Transesophageal Echocardiography in Heart and Lung Transplantation

Intraoperative Transesophageal Echocardiographic Guidance in Cardiac Surgery

Transesophageal echocardiography (TEE) is a valuable tool for diagnosing structural heart diseases, offering superior resolution compared to transthoracic echocardiography. It allows for real-time evaluation of cardiac valves and both systolic and diastolic heart function. Additionally, TEE facilitates the prompt detection of potential complications during cardiac surgeries, such as paravalvular leaks, iatrogenic aortic dissections, and pericardial effusions. Advances in imaging, including 3D echocardiography, have further enhanced the visualization of complex structures like cardiac valves, providing "surgical views" that improve preoperative planning. These features have also made TEE indispensable for postoperative evaluation of cardiac valve repairs and for intraoperative guidance during minimally invasive procedures. This review article aims to summarize the indications for using TEE as an intraoperative tool in cardiac surgery.

Survey of Extracorporeal Life Support Application in Lung Transplantation

INTRODUCTION

Lung transplantation has been evolving since its inception in 1963. Over recent years, literature has suggested a shift in the perioperative strategy of mechanical support toward extracorporeal membrane oxygenation (ECMO) as the preferred modality of extracorporeal life support (ECLS) in lung transplantation. The Survey of ECLS Application in Lung transplantation (SEAL) was designed to elucidate the current practice patterns of perioperative ECLS within the United States.

METHODS

In this cross-sectional study, a physician from 62 adult lung transplantation centers across the United States of America (USA) was surveyed on their institutional practices regarding the perioperative management of lung transplantation patients, with a focus on mechanical support.

RESULTS

The survey completion rate was 74% (46/62 eligible institutions). Most transplant centers utilize venoarterial (VA) ECMO (78%, 36/46) and/or venovenous (VV) ECMO (93%, 29/43) as a bridge to lung transplantation. When ECLS is used intraoperatively, 61% of (28/46) responding programs use VA ECMO as their preferred support. All programs use transesophageal echocardiography (TEE) intraoperatively, 85% (33/39) cannulate for ECMO centrally, and 74% (29/39) use a combination of inhaled and intravenous anesthesia while using ECMO intraoperatively. Most programs do not use antifibrinolytic during VA ECMO (62%, 28/45). Anticoagulation management and VA ECMO flows throughout the procedure showed considerable variation.

CONCLUSION

Data from SEAL illustrates that though there are some practice commonalities within the United States, there is also quite a bit of variability in practice. Multiple dominant practices within the USA are consistent with a recently published International Society of Heart and Lung Transplantation consensus.

The role of extracorporeal membrane oxygenation in thoracic anesthesia

PURPOSE OF REVIEW

Circulatory and respiratory support with extracorporeal membrane oxygenation (ECMO) has gained widespread acceptance during high-end thoracic surgery. The purpose of this review is to summarize the recent knowledge and give an outlook for future developments.

RECENT FINDINGS

A personalized approach of ECMO use is state of the art for monitoring during surgery. Personalization is increasingly applied during anesthesia for high-end surgery nowadays. This is reflected in the point of care testing (POCT) for anticoagulation and cardiac function during surgery on ECMO combining specific patient data into tailored algorithms. For optimizing protective ventilation MP (mechanical power) is a promising parameter for the future. These personalized methods incorporating numerous patient data are promising for the improvement of morbidity and mortality in high-end thoracic surgery. However, clinical data supporting improvement are not available to date but can be awaited in the future.

SUMMARY

Clinical practice during surgery on ECMO is increasingly personalized. The effect of personalization on morbidity and mortality must be examined in the future. Undoubtedly, an increase in knowledge can be expected from this trend towards personalization.

Efficacy and safety of videolaryngoscopes for transesophageal echocardiography probe insertion: A trial sequential meta-analysis

OBJECTIVE

This meta-analysis aimed to compare videolaryngoscope (VL)-assisted transesophageal echocardiography (TEE) probe insertion with conventional methods in terms of efficacy and safety.

METHODS

Several major databases such as Medline and Embase were systematically searched to identified relevant studies from inception to June 2024. The primary outcome was complication rate, defined as the proportion of patients experiencing complications related to TEE probe insertion. Injuries at specific sites (e.g., posterior hypopharyngeal wall) from both groups were also analyzed. The secondary outcomes included the first-attempt success rate and total insertion time of VL and conventional methods.

RESULTS

Seven trials involving 716 participants were identified. The use of VL was found to significantly reduce the complication rate (risk ratio[RR]:0.28, 95% confidence interval[CI]:0.17-0.46, P < 0.00001) and increased the first-attempt success rate [FASR] (RR:1.33, 95%CI: 1.10-1.60, P = 0.003) compared with conventional methods. These findings were confirmed by trial sequential analysis. No significant difference was found in the TEE insertion time among the two techniques (mean difference: -2.94s, 95%CI: -10.28-4.4, P = 0.43). VL significantly reduced the risk of trauma to the hypopharyngeal wall but showed no significant benefits in other areas (e.g., pyriform sinus). The certainty of evidence was moderate for the complication rate, very low for the FAS rate, and low for the TEE insertion time.

CONCLUSION

The use of VL for TEE probe insertion is associated with a significantly lower complication rate and higher FAS rate than conventional methods. These findings suggest that VL enhances patient safety and improves the efficiency of TEE probe insertion.

ISHLT consensus statement on the perioperative use of ECLS in lung transplantation: Part II: Intraoperative considerations

The use of extracorporeal life support (ECLS) throughout the perioperative phase of lung transplantation requires nuanced planning and execution by an integrated team of multidisciplinary experts. To date, no multidisciplinary consensus document has examined the perioperative considerations of how to best manage these patients. To address this challenge, this perioperative utilization of ECLS in lung transplantation consensus statement was approved for development by the International Society for Heart and Lung Transplantation Standards and Guidelines Committee. International experts across multiple disciplines, including cardiothoracic surgery, anesthesiology, critical care, pediatric pulmonology, adult pulmonology, pharmacy, psychology, physical therapy, nursing, and perfusion, were selected based on expertise and divided into subgroups examining the preoperative, intraoperative, and postoperative periods. Following a comprehensive literature review, each subgroup developed recommendations to examine via a structured Delphi methodology. Following 2 rounds of Delphi consensus, a total of 39 recommendations regarding intraoperative considerations for ECLS in lung transplantation met consensus criteria. These recommendations focus on the planning, implementation, management, and monitoring of ECLS throughout the entire intraoperative period.

New Non-Invasive Imaging Technologies in Cardiac Transplant Follow-Up: Acquired Evidence and Future Options

Heart transplantation (HT) is the established treatment for end-stage heart failure, significantly enhancing patients' survival and quality of life. To ensure optimal outcomes, the routine monitoring of HT recipients is paramount. While existing guidelines offer guidance on a blend of invasive and non-invasive imaging techniques, certain aspects such as the timing of echocardiographic assessments and the role of echocardiography or cardiac magnetic resonance (CMR) as alternatives to serial endomyocardial biopsies (EMBs) for rejection monitoring are not specifically outlined in the guidelines. Furthermore, invasive coronary angiography (ICA) is still recommended as the gold-standard procedure, usually performed one year after surgery and every two years thereafter. This review focuses on recent advancements in non-invasive and contrast-saving imaging techniques that have been investigated for HT patients. The aim of the manuscript is to identify imaging modalities that may potentially replace or reduce the need for invasive procedures such as ICA and EMB, considering their respective advantages and disadvantages. We emphasize the transformative potential of non-invasive techniques in elevating patient care. Advanced echocardiography techniques, including strain imaging and tissue Doppler imaging, offer enhanced insights into cardiac function, while CMR, through its multi-parametric mapping techniques, such as T1 and T2 mapping, allows for the non-invasive assessment of inflammation and tissue characterization. Cardiac computed tomography (CCT), particularly with its ability to evaluate coronary artery disease and assess graft vasculopathy, emerges as an integral tool in the follow-up of HT patients. Recent studies have highlighted the potential of nuclear myocardial perfusion imaging, including myocardial blood flow quantification, as a non-invasive method for diagnosing and prognosticating CAV. These advanced imaging approaches hold promise in mitigating the need for invasive procedures like ICA and EMB when evaluating the benefits and limitations of each modality.

Current status and training needs of trainee anesthesiologists in lung transplantation anesthesia in China: A single-center survey

Background

Perioperative management involving anesthesiologists plays an important role in prognosis of recipients after lung transplantation. Since the development of lung transplantation, the demand for specialized anesthesiologists continues to increase. As the largest lung transplant center in China, the Wuxi People's Hospital was tasked with trainee anesthesiologists throughout the country in lung transplantation anesthesia. This study aimed to evaluate the current status and training needs of anesthesiologists for the anesthetic management of lung transplantation in Wuxi People's Hospital between 2015 to 2020.

Methods

Overall, 53 trainee anesthesiologists for lung transplantation from 35 hospitals were investigated anonymously in our survey. The questionnaire included the anesthesiologists' demographic information, level of satisfaction, training needs and current status in their hospitals. We divided the doctors into two groups depending on the trainee anesthesiologists' seniority and professional title: intermediate and senior. Survey data were compared between the groups.

Results

Significantly more doctors in senior-level positions had clinical research experience than did doctors in intermediate-level positions (P = 0.041). All doctors were highly or very highly satisfied with the training received. Doctors in intermediate-level positions preferred training periods of 4-6 months, while those in senior-level positions preferred 1-3 months of training (P = 0.044). Most doctors considered theoretical courses to be lacking (69.0%), followed by a lack of scenario simulation teaching (54.8%). The most desirable programs were transesophageal echocardiography (TEE, 71.4%) and extracorporeal membrane oxygenation (ECMO, 64.3%). ECMO technology was available in the hospitals of 95.2% of respondents; however, only 2.4% of doctors said the anesthesiology department took charge of perioperative ECMO. Significantly more senior-level doctors chose calibrated pulse contour analysis (P = 0.018) and significantly more intermediate-level ones chose TEE (P = 0.049). Disappointingly, 21.4% doctors reported a lack of certification evaluation for trainee anesthesiologists at their hospitals.

Conclusions

Different training programs should be set up according to the trainee anesthesiologists' level of seniority and training needs. Theoretical courses and scenario simulation training must be added to improve the training program. Moreover, the training of TEE and ECMO requires greater attention. Finally, a standardized completion assessment is required for trainee anesthesiologists.

Anesthetic Management During Lung Transplantation - What's New in 2021?

As outcomes of lung transplantation (LTx) are improving transplant centers are pushing boundaries. There has been a steady increase in the medical complexity of lung transplant candidates. Many transplant centers are listing older patients with comorbidities, and there has been a steady rise in the number of candidates supported with extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation. There has been a growing appreciation of the importance intraoperative management of potentially modifiable risk factors has on postoperative outcomes. Evidence suggests that LTx even in high-risk patients requiring perioperative ECMO can offer excellent results. This article outlines the current state-of-the-art intraoperative management of LTx.

Commentary: Planes, trains, and automobiles-Effective use of prolonged ex vivo heart preservation

Throughout the world, a shortage of donor organs has prompted development of unique strategies to expand the donor pool. Here, we review a report by Medressova and colleagues to the Journal of Cardiac Surgery detailing the 3-year follow-up of a patient who successfully underwent a heart transplant after 17 hours of ex-vivo preservation.

A Narrative Review of the 2020 Guidelines for Use of Transesophageal Echocardiography to Assist with Surgical Decision- Making by the Cardiac Anesthesiologist in the Operating Room

Transesophageal echocardiography (TEE) has become an integral part in helping to diagnose, manage, and assess interventions in the cardiac operating room. Multiple guidelines have been created by the American Society of Echocardiography for performing a TEE examination for different cardiac pathologies. The operating room can provide unique challenges when performing a TEE examination, which include hemodynamic instability, time constraints, and use of general anesthesia. The Guideline for the use of TEE to assist in surgical decision- making in the operating room recently was published to provide a starting protocol for conducting a TEE examination for different cardiac surgeries and for using the information obtained to interpret and to communicate findings to the surgical team. This present narrative review focuses and expands upon the relevant portions for the cardiac anesthesiologist.

Transesophageal echocardiography for perioperative management in thoracic surgery

PURPOSE OF REVIEW

Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures.

RECENT FINDINGS

Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion.

SUMMARY

Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.

Anesthesia for Combined Heart and Liver Transplantation

A heart or liver transplantation procedure performed in isolation itself presents multiple challenges for the perioperative team. Accordingly, combining both transplants yields a vastly more complicated surgery, with many unique multisystem and multidisciplinary considerations. Although combined heart and liver transplantations are being performed with increasing frequency, nationwide experience is relatively limited at most institutions. The aim of this review is to discuss the perioperative challenges presented to the anesthesiology teams and provide evidence-based guidance for the management of these daunting procedures.