Transthoracic and transoesophageal echocardiography: a systematic review of feasibility and impact on diagnosis, management and outcome after cardiac surgery

Capillary refill time assessment after fluid challenge in patients on venoarterial extracorporeal membrane oxygenation: A retrospective study

BACKGROUND

Monitoring fluid therapy is challenging in patients assisted with Veno-arterial ECMO. The aim of our study was to evaluate the usefulness of capillary refill time to assess the response to fluid challenge in patients assisted with VA-ECMO.

METHODS

Retrospective monocentric study in a cardiac surgery ICU. We assess fluid responsiveness after a fluid challenge in patients on VA-ECMO. We recorded capillary refill time before and after fluid challenge and the evolution of global hemodynamic parameters.

RESULTS

A total of 27 patients were included. The main indications for VA-ECMO were post-cardiotomy cardiogenic shock (44%). Thirteen patients (42%) were responders and 14 non-responders (58%). In the responder group, the index CRT decreased significantly (1.7 [1.5; 2.1] vs. 1.2 [1; 1.3] s; p = 0.01), whereas it remained stable in the non-responder group (1.4 [1.1; 2.5] vs. 1.6 [0.9; 1.9] s; p = 0.22). Diagnosis performance of CRT variation to assess response after fluid challenge shows an AUC of 0.68 (p = 0.10) with a sensitivity of 79% [95% CI, 52-92] and a specificity of 69% [95% CI, 42-87], with a threshold at 23%.

CONCLUSION

In patients treated with VA-ECMO index capillary refill time is a reliable tool to assesses fluid responsiveness.

SPECIALTY

Critical care, Cardiac surgery, ECMO.

Novel Three-Dimensionally Printed Ultrasound Probe Simulator and Heart Model for Transthoracic Echocardiography Education

Simulation-based training is an essential component in the education of transthoracic echocardiography (TTE). Nevertheless, current TTE teaching methods may be subject to certain limitations. Hence, the authors in this study aimed to invent a novel TTE training system employing three-dimensional (3D) printing technology to teach the basic principles and psychomotor skills of TTE imaging more intuitively and understandably. This training system comprises a 3D-printed ultrasound probe simulator and a sliceable heart model. The probe simulator incorporates a linear laser generator to enable the visualization of the projection of the ultrasound scan plane in a 3D space. By using the probe simulator in conjunction with the sliceable heart model or other commercially available anatomic models, trainees can attain a more comprehensive understanding of probe motion and related scan planes in TTE. Notably, the 3D-printed models are portable and low-cost, suggesting their potential utility in various clinical scenarios, particularly for just-in-time training.

Variations in current clinical practice of postoperative pericardial effusion: a questionnaire study

OBJECTIVE

Postoperative pericardial effusion (PPE) occurs frequently after cardiac surgery, potentially leading to life-threatening cardiac tamponade. Specific treatment guidelines are currently lacking, possibly leading to variations in clinical practice. Our goal was to assess clinical PPE management and evaluate variation between centres and clinicians.

METHODS

A nationwide survey was sent to all interventional cardiologists and cardiothoracic surgeons in the Netherlands, regarding their preferred diagnostic and treatment modality of PPE. Clinical preferences were explored utilising four patient scenarios, each with a high/low echocardiographic and clinical suspicion of cardiac tamponade. Scenarios were also stratified by three PPE sizes (<1 cm, 1-2 cm, >2 cm).

RESULTS

In total, 46/140 interventional cardiologists and 48/120 cardiothoracic surgeons responded (27/31 contacted centres). Cardiologists favoured routine postoperative echocardiography in all patients (44%), whereas cardiothoracic surgeons preferred routine imaging after specific procedures, especially mitral (85%) and tricuspid (79%) valve surgery. Overall, pericardiocentesis (83%) was preferred over surgical evacuation (17%). Regarding all patient scenarios, cardiothoracic surgeons significantly preferred evacuation compared with cardiologists (51% vs 37%, p<0.001). This was also observed with cardiologists employed in surgical centres compared with non-surgical centres (43% vs 31%, p=0.02). Inter-rater analysis varied from poor to near-excellent (к 0.22-0.67), suggesting varying PPE treatment preferences within one centre.

CONCLUSION

There is significant variation in the preferred management of PPE between hospitals and clinicians, even within the same centre, possibly due to the lack of specific guidelines. Therefore, robust results of a systematic approach to PPE diagnosis and treatment are needed to formulate evidence-based recommendations and optimise patient outcome.

Predictive Value of the Transthoracic Echocardiography Index for Acute Kidney Injury after Cardiac Valve Surgery

Background: We aimed to demonstrate whether the preoperative transthoracic echocardiography index (TTEI) could improve the predictive value of clinical parameters for cardiac valve surgery-associated acute kidney injury (CVS−AKI). Methods: A total of 213 patients who underwent surgical CVS at Renmin Hospital of Wuhan University were consecutively recruited in this retrospective study. TTE assessments were performed within 7 days before surgery and logistic regression was used to determine TTEI. A nomogram was constructed by integrating TTEI and clinical features, and the net reclassification index (NRI) and integrated discrimination improvement (IDI) were applied to evaluate the improvement in TTEI for CVS−AKI. Results: Among them, 66 patients (30.9%) developed CVS−AKI. The TTEI was calculated as follows: −6.579 + 0.068 × pulmonary artery systolic pressure (mmHg) −0.742 × LVEF (>55%, yes or no) + 0.346 × left ventricle posterior wall thickness (mm). The nomogram based on the TEEI and other clinical factors possessed excellent performance (C-index = 0.880), had great calibration and discrimination, and was clinically useful. Furthermore, NRI (0.07, 95% confidence interval, 95%CI, 0.01−0.12, p = 0.02) and IDI (0.08, 95%CI, 0.01−0.20, p = 0.02) indicated that TTEI could significantly improve the predictive value of clinical features for CVS−AKI. Conclusions: As a simple access and cost-effective parameter, the preoperative TTEI may be a reliable and useful factor for CVS−AKI.

Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine

Purpose

To provide consensus, and a list of experts’ recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting.

Methods

The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians–researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against.

Results

This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus.

Conclusions

This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06486-z.

Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade

Background

Pericardial effusion is a known complication of post-open cardiac surgery which can progress to life-threatening cardiac tamponade. Classical signs of tamponade such as hypotension and pulsus paradoxus are often absent. Diagnosing acute cardiac tamponade with transthoracic echocardiography (TTE) can be challenging in post-cardiac surgical patients due to distorted anatomy and limited scanning windows by the presence of surgical dressings or scar. Additionally, this patient population is more likely to have a loculated pericardial effusion, or an effusion that is isoechoic in appearance secondary to clotted blood. These findings can be challenging to visualize with traditional TTE. Missed diagnosis of cardiac tamponade due to loculated pericardial clot can result in delayed diagnosis and clinical management.

Case presentation

We report a case series that illustrates the diagnostic challenge and value of resuscitative transesophageal echocardiography (TEE) in the emergency department (ED) for the diagnosis of cardiac tamponade due to posterior loculated pericardial clot in post-surgical coronary artery bypass graft (CABG) patients.

Conclusions

Cardiac tamponade due to loculated posterior pericardial clot post-CABG requires prompt diagnosis and appropriate management to avoid the potential for hemodynamic instability. Transesophageal echocardiography allows a rapid diagnosis, early appropriate referral and an opportunity to institute appropriate therapeutic measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00225-7.

Rare malignant spindle cell sarcoma of the left atrium diagnosed with TEE: A case report

INTRODUCTION

One of the purposes of echocardiography is to determine the nature of a space-occupying lesion. The conventional transthoracic echocardiogram (TTE) is the preferred method for the diagnosis of cardiac space-occupying lesions as it can reveal the baseline information. For patients with poor conditions, however, TTE cannot clearly display the boundary, it has a limited role in determining the nature of the lesions.

PATIENT CONCERNS

A 47-year-old woman presented with intermittent fever for 7 days and chest distress/shortness of breath for 5 days.

DIAGNOSIS

In our current case, we inferred the nature of space-occupying lesions in the left atrium more accurately using transesophageal echocardiography (TEE) than TTE, which may offer diagnostic evidence for surgical treatment.

INTERVENTIONS

The patient underwent surgical resection of the left atrial tumor and reconstruction of the left atrial wall. However, the patient's posterior lobe of the mitral valve was infiltrated by tumor, which was difficult to completely remove.

OUTCOMES

Echocardiography was performed 3 months after surgery and the tumor recurred in the posterior lobe of the mitral valve. Although almost all tumors have been removed by surgery, the average survival time is often less than 1 year, as it is difficult to completely remove and easy to relapse with poor prognosis.

CONCLUSION

Transesophageal echocardiography (TEE) plays a relatively more important role in the determination and differential diagnosis of cardiac space-occupying lesions.

Routine Intraoperative Inhaled Milrinone and Iloprost Reduces Inotrope Use in Patients Undergoing Cardiac Surgery: A Retrospective Cohort Pilot Study

BACKGROUND

Catecholamine inotropes are frequently used after cardiopulmonary bypass (CPB) but may have undesirable effects. The aim was to identify whether the routine use of inhaled pulmonary vasodilators might reduce the requirement for inotrope drugs after cardiac surgery.

METHODS

Retrospective cohort study of sequential patients undergoing cardiac surgery at the Royal Melbourne Hospital performed by a single surgeon and anesthesia care team, within 14 months before and after routine implementation of inhaled pulmonary vasodilators, August 2017. Milrinone 4 mg and iloprost 20 µg were inhaled using a vibrating mesh nebulizer (Aerogen) before initiation of CPB and at chest closure. Other aspects of clinical management were unaltered over the time period. Two investigators blinded to each other extracted data from electronic and written medical records. The primary outcome was any use of inotropes in the perioperative period; a Fisher exact test was used to analyze any differences between the 2 groups. Demographic data, hemodynamic data, and use of inotropes and vasopressors were collected from induction of anesthesia to 36 hours postoperative in the intensive care unit (ICU). Hospital and ICU length of stay, cost, and complications were collected.

RESULTS

Any use of inotropes was significantly lower with inhaled pulmonary dilators (62.5% vs 86.8%, odds ratio [95% confidence interval {CI}], 0.253 (0.083-0.764); P = .011), including intraoperative inotrope use (37.5% vs 86.8%, odds ratio [95% CI], 0.091 (0.03-0.275); P < .001). ICU length of stay was significantly lower with inhaled pulmonary dilators (45 hours, interquartile range [IQR], 27-65 vs 50 hours, IQR, 45-74; P = .026). There were no significant differences among major postoperative complications or costs between groups.

CONCLUSIONS

Routine use of inhaled milrinone 4 mg and iloprost 20 µg before and after CPB is associated with reduced postoperative inotrope use.

Impact of goal directed basic echocardiography on diagnostic and therapeutic management in an ICU of cardiac surgery

OBJECTIVE

Few studies have evaluated the impact in diagnosis and therapeutic management of basic transthoracic echocardiography in postoperated cardiac surgery. The aim of our study was to evaluate the impact of basic transthoracic echocardiography in the management of this kind of patients.

DESIGN

Over an 18-month period, we prospectively studied all patients admitted to a university hospital Intensive Care Unit following heart surgery. We evaluated clinically all of them to establish a diagnosis and an initial treatment. We performed basic transthoracic echocardiography for a diagnosis evaluation that was compared with clinical diagnosis. If they differed, we assessed to change treatment and evaluate the therapeutic response. We performed a descriptive analysis.

RESULTS

We included 136 patients and performed 203 echocardiographies. Transthoracic echocardiography differed of initial diagnosis in 101 (49.8%) echocardiographies. In 56 of these echocardiographies (55.44%), we could give an alternative diagnosis with a change in the treatment in 30patients (53,6%). We found clinical improvement in 26 patients (86.76%) in the following 30-60minutes.

CONCLUSIONS

Basic transthoracic echocardiography is useful in diagnostic and therapeutic management of postoperative cardiac surgery patients. We could not confirm the clinical diagnosis in half of the performed echocardiographies. In most patients in whom we observe a change in the diagnosis due to echocardiography, we observed a clinical improvement after changing the treatment.

Point-of-care ultrasound: its growing application in hospital medicine

Point-of-care ultrasound is emerging as an important adjunct to the clinical examination. Ultrasonography has long been seen as a modality for experts but this is changing and it is hoped that, with appropriate training, point-of-care ultrasound will become a modern-day diagnostic necessity.

Enhanced recovery after cardiac surgery

The concept of early recovery after surgery (ERAS) consists of bundle interventions during the pre-, intra- and postoperative periods and team work. The ERAS, which is a multimodal strategy, enables one to limit the neurohumoral response to the surgery, maintain homeostasis, reduce the risk of complications, shorten the hospital stay, accelerate the return to everyday functioning, improve the patient’s satisfaction, achieve a satisfactory quality of life and finally reduce the treatment costs and eliminate any redundant and ineffective practices. Almost every patient can be classified for the ERAS strategy except for patients undergoing urgent and emergency surgery. The necessity to give up ERAS can result from poor organisation and management. Moreover, the procedure itself can be the cause of the lack of adherence to the planned standard. It is necessary to use protocols and checklists. While fulfilling this doctrine, the anaesthesiologist becomes a perioperative specialist.

Anesthetist-delivered intraoperative transesophageal echocardiography in pediatric cardiac surgery

This article reviews the evidence for anesthetist-delivered perioperative transesophageal echocardiography for children undergoing cardiac surgery. It addresses the additional issues of training, developing practice, accreditation, and the requirement for collaboration with pediatric cardiologists, surgeons and other members of the perioperative team. Finally an overview of the potential structure of an anesthetist-delivered perioperative transesophageal echocardiography service is presented.

Coronary artery bypass graft surgery complications: A review for emergency clinicians

INTRODUCTION

Coronary artery bypass graft (CABG) surgery remains a high-risk procedure, and many patients require emergency department (ED) management for complications after surgery.

OBJECTIVE

This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of post-CABG surgery complications.

DISCUSSION

While there has been a recent decline in all cardiac revascularization procedures, there remains over 200,000 CABG surgeries performed in the United States annually, with up to 14% of these patients presenting to the ED within 30 days of discharge with post-operative complications. Risk factors for perioperative mortality and morbidity after CABG surgery can be divided into three categories: patient characteristics, clinician characteristics, and postoperative factors. Emergency physicians will be faced with several postoperative complications, including sternal wound infections, pneumonia, thromboembolic phenomena, graft failure, atrial fibrillation, pulmonary hypertension, pericardial effusion, strokes, renal injury, gastrointestinal insults, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary surgical team is needed, which improves patient outcomes. This review provides several guiding principles for management of acute complications. Understanding these complications and an approach to the management of hemodynamic instability is essential to optimizing patient care.

CONCLUSIONS

Postoperative complications of CABG surgery can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Early surgical consultation is imperative, as is optimizing the patient's hemodynamics, including preload, heart rate, cardiac rhythm, contractility, and afterload.

The ability of left ventricular end-diastolic volume variations measured by TEE to monitor fluid responsiveness in high-risk surgical patients during craniotomy: a prospective cohort study

BACKGROUND

This study was aimed to evaluate the ability of left ventricular end-diastolic volume variations (LVEDVV) measured by transesophageal echocardiography (TEE) compared with stroke volume variation (SVV) obtained by the FloTrac/Vigileo monitor to predict fluid responsiveness, in patients undergoing craniotomy with goal direct therapy.

METHODS

We used SVV obtained by the FloTrac/Vigileo monitor to manage intraoperative hypotension in adult patients undergoing craniotomy (ASA III - IV) after obtaining IRB approval and informed consent. The LVEDVV were measured by TEE through the changes of left ventricular short diameter of axle simultaneously. When cardiac index (CI) ≤ 2.5 and SVV ≥ 15%, comparisons were made between the two devices before and after volume expansion.

RESULTS

We enrolled twenty-six patients referred for craniotomy in this study and 145 pairs of data were obtained. Mean Vigileo-SVV and TEE-LVEDVV were 17.8 ± 2.78% and 22.1 ± 7.25% before volume expansion respectively, and were 10.95 ± 2.8% and 13.58 ± 3.78% after volume expansion respectively (P < 0.001). The relationship between Vigileo-SVV and TEE-LVEDVV was significant (r2 = 0.55; p < 0.001). Agreement between Vigileo-SVV and TEE-LVEDVV was 3.3% ± 3.9% (mean bias ± SD, Bland-Altman).

CONCLUSIONS

For fluid responsiveness of patients during craniotomy in ASA III-IV, LVEDVV measured by left ventricular short diameter of axle using M type echocaidiographic measurement seems an acceptable monitoring indicator. This accessible method has promising clinical applications in situations where volume and cardiac function monitoring is of great importance during surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-TRC-13003583 , August 20, 2013.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery

OBJECTIVES

The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery.

DESIGN

Prospective observational study.

SETTING

Tertiary university hospital.

PARTICIPANTS

The study comprised 51 patients aged 18 years or older presenting for cardiac surgery.

INTERVENTIONS

Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01).

CONCLUSIONS

Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.