-D microprobe provided high-quality TEE images more consistently than the ICE probe in the majority of dogs in this study; however, the lack of lateral motion can diminish its utility in some dogs.

Acute Heart Failure: Diagnostic-Therapeutic Pathways and Preventive Strategies-A Real-World Clinician's Guide

Acute heart failure (AHF) is the most frequent cause of unplanned hospital admission in patients of >65 years of age and it is associated with significantly increased morbidity, mortality, and healthcare costs. Different AHF classification criteria have been proposed, mainly reflecting the clinical heterogeneity of the syndrome. Regardless of the underlying mechanism, peripheral and/or pulmonary congestion is present in the vast majority of cases. Furthermore, a marked reduction in cardiac output with peripheral hypoperfusion may occur in most severe cases. Diagnosis is made on the basis of signs and symptoms, laboratory, and non-invasive tests. After exclusion of reversible causes, AHF therapeutic interventions mainly consist of intravenous (IV) diuretics and/or vasodilators, tailored according to the initial hemodynamic status with the addition of inotropes/vasopressors and mechanical circulatory support if needed. The aim of this review is to discuss current concepts on the diagnosis and management of AHF in order to guide daily clinical practice and to underline the unmet needs. Preventive strategies are also discussed.

The value of myocardial strain imaging in the evaluation of patients with repaired Tetralogy of Fallot: a review of the literature

Tetralogy of Fallot (ToF) is considered to be the most common, complex, cyanotic congenital heart disease (CHD) representing 7-10% of all congenital heart defects, whereas the patients with ToF are the most frequently operated in their early infancy or childhood. Cardiac magnetic resonance (CMR) consists a valuable imaging technique for the diagnosis and serial follow-up of CHD patients. Furthermore, in recent years, advanced echocardiography imaging techniques have come to the fore, aiming to achieve a complete and more accurate evaluation of cardiac function using speckle tracking imaging modalities. We conducted a review of the literature in order to assess the myocardial deformation of patients with repaired ToF (rToF) using echocardiographic and CMR parameters. Patients with rToF have impaired myocardial strain parameters, that are well standardized either with the use of speckle tracking echocardiography or with the use of CMR imaging. Subclinical left ventricular dysfunction (low GLS) and myocardial dyssynchrony are commonly identified in rToF patients. Impaired left atrium (LA) and right atrium (RA) mechanics are, also, a common finding in this study population, but the studies using atrial strain are a lot fewer than those with LV and RV strain. No studies using myocardial work were identified in the literature, as far as rToF patients are concerned, which makes it an ideal field for further investigation.

Role of Cardiovascular Imaging in the Follow-Up of Patients with Fontan Circulation

Since its first description in 1971, the Fontan procedure and its modifications have led to a substantial improvement in the survival rates of patients with a variety of types of complex Congenital Heart Disease (CHD) characterised by the presence of a single, dominant ventricle. However, despite the significant improvement of the prognosis over the years, Fontan patients are still exposed to several cardiovascular and systemic complications. It is, therefore, important to fully understand the pitfalls hidden behind a Fontan anatomy and the potential predictors of ventricular failure. Cardiovascular imaging plays a key role in this context, allowing for the early identification of complications with important prognostic implications. Echocardiography remains the first-line imaging modality for serial evaluation of Fontan patients. However, there is a growing role of cardiovascular magnetic resonance and cardiac computed tomography from pre-operative assessment to longitudinal follow-up. The aim of this paper will be to provide a comprehensive overview of the role, strengths, and weaknesses of each imaging modality in the assessment of congenital cardiac conditions palliated with the Fontan procedure.

Multimodality imaging approach of patent foramen ovale: Practical considerations for transient ischemic attack/stroke

A patent foramen ovale, which is present in up to 25% of the population, is a risk factor for cryptogenic stroke (which accounts for 15%-40% of strokes) and transient ischemic attack via paradoxical embolism. This narrative review focuses on the multimodality imaging approach of the diagnosis and periprocedural guidance of patent foramen ovale, with an emphasis on the use of agitated saline as contrast medium in echocardiography, starting from embryologic aspects. Therefore, we aimed to make a concise and complete presentation of the protocol used for this type of evaluation, along with multimodality imaging approach of the patent foramen ovale and practical considerations for transient ischemic attack/stroke.

Usefulness of Three-Dimensional Transthoracic Echocardiographic Planimetry in a 4-Month-Old Infant with Comorbid Aortic Stenosis and Coarctation of the Aorta Complicated with Low Left Ventricular Ejection Fraction

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Comorbid valvular AS, CoA, and LV dysfunction can complicate the order of interventions.

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Continuity equation cannot be used to assess AS severity in the setting of decreased LVEF.

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3D-TTE planimetry can evaluate AS severity in infants with good acoustic windows.

Child Neurology: Case Report of Lambl Excrescences in a Pediatric Patient With Multifocal Strokes

Lambl excrescences are fibrinous connective tissue strands found predominantly on left-sided cardiac valves. These valvular strands are typically benign, but have been implicated as a potential etiology of embolic strokes in adult patients. The significance of Lambl excrescences in pediatric stroke cases is unclear and not previously reported in the literature. In this study, we describe a 10-year-old boy who presented with acute-onset right-sided hemiplegia, found to have multifocal embolic strokes of various ages. Extensive stroke workup was unrevealing, aside from the presence of small, filamentous, strand-like densities associated with the mitral and aortic valves noted on a transesophageal echocardiogram consistent with Lambl excrescences. In this case report, we review Lambl excrescences and their significance in acute stroke and management options for the prevention of future ischemia in these patients.

Interrogation of superior vena cava by deep transgastric transesophageal echocardiography imaging: Clinical applications

The advantages of intraoperative deep transgastric interrogation by transesophageal echocardiography (TEE) of the superior vena cava (SVC) in comparison to the standard bicaval view was studied in pediatric cardiac surgical cases. The view was found to be helpful in obtaining additional data in pediatric cardiac surgical patients.

Pulse Wave Analysis Using the Pressure Recording Analytical Method to Measure Cardiac Output in Pediatric Cardiac Surgery Patients: A Method Comparison Study Using Transesophageal Doppler Echocardiography as Reference Method

BACKGROUND

Cardiac output (CO) is a key determinant of oxygen delivery, but choosing the optimal method to obtain CO in pediatric patients remains challenging. The pressure recording analytical method (PRAM), implemented in the MostCareUp system (Vygon), is an invasive uncalibrated pulse wave analysis (PWA) method to measure CO. The objective of this study is to compare CO measured by PRAM (PRAM-CO; test method) with CO simultaneously measured by transesophageal Doppler echocardiography (TEE-CO; reference method) in pediatric patients.

METHODS

In this prospective observational method comparison study, PRAM-CO and TEE-CO were assessed in pediatric elective cardiac surgery patients at 2 time points: after anesthesia induction and after surgery. The study was performed in a German university medical center from March 2019 to March 2020. We included pediatric patients scheduled for elective cardiac surgery with arterial catheter and TEE monitoring. PRAM-CO and TEE-CO were compared using Bland-Altman analysis accounting for repeated measurements per subject, and the percentage error (PE).

RESULTS

We included 52 PRAM-CO and TEE-CO measurement pairs of 30 patients in the final analysis. Mean ± SD TEE-CO was 2.15 ± 1.31 L/min (range 0.55-6.07 L/min), and mean PRAM-CO was 2.21 ± 1.38 L/min (range 0.55-5.90 L/min). The mean of the differences between TEE-CO and PRAM-CO was -0.06 ±0.38 L/min with 95% limits of agreement (LOA) of 0.69 (95% confidence interval [CI], 0.53-0.82 L/min) to -0.80 L/min (95% CI, -1.00 to -0.57 L/min). The resulting PE was 34% (95% CI, 27%-41%).

CONCLUSIONS

With a PE of <45%, PRAM-CO shows clinically acceptable agreement with TEE-CO in hemodynamically stable pediatric patients before and after cardiac surgery.

Intraoperative epicardial echocardiography or transoesophageal echocardiography in CHD: how much does it matter?

BACKGROUND

Intraoperative imaging determines the integrity of surgical repairs. Transoesophageal echocardiography represents standard care for intraoperative imaging in CHD. However, some conditions preclude its use, and epicardial echocardiography is used alternatively. Minimal literature exists on the impact of epicardial echocardiography versus transoesophageal echocardiography. We aimed to evaluate accuracy between the two modalities and hypothesised higher imaging error rates for epicardial echocardiography.

METHODS

We retrospectively reviewed all epicardial echocardiograms performed over 16 years and compared them to an age- and procedure-matched, randomly selected transoesophageal echocardiography cohort. We detected un- or misidentified cardiac lesions during the intraoperative imaging and evaluated patient outcomes. Data are presented as a median with a range, or a number with percentages, with comparisons by Wilcoxon two-sample test and Fisher's exact test.

RESULTS

Totally, 413 patients comprised the epicardial echocardiography group with 295 transoesophageal echocardiography matches. Rates of imaging discrepancies, re-operation, and incision infection were similar. About 13% of epicardial echocardiography patients had imaging discrepancies versus 16% for transoesophageal (p = 0.2352), the former also had smaller body sizes (p < 0.0001) and more genetic abnormalities (33% versus 19%, p < 0.0001). Death/mechanical support occurred more frequently in epicardial echocardiography patients (16% versus 6%, p < 0.0001), while hospitalisations were longer (25 versus 19 days, p = 0.0003).

CONCLUSIONS

Diagnostic accuracy was similar between patients undergoing epicardial echocardiography and transoesophageal echocardiography, while rates of death and mechanical support were increased in this inherently higher risk patient population. Epicardial echocardiography provides a reasonable alternative when transoesophageal echocardiography is not feasible.

Prognostic value of left atrial strain in patients with congenital aortic stenosis

Aim

To explore whether left atrial (LA) strain with speckle tracking echocardiography (STE) can contribute to prognostication in patients with congenital aortic stenosis (CAS).

Methods and results

In this prospective study, consecutive outpatients with stable CAS and healthy adults were enrolled between 2011 and 2015. Left atrial function was analysed with STE using Tomtec software. Associations between LA strain (LAS) measurements and primary composite outcome (any adverse cardiovascular event, hospitalization, or re-intervention) and secondary outcome (re-interventions) were assessed with Cox regression analysis. In total, 98 patients with CAS (mean age: 35.0 ± 11.9 year, female: 59.2%) and 121 controls (age: 43.9 ± 13.8 year, female: 55.4%) were included. The majority of patients were in NYHA class I: 97 (99%) at baseline. At baseline, LA conduit strain (LAS-cd) and strain rate (LASR-cd) were significantly lower in patients than in controls when corrected for age and sex (−18.1 ± 8.7 vs. −23.5 ± 9.9%, P = 0.001 and −0.73 ± 0.31 vs. −1.02 ± 0.43/s, P < 0.001). During a median follow-up of 6.4 years (5.7–7.1), the primary composite outcome occurred in 48 (39.6%) patients. Kaplan–Meier analysis showed that decreased LAS-cd (<21%) was associated with a higher occurrence of the primary outcome (log-rank: P = 0.008). Depressed LAS-cd and LASR-cd were both associated with the primary composite outcome [univariable hazard ratio (HR) = 0.64(0.46–0.88), P = 0.005 and HR = 0.68(0.55–0.83), P < 0.001, respectively]; adjusted HR (for LAS-cd and LASR-cd, respectively): 0.31(0.09–1.04), P = 0.06 and 0.49(0.26–0.89), P = 0.02.

Conclusion

Impairment in LA conduit function assessed with STE carries prognostic value in patients with CAS and can be implemented in clinical management.

Multimodality Imaging of Sinus Venosus Atrial Septal Defect: A Challenging Diagnosis in Adults

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SVASD should be suspected in cases of unexplained RV volume overload.

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Direct visualization of SVASD with TTE is difficult in adults compared with children.

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TEE is helpful for diagnosing SVASD and associated pulmonary venous abnormalities.

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Multimodal imaging techniques offer incremental value in the workup of SVASD.

Ultrasound assessment of the inferior vena cava in children: A comparison of sub-xiphoid and right lateral coronal views

OBJECTIVES

The inferior vena cava collapsibility index (IVCCI) has been used to assess the respiratory variation of the inferior vena cava (IVC) diameter and hence intravascular volume. The sub-xiphoid view (SXV) is the standard view to evaluate the IVC. The right lateral transabdominal view (RLV) has been shown in adults to be an alternative view to evaluate the IVC when the SXV is not feasible. The aim of the study was to compare IVC dimensions from these two views and thus determine whether the RLV view can be used instead of the SXV in pediatric patients.

METHODS

We conducted a single-center prospective observational crossover study. Study subjects were ASA physical status 1-2 children, 1-12 years of age scheduled for elective surgery under general anesthesia. Anesthesia was maintained by mask with spontaneous ventilation with end-tidal sevoflurane at 2%-5% after the induction of anesthesia. IVCCI was measured using M-mode in both the SXV and RLV.

RESULTS

The study cohort included 50 children with a mean age of 5.1 years. The median value for the IVCCI-sx was 0.45 (IQR: 0.28-0.70) while the IVCCI-rl was 0.30 (0.19-0.5). The mean difference between the two groups was 0.12 (95% CI: 0.177-0.066, p < .001, two-tailed paired t-test). Spearman's rank correlation coefficient was 0.66. The univariate linear regression model was IVCCIsx = 0.21 + 0.77 × IVCCIrl.

CONCLUSIONS

IVCCIrl was lower than IVCCIsx. IVCCI measured from the right lateral view tended to overestimate the patient's fluid-responsiveness and therefore these two values are not interchangeable.

Intracardiac Echocardiogram: Feasibility, Efficacy, and Safety for Guidance of Transcatheter Multiple Atrial Septal Defects Closure

We aimed to determine the feasibility, efficacy, success, and safety of intracardiac echocardiography (ICE) in transcatheter multiple atrial septal defect (ASD) closure. Of 185 patients with multiple ASDs who underwent transcatheter closure, 140 (76%) patients who weighed <30kg with a narrow distance between defects or in whom single device closure was anticipated were guided by ICE and 45 patients were guided by three-dimensional (3D) transesophageal echocardiography (TEE) with or without ICE. Patients in the ICE group were relatively younger and weighed less than those in the 3D TEE group (p < 0.0001). The ratio of the distance between defects >7 mm was high, and more cases required ≥2 devices in the 3D TEE group than those in the ICE group (p < 0.0001). All patients in the 3D TEE group and seven patients (5%) in the ICE group were operated on under general anesthesia (p < 0.0001). The fluoroscopic time was shorter in the ICE group (13.98 ± 6.24 min vs. 24.86 ± 16.47 min, p = 0.0005). No difference in the complete closure rate and complications was observed. ICE-guided transcatheter and 3D TEE were feasible, safe, and effective in successful multiple ASD device closures, especially for young children and patients at high risk under general anesthesia.

Prospective evaluation of complications associated with transesophageal echocardiography in dogs with congenital heart disease

Background

Transesophageal echocardiography (TEE) is useful in the assessment and procedural monitoring of congenital heart disease (CHD) with a relatively low complication rate in humans.

Objectives

To evaluate the safety of TEE and report complications in dogs.

Animals

Forty client‐owned dogs with CHD.

Methods

Prospective observational study including gastroesophagoscopy before and after TEE imaging. TEE was planned with a GE 6VT‐D adult probe in dogs weighing ≥4 kg and a GE 10T‐D microprobe alternating with an intracardiac echocardiography probe placed in the esophagus in dogs <4 kg. Difficulties with probe placement, probe interference and TEE probe imaging times were recorded. Dogs were monitored in the recovery period after TEE using an established nausea scoring system.

Results

New gastroesophageal abnormalities were identified after TEE in 4 dogs including 4 areas of mucosal damage involving <25% of the lower esophageal sphincter (n = 4) and 1 lesion at the heart base (n = 1) and were not attributed to longer imaging times or a specific probe. Lesions identified before TEE in 4 dogs remained unchanged after TEE. The 6VT‐D probe could not be placed in 1 dog with enlarged tonsils, and it obstructed fluoroscopic views in 3 dogs. The probes did not compress any structures in dogs in which fluoroscopy was performed (n = 20). Four dogs had evidence to suggest nausea after the procedure.

Conclusions and Clinical Importance

While major complications remain possible, complications in this study were mild and few in number. Dog size and probe characteristics are factors to consider when performing TEE.

Renaissance of Cardiac Imaging to Assist Percutaneous Interventions in Congenital Heart Diseases:The Role of Three-Dimensional Echocardiography and Multimodality Imaging

Percutaneous interventions have completely refashioned the management of children with congenital heart diseases (CHD) and the use of non-invasive imaging has become the gold standard to plan and guide these procedures in the modern era. We are now facing a dual challenge to improve the standard of care in low-risk patients, and to shift our strategies from the classic open chest surgery to imaging-guided percutaneous interventions in high-risk patients. Such rapid evolution of ultrasound technologies over the last 20 years have permitted the integration of transthoracic, transesophageal and intracardiac echocardiography into the interventional workflow to improve image guidance and reduce radiation burden from fluoroscopy and angiography. Specifically, miniaturization of transesophageal probe and advances in three-dimensional (3D) imaging techniques have enabled real-time 3D image guidance during complex interventional procedure, In addition, multimodality and fusion imaging techniques harness the strengths of different modalities to enhance understanding of anatomical and spatial relationship between different structures, improving communication and coordination between interventionalists and imaging specialists. In this review, we aim to provide an overview of 3D imaging modalities and multimodal fusion in procedural planning and live guidance of percutaneous interventions. At the present times, 3D imaging can no longer be considered a luxury but a routine clinical tool to improve procedural success and patient outcomes.

Anatomy of the Tricuspid Valve and Pathophysiology of Tricuspid Regurgitation

Transcatheter valve interventions have seen a significant increase in the past decade. The combination of improved techniques and available tools provides less invasive options supplementing surgical therapies. The tricuspid valve (TV) apparatus is a complex structure between the right atrium and the right ventricle; it generally consists of 3 leaflets (anterior, posterior, and septal) inserted in the fibrous tricuspid annulus and connected to the papillary muscle via the chordae tendinae. This article reviews TV anatomy, the pathophysiology of tricuspid regurgitation, and multimodality imaging to study TV, as well as provides an overview of transcatheter TV intervention.

Clinical implication of intraoperative ventricular-arterial coupling in pediatric patients undergoing ventricular septal defects repair: A retrospective cohort study

BACKGROUND

Ventricular-arterial coupling is the ratio of arterial elastance to ventricular end-systolic elastance.

AIMS

The objective of this study was to determine the clinical implication of intraoperative ventricular-arterial coupling derived from the pressure-area relationship using transesophageal echocardiography.

METHODS

This retrospective study reviewed the medical records of 72 pediatric patients with ventricular septal defects who underwent corrective surgery with cardiopulmonary bypass. The single-beat modified method was used to assess ventricular-arterial coupling. Logistic regression analyses were performed to determine the correlation between ventricular-arterial coupling and early postoperative outcomes, including the maximum vasoactive-inotropic score, length of mechanical ventilation, and length of hospital stay.

RESULTS

Ventricular-arterial coupling after cardiopulmonary bypass significantly increased (from 1.0 ± 0.4 to 1.4 ± 0.8, p < .001), indicating a disproportionate increase in the arterial elastance index (from 11.5 ± 5.1 to 19.8 ± 7.5 mmHg/cm² /m² , p < .001) compared with the ventricular end-systolic elastance index (from 13.0 ± 6.9 to 16.9 ± 9.0 mmHg/cm² /m² , p < .001). Logistic regression analyses revealed that high postoperative ventricular-arterial coupling was independently associated with higher postoperative maximum vasoactive-inotropic score (>10; odds ratio [OR], 8.04; 95% confidence interval [CI], 1.38-46.85, p = .020), longer postoperative mechanical ventilation (>15 h; OR: 11.00; 95% CI: 1.26-96.45, p = .030), and longer postoperative hospital stay (>7 days; OR: 2.98; 95% CI: 1.04-8.58, p = .043).

CONCLUSIONS

Ventricular-arterial coupling can be easily obtained from the intraoperative transesophageal echocardiography in pediatric patients undergoing ventricular septal defects repair. High postoperative ventricular-arterial coupling is strongly associated with worse early postoperative outcomes. Ventricular-arterial coupling shows promise as an intraoperative analysis tool that can provide insight into the impact of interventions on cardiovascular performance and identify potential targets for treatment in this population.

Concomitant pulmonary valve replacement with intracardiac repair for adult tetralogy of Fallot

Objectives :

Adult patients undergoing tetralogy of Fallot (TOF) repair have a higher risk of mortality compared to pediatric patients. Pulmonary regurgitation (PR) further predisposes these patients to heart failure, arrhythmias, and sudden death. Pulmonary valve replacement (PVR) may improve the symptoms in these patients but, fails to reverse the other deleterious effects. Aim of our study was to evaluate the effect of concomitant PVR with TOF repair on right ventricular (RV) parameters, cardiopulmonary exercise capacity, and bioprosthetic valve durability at mid-term.

Materials and Methods:

Between January 2013 and August 2018, 37 adolescents and adults with TOF who had hypoplastic pulmonary annulus underwent concomitant TOF repair with PVR at our institute. We retrospectively collected the data from the hospital records including follow-up.

Results :

Mean age of the patients was 18.48 ± 7.53 years. Bioprosthetic valve size ranged from 19 mm to 25 mm. There was no early or late mortality. No patient had developed significant perioperative complications. At a mean follow-up of 53.3 ± 16.4 months, there was no significant change in mean QRS duration, RV function, RV end-systolic and end-diastolic dimensions, RV myocardial performance index, and functional status (including NYHA class and 6-min walk test) compared to at-discharge values. Four patients developed prosthetic valve degeneration with mild PR and without significant increase in gradient.

Conclusion :

Concomitant PVR with TOF repair in adult provides excellent mid-term outcome, with a minimal rate of pulmonary valve degeneration. It not only eases the early postoperative course but also preserves the RV function as well as functional status at mid-term.

Complications after transesophageal echocardiogram in pediatric patients with gastrostomy tube and/or Nissen fundoplication

INTRODUCTION

Transesophageal echocardiography (TEE) is frequently used in children with and without congenital heart disease when transthoracic echocardiography is inadequate for visualizing cardiac structures. Recent guidelines state relative contraindications of TEE include post-gastrostomy tube (GT) or Nissen fundoplication surgery. No data exist documenting the incidence of complications in this population after a TEE. Aim of this study was to document the incidence of abdominal complications after TEE in pediatric patients who previously had a GT or Nissen fundoplication.

METHODS

Single institution retrospective study was performed evaluating patients from 2013 through 2020. Patients were included if they had previously undergone a GT or Nissen procedure and subsequently underwent a TEE procedure. Baseline demographics were obtained. Major (esophageal/gastric perforation, oropharyngeal dysphagia, GT displacement, and Nissen breakdown) and minor (abdominal pain, feeding intolerance, and GT leakage) complications were recorded.

RESULTS

Total of 34 patients underwent 48 TEE procedures. Age was 6.2 ± 6.6 years (median 3.0 years, .4 - 23.0 years) and weight was 18.5 ± 14.8 kgs (median 12.4 kgs, 4.2 - 57.5 kg) at time of TEE. Twenty-nine patients had congenital heart disease. Five patients had a Nissen fundoplication, 14 patients had a GT, and 15 patients had both procedures prior to the TEE. No patient had a major abdominal complication after the TEE. One patient had abdominal pain (2.1%), one patient had feeding intolerance and leakage around the GT site (2.1%), and two patients had leakage around the GT site (4.2%) after the TEE. Patients that experienced complications were significantly younger (1.7 ± 1.1 years vs. 6.6 ± 6.7 years, P < .01) and weighed less (8.7 ± 3.5 kg vs. 20.1 ± 15.5 kg, P < .01) than those that had no complications. All minor complications resolved with minimal interventions required.

CONCLUSION

In this study, major abdominal complications did not occur after a TEE procedure in pediatric patients that had previous abdominal surgeries. The incidence of minor complications was relatively low and was easily remedied in this patient population. Though a relative contraindication by guidelines, TEE imaging, including transgastric views, can be performed relatively safely in pediatric patients with prior abdominal surgeries if needed.

Transesophageal echocardiography probe induced recurrent VF in a child with severe RV dysfunction: Report of a rare case

The safety of transesophageal echocardiography (TEE) probes has been documented in pediatric patients (neonates, infants, and small children even < 2.5 kg). The overall safety profile of TEE probe is quite favorable with a reported incidence of complications of 1%-3%. However, insertion of the TEE probe can induce vagal and sympathetic reflexes such as hypertension or hypotension, nonsustained ventricular and supraventricular tachyarrhythmias, or bradyarrhythmias (third degree heart block), and even angina and myocardial infarction. We hereby document a repeated intraoperative ventricular fibrillation precipitated by TEE probe in a 2-year-old, 10 kg pediatric patient diagnosed with ostium secundum-atrial septal defect, supravalvular pulmonary stenosis, and severe right ventricular dysfunction. The international review board approval or waiver and clinical trial registrations are not applicable for this case report publication.

Transpulmonary thermodilution in patients treated with veno-venous extracorporeal membrane oxygenation

BACKGROUND

We tested the effect of different blood flow levels in the extracorporeal circuit on the measurements of cardiac stroke volume (SV), global end-diastolic volume index (GEDVI) and extravascular lung water index derived from transpulmonary thermodilution (TPTD) in 20 patients with severe acute respiratory distress syndrome (ARDS) treated with veno-venous extracorporeal membrane oxygenation (ECMO).

METHODS

Comparative SV measurements with transesophageal echocardiography and TPTD were performed at least 5 times during the treatment of the patients. The data were interpreted with a Bland-Altman analysis corrected for repeated measurements. The interchangeability between both measurement modalities was calculated and the effects of extracorporeal blood flow on SV measurements with TPTD was analysed with a linear mixed effect model. GEDVI and EVLWI measurements were performed immediately before the termination of the ECMO therapy at a blood flow of 6 l/min, 4 l/min and 2 l/min and after the disconnection of the circuit in 7 patients.

RESULTS

170 pairs of comparative SV measurements were analysed. Average difference between the two modalities (bias) was 0.28 ml with an upper level of agreement of 40 ml and a lower level of agreement of -39 ml within a 95% confidence interval and an overall interchangeability rate between TPTD and Echo of 64%. ECMO blood flow did not influence the mean bias between Echo and TPTD (0.03 ml per l/min of ECMO blood flow; p = 0.992; CI - 6.74 to 6.81). GEDVI measurement was not significantly influenced by the blood flow in the ECMO circuit, whereas EVLWI differed at a blood flow of 6 l/min compared to no ECMO flow (25.9 ± 10.1 vs. 11.0 ± 4.2 ml/kg, p = 0.0035).

CONCLUSIONS

Irrespectively of an established ECMO therapy, comparative SV measurements with Echo and TPTD are not interchangeable. Such caveats also apply to the interpretation of EVLWI, especially with a high blood flow in the extracorporeal circulation. In such situations, the clinician should rely on other methods of evaluation of the amount of lung oedema with the haemodynamic situation, vasopressor support and cumulative fluid balance in mind.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00021050). Registered 03/30/2020 https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017237.

A Spatial Near-Field Clutter Reduction Filter Preserving Tissue Speckle in Echocardiography

Near-field (NF) clutter in echocardiography is depicted as a diffuse haze hindering the visualization of the myocardium and the blood-pool, thereby degrading its diagnostic value. Several clutter filters have been developed, which are limited in patients with contraction motion and rhythm anomalies, and in 3-D ultrasound (US). This study introduces a new NF clutter reduction method, which preserves US speckles required for strain imaging. The filter developed detects the NF clutter region in the spatial frequency domain. The filter employs an oriented, multiscale approach, and assumes the NF clutter to be predominantly present in the highest and lowest bandpass images. These bandpass images were filtered, whilst sparing features in the myocardium and NF clutter-free regions. The performance of the filter was assessed in a volunteer study, in ten 3-D apical and parasternal view acquisitions, and in a retrospective clinical study composed of 20 cardiac patients with different indications for echocardiography. The filter reduced NF clutter in all data sets, whilst preserving all or most of the myocardium. Additionally, it demonstrated a consistent enhancement of image quality, with an increase in contrast of 4.3 dB on average, and generated a clearer myocardial boundary distinction. Furthermore, the speckles were preserved according to the quality index based on local variance, the structural similarity index method, and normalized cross correlation values, being 0.82, 0.92, and 0.95 on average, respectively. Global longitudinal strain measurements on NF clutter reduced images were improved or equivalent compared to the original acquisitions, with an average increase in strain signal-to-noise ratio of 34%.