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Background: Transthoracic echocardiographic (TTE) indices of myocardial function among survivors of out-of-hospital cardiac arrest (OHCA) have been related to neurological outcome; however, results are inconsistent. We hypothesized that changes in average peak systolic mitral annular velocity (s') from 24 h (h) to 72 h following start of targeted temperature management (TTM) predict six-month neurological outcome in comatose OHCA survivors., Methods: We investigated the association between peak systolic velocity of the mitral plane (s') and six-month neurological outcome in a population of 99 patients from a randomised controlled trial comparing TTM at 33 ± 1 °C for 24 h (h) (n = 47) vs. 48 h (n = 52) following OHCA (TTH48-trial). TTE was conducted at 24 h, 48 h, and 72 h after reaching target temperature. The primary outcome was 180 days neurological outcome assessed by Cerebral Performance Category score (CPC180) and the primary TTE outcome measure was s'. Secondary outcome measures were left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), e', E/e' and tricuspid annular plane systolic excursion (TAPSE)., Results: Across all three scan time points s' was not associated with neurological outcome (ORs: 24 h: 1.0 (95%CI: 0.7-1.4, p = 0.98), 48 h: 1.13 (95%CI: 0.9-1.4, p = 0.34), 72 h: 1.04 (95%CI: 0.8-1.4, p = 0.76)). LVEF, GLS, E/e', and TAPSE recorded on serial TTEs following OHCA were neither associated with nor did they predict CPC180. Estimated median e' at 48 h following TTM was 5.74 cm/s (95%CI: 5.27-6.22) in patients with good outcome (CPC180 1-2) vs. 4.95 cm/s (95%CI: 4.37-5.54) in patients with poor outcome (CPC180 3-5) (p = 0.04)., Conclusions: s' assessed on serial TTEs in comatose survivors of OHCA treated with TTM was not associated with CPC180. Our findings suggest that serial TTEs in the early post-resuscitation phase during TTM do not aid the prognostication of neurological outcome following OHCA., Trial Registration: NCT02066753 . Registered 14 February 2014 - Retrospectively registered.

Most indications for performing echocardiography focus on the evaluation of properties intrinsic to the heart. However, numerous extra-cardiac conditions indirectly convey changes to the echocardiographic appearance through alterations in the governing physiology. Pulmonary embolism increases pulmonary arterial pressure if a sufficient cross-sectional area of the pulmonary vascular bed is occluded. This may result in dilatation of the right ventricle and, in severe cases, concomitant early diastolic septal collapse into the left ventricle. Acute respiratory failure has been shown to yield a similar echocardiographic appearance in experimental conditions due to the resultant pulmonary vasoconstriction. Echocardiography in the presence of pulmonary disease can reveal underlying cardiac pathologies such as pulmonary hypertension that contribute to the clinical severity of respiratory distress. Positive pressure ventilation affects preload, afterload, and compliance of both ventricles. The echocardiographic net result cannot be uniformly anticipated, but provides information on the deciding physiology or pathophysiology. Mediastinal pathology including tumors, herniation of abdominal content, and pleural effusion can often be visualized directly with echocardiography. Mediastinal pathologies adjacent to the heart may compress the myocardium directly, thus facilitating echocardiographic and clinical signs of tamponade in the absence of pericardial effusion. In conclusion, many pathologies of extra-cardiac origin influence the echocardiographic appearance of the heart. These changes do not reflect properties of the myocardium but may well be mistaken for it. Hence, these conditions are essential knowledge to all physicians performing echocardiography across the spectrum from advanced cardiological diagnostics to rapid point-of-care focused cardiac ultrasonography., (© 2018 Wiley Periodicals, Inc.)

Purpose of Review: A need for further assessment of patients in the perioperative setting and an increasing availability of ultrasonography equipment have facilitated the diffusion of ultrasonography and lately focused transthoracic echocardiography (TTE) in anesthesiology practice. This review will discuss the possible use of focused TTE in the perioperative setting and provides an update on present and future perspectives., Recent Findings: Several studies focusing on patient management and diagnostic accuracy of perioperative, focused TTE, have been published recently. Several multidisciplinary guidelines addressing use and educational aspects of focused ultrasonography are available, yet guidelines focusing solely on the use in the perioperative setting are lacking., Summary: Hemodynamically significant cardiac disease or pathophysiology can be disclosed using TTE. Focused TTE is feasible for perioperative patient management and monitoring and will be an inevitable and indispensable tool for the anesthetist. Future research should focus on the outcome of perioperative TTE performed by anesthetists, using rigorous study designs and patient-centered outcomes such as mortality and morbidity.

Background: Previous studies addressing teaching and learning in point-of-care ultrasound have primarily focussed on image interpretation and not on the technical quality of the images. We hypothesized that a limited intervention of 10 supervised examinations would improve the technical skills in Focus Assessed Transthoracic Echocardiography (FATE) and that physicians with no experience in FATE would quickly adopt technical skills allowing for image quality suitable for interpretation., Methods: Twenty-one physicians with no previous training in FATE or echocardiography (Novices) participated in the study and a reference group of three examiners with more than 10 years of experience in echocardiography (Experts) was included. Novices received an initial theoretical and practical introduction (2 hours), after which baseline examinations were performed on two healthy volunteers. Subsequently all physicians were scheduled to a separate intervention day comprising ten supervised FATE examinations. For effect measurement a second examination (evaluation) of the same two healthy volunteers from the baseline examination was performed., Results: At baseline 86% of images obtained by novices were suitable for interpretation, on evaluation this was 93% (p = 0.005). 100% of images obtained by experts were suitable for interpretation. Mean global image rating on baseline examinations was 70.2 (CI 68.0-72.4) and mean global image rating after intervention was 75.0 (CI 72.9-77.0), p = 0.0002. In comparison, mean global image rating in the expert group was 89.8 (CI 88.8-90.9)., Conclusions: Improvement of technical skills in FATE can be achieved with a limited intervention and upon completion of intervention 93% of images achieved are suitable for clinical interpretation.

Background: Veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) is commonly used to provide haemodynamic support for patients with severe cardiac failure. However, timing ECMO weaning remains challenging. We aimed to examine if an integrative weaning approach based on predefined haemodynamic, respiratory and echocardiographic criteria is associated with successful weaning. Methods: All patients weaned from ECMO between April 2017 and April 2019 at Aarhus University Hospital, Denmark, were consecutively enrolled. Predefined haemodynamic, respiratory and echocardiographic criteria were assessed before and during ECMO flow reduction. A weaning attempt was commenced in haemodynamic stable patients and patients remaining stable at minimal flow were weaned from ECMO. Comparisons were made between patients who met the criteria for weaning at first attempt and patients who did not meet these criteria. Patients completing a full weaning attempt with no further need for mechanical support within 24 h were defined as successfully weaned. Results: A total of 38 patients were included in the study, of whom 26 (68%) patients met the criteria for weaning. Among these patients, 25 (96%) could be successfully weaned. Successfully weaned patients were younger and had less need for inotropic support and ECMO duration was shorter. Fulfilling the weaning criteria was associated with successful weaning and both favourable 30‐d survival and survival to discharge. Conclusion: An integrative weaning approach based on haemodynamic, respiratory and echocardiographic criteria may strengthen the clinical decision process in predicting successful weaning in patients receiving ECMO for refractory cardiac failure. [ABSTRACT FROM AUTHOR]

Objectives The aim of the study was to investigate if pleurocentesis in patients with pleural effusion would lead to changes in systolic and diastolic function of the left ventricle. Design The study was descriptive, and patients were their own controls. Setting The setting was a single-center university hospital. Participants Patients with pleural effusion requiring pleurocentesis were eligible for inclusion. Interventions The participants who had pleurocentesis performed were available for analysis. Measurements and Main Results Prior to pleurocentesis and approximately 1 hour after, patients were examined primarily with transthoracic echocardiography. The examination included measurements of left ventricular volumes and measures of diastolic function assessed by Doppler echocardiography. Thirty-five patients were included, and 11 later were excluded, yielding a study population of 24. Preload, expressed as left ventricular end-diastolic volume, increased significantly from before to after pleurocentesis (p = 0.014). None of the diastolic parameters showed significant results. Significant changes were observed for heart rate, supplementary O 2 , respiratory frequency, and saturation. Conclusions Pleurocentesis increased left ventricular preload and improved respiratory function. [ABSTRACT FROM AUTHOR]

Background The aim of the study was to compare the diagnostic accuracy of point-of-care cardiac ultrasonography performed by a novice examiner against results from a specialist in cardiology with expert skills in echocardiography, with regard to the assessment of six clinically relevant cardiac conditions in a population of ward patients from the Department of Cardiology or the Department of Cardiothoracic Surgery. Methods Cardiac ultrasonography was performed by a novice examiner at the bedside and images were interpreted in a point-of-care context with dichotomous outcomes (yes/no). Six outcome categories were defined: 1) pericardial effusion (⩾10 mm), 2) left ventricular dilatation (⩾62 mm), 3) right ventricular dilatation (⩾42 mm or ⩾ left ventricular diameter), 4) left ventricular hypertrophy (⩾13 mm), 5) left ventricular failure (EF ⩽ 40%), 6) aortic stenosis (maximum flow velocity ⩾3 m/s). The examiner was blinded to the patients' medical history and results from previous echocardiographic examinations. Results from the interpreted point-of-care ultrasonography examination were compared with echocardiographic diagnosis made by a specialist in cardiology. Results A total of 102 medical and surgical patients were included. Assessments were made in six categories totalling 612 assessments. There was agreement between the novice examiner and the specialist in 95.6% of the cases; overall sensitivity was 0.91 and specificity was 0.97. Positive predictive value was 0.92 and negative predictive value was 0.97. Kappa statistics showed good agreement between observers (κ=0.88). Conclusions This study showed that a novice examiner was able to detect common and significant heart pathology in six different categories with good accuracy using POC ultrasonography [ABSTRACT FROM AUTHOR]

Objective: The authors hypothesized that preoperative N-terminal probrain natriuretic peptide (NT-proBNP) correlates well with longitudinal strain measurements and with Doppler measurements of diastolic function. Design: Prospective observational study. Setting: University teaching hospital. Participants: Forty patients undergoing elective cardiac surgery. Interventions: Aortic valve replacement, coronary artery bypass grafting, or a combination of these procedures. Measurements and Main Results: Plasma NT-proBNP concentration was obtained by analyzing blood samples with a commercially available kit. Left ventricular systolic function was assessed by speckle tracking ultrasound strain measurements and left ventricular diastolic function was assessed by 2 Doppler methods: E/A ratio and E/E′ ratio. Tissue Doppler imaging velocities (E′ and A′) were measured in the basal septum (annular) and pulse-wave Doppler was used to measure mitral in-flow profile (E and A). The correlation between global strain data from the speckle tracking ultrasound measurement and NT-proBNP levels was ρ = 0.35 (p = 0.026). With a cutoff value of −15% in global strain measurements, there was a significant difference in NT-proBNP levels (117 v 57 pg/mL, p = 0.048). E/E′ values correlated with NT-proBNP levels (ρ = 0.46, p = 0.011). With a cutoff of 15 in E/E′ values, there were significant differences in corresponding NT-proBNP levels (33 v 113 pg/mL, p = 0.004). Conclusions: A correlation was found between plasma levels of NT-proBNP and speckle tracking ultrasound strain measurements by an easily employed method applicable in the anesthesia and preoperative settings. In addition, the well-established marker of diastolic function, E/E′, correlated well with NT-proBNP, whereas the E/A ratio failed to show any association. [ABSTRACT FROM AUTHOR]

Background. The use of echocardiography in intensive care settings impacts decision making. A prerequisite for the use of echocardiography is relative resistance to changes in volume status and levels of positive pressure ventilation (PPV). Studies on indices of diastolic function report conflicting results with regard to dependence on volume status. Evidence is scarce on PPV. Methods. Ten healthy subjects were exposed to 6 levels of positive end-expiratory pressure (PEEP) and pressure support (PS) following a baseline reading. All ventilator settings were performed at three positions: horizontal, reverse-Trendelenburg, and Trendelenburg. Echocardiography was performed throughout. Results. During spontaneous breathing, early diastolic transmitral velocity (E) changed with positioning (P < 0.001), whereas early diastolic velocity of the mitral annulus (e') was independent (P = 0.263). With PPV, E and e' proved preload dependent (P values < 0.001). Increases in PEEP, PS, or a combination influenced E and e' in reverse-Trendelenburg- and horizontal positions, but not in the Trendelenburg position. Discussion. The change towards preload dependency of e' with PPV suggests that PPV increases myocardial preload sensitivity. The susceptibility of E and e' to preload changes during PPV discourages their use in settings of volume shifts or during changes in ventilator settings. Conclusion. Positioning and PPV affect E and e'. [ABSTRACT FROM AUTHOR]

Introduction: Focused cardiac ultrasound can potentially identify reversible causes of cardiac arrest during advanced life support (ALS), but data on the timing of image acquisition are lacking. This study aimed to compare the quality of images obtained during rhythm analysis, bag-mask ventilations, and chest compressions.Methods: Adult patients in cardiac arrest were prospectively included during 23 months at a Danish community hospital. Physicians who had completed basic ultrasound training performed subcostal focused cardiac ultrasound during rhythm analysis, bag-mask ventilations, and chest compressions. Image quality was categorised as either useful for interpretation or not. Two echocardiography experts rated images useful for interpretation if all the following characteristics could be determined: 1) right ventricle larger than left ventricle, 2) pericardial fluid, and 3) collapsing ventricles.Results: Images were obtained from 60 of 114 patients undergoing ALS. A higher proportion of the images obtained during rhythm analysis and bag-mask ventilations were useful for interpretation when compared with chest compressions (rhythm analysis vs chest compressions: OR 2.2 (95%CI 1.3-3.8), P = 0.005; bag mask ventilations vs chest compressions: OR 2.0 (95%CI 1.1-3.7), P = 0.03). There was no difference between images obtained during rhythm analysis and bag-mask ventilations (OR 1.1 (95%CI 0.6-2.0), P = 0.74).Conclusion: The quality of focused cardiac ultrasound images obtained during rhythm analysis and bag-mask ventilations was superior to that of images obtained during chest compressions. There was no difference in the quality of images obtained during rhythm analysis and bag-mask ventilations. Bag-mask ventilations may constitute an overlooked opportunity for image acquisition during ALS. [ABSTRACT FROM AUTHOR]

Aim To evaluate post-cardiac arrest myocardial dysfunction during prolonged targeted temperature management (TTM) compared with standard TTM in comatose out-of-hospital cardiac arrest (OHCA) survivors. Methods A randomised, controlled trial comparing myocardial function after TTM at 33 ±1 ° C for 48 h compared with 24 h. A total of 105 OHCA patients were computer-randomised to 24 h (n = 50) or 48 h (n = 55) of TTM. Transthoracic echocardiography was performed after 24 h, 48 h and 72 h. Echocardiographic parameters were evaluated by an investigator who was blinded to randomisation. The primary endpoint was peak systolic mitral annular velocity (Ś) measured as the difference in the period from 24 h to 72 h. The model was adjusted for age, primary rhythm and heart rate. The secondary outcomes were global peak longitudinal strain, left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE) and the diastolic measures e’ and E/e’. Results The mean difference of S’ was significantly increased in the 48 h group compared with the 24 h group: −1.14 cm/s (−1.83; −0.45), p = 0.001. This difference was consistent after adjusting the data ( p = 0.008). However, there were no significant changes between the study groups with respect to the adjusted secondary outcomes of global peak longitudinal strain ( p = 0.07), LVEF ( p = 0.31), TAPSE ( p = 0.91), e’ ( p = 0.26) and E/e’ ( p = 0.18). Conclusion Prolonged TTM at 33 °C of 48 h compared with 24 h in comatose OHCA survivors may improve the recovery of post-cardiac arrest left myocardial dysfunction demonstrated by the echocardiographic outcome, S’. ClinicalTrials.gov identifier: NCT02066753. [ABSTRACT FROM AUTHOR]

Abstract: Background: Ultrasonographic evaluation of the inferior vena cava (IVC) provides information on central hemodynamics and predicts fluid responsiveness during positive pressure ventilation. In spontaneously breathing patients, the correlations between IVC dynamics and the hemodynamic response to volume shifts remain to be described. Objectives: We aimed to describe the correlation between IVC dynamics and the changes in cardiac output (CO) caused by controlled hemorrhage. Methods: Healthy donors from the blood bank were eligible for inclusion. Measurements of the IVC and CO were performed before and immediately after blood donation using ultrasound methods. A control group served to evaluate the effect of resting. Results: Thirty-seven participants completed the study. IVC collapsibility index (IVC-CI) and IVC end expiratory diameter (IVCe) both changed significantly after blood donation (p < 0.001). The baseline IVC-CI and IVCe did not correlate with the change in CO (p-values ≥ 0.40). The alterations in IVC-CI and IVCe induced by blood donation also did not correlate with the change in CO (p ≥ 0.71). The sensitivities of IVC-CI or IVCe, defined as an increase in IVC-CI and a decrease in IVCe, for picking up any decrease in CO were 81.3% and 84.4%, respectively. In the control group, no effect was seen between measurements. Conclusion: IVC-CI and IVCe did not correlate with the magnitude of hemodynamic response to early hemorrhage. The sensitivity of serial IVC measurements was approximately 80% for detecting early blood loss. [Copyright &y& Elsevier]