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We implemented a new policy at our institution where the responsibility for intensive care unit (ICU) patient transports to the operating room (OR) was changed from the anesthesia to the ICU service. We hypothesized that this approach would be associated with increased on-time starts and decreased turnover times.In the historical model, intubated patients or those on mechanical circulatory assistance (MCA) were transported by the anesthesia service to the OR ("pre-ICU Pickup"). In our new model, these patients are transported by the ICU service to the preoperative holding area (Pre-op) where care is transferred to the anesthesia service ("post-ICU Transfer"). If judged necessary by the ICU or anesthesia attending, the patient was transported by the anesthesia service ("post-ICU Pickup"). We retrospectively reviewed case tracking data for patients undergoing surgery before (January 2014 to May 2015) and after implementation (July 2016 to June 2017) of the new policy. The primary outcome was the proportion of elective, weekday first-case, on-time starts. To adjust for confounders including comorbidities and time trends, we performed a segmented logistic regression analysis assessing the effect of our intervention on the primary outcome. Secondary outcomes were turnover times and compliance with preoperative checklist documentation.We identified 95 first-start and 86 turnover cases in the pre-ICU Pickup, 70 first-start and 88 turnover cases in the post-ICU Transfer, and 6 turnover cases in the post-ICU Pickup group. Ignoring time trends, the crude proportion of on-time starts increased from 32.6% in the pre-ICU Pickup to 77.1% in the post-ICU Transfer group. After segmented logistic regression adjusting for age, sex, American Society of Anesthesiologists (ASA) physical status, Sequential Organ Failure Assessment (SOFA) score, respiratory failure, endotracheal intubation, MCA, congestive heart failure (CHF), valvular heart disease, and cardiogenic and hemorrhagic shock, the post-ICU Transfer group was more likely to have an on-time start at the start of the intervention than the pre-ICU Pickup group at the end of the preintervention period (odds ratio, 11.1; 95% confidence interval [CI], 1.3-125.7; P = .043). After segmented linear regression adjusting for the above confounders, the estimated difference in mean turnover times between the post-ICU Pickup and pre-ICU Transfer group was not significant (-6.9 minutes; 95% CI, -17.09 to 3.27; P = .17). In post-ICU Transfer patients, consent, history and physical examination (HP), and site marking were verified before leaving the ICU in 92.9%, 93.2%, and 89.2% of the cases, respectively. No adverse events were reported during the study period.A transition from the anesthesia to the ICU service for transporting ICU patients to the OR did not change turnover times but resulted in more on-time starts and high compliance with preoperative checklist documentation.

Objectives Our study goals were to evaluate the 3-dimensional matrix array transesophageal echocardiographic (3D-MTEE) probe by assessing the image quality of native valves and other intracardiac structures. Background Because 3-dimensional transesophageal echocardiography with gated rotational acquisition is not used routinely as the result of artifacts, lengthy acquisition, and processing, a 3D-MTEE probe was developed (Philips Medical Systems, Andover, Massachusetts). Methods In 211 patients, 3D-MTEE zoom images of the mitral valve (MV), aortic valve, tricuspid valve, interatrial septum, and left atrial appendage were obtained, followed by a left ventricular wide-angled acquisition. Images were reviewed and graded off-line (Xcelera with QLAB software, Philips Medical Systems). Results Excellent visualization of the MV (85% to 91% for all scallops of both MV leaflets), interatrial septum (84%), left atrial appendage (86%), and left ventricle (77%) was observed. Native aortic and tricuspid valves were optimally visualized only in 18% and 11% of patients, respectively. Conclusions The use of 3D-MTEE imaging, which is feasible in most patients, provides superb imaging of native MVs, which makes this modality an excellent choice for MV surgical planning and guidance of percutaneous interventions. Optimal aortic and tricuspid valve imaging will depend on further technological developments. Fast acquisition and immediate online display will facilitate wider acceptance and routine use in clinical practice.

From the *Department of Anesthesiology, Rush University Medical Center, Chicago, IL; †Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL; ‡Hospital of the University of Pennsylvania, Philadelphia, PA; and §Department of Anesthesiology Montefiore Medical Center, Bronx, NY. Address reprint requests to Kimberly L. Kesner, MD, Department of Anesthesiology, Rush University Medical Center, 1653 W. Congress Parkway, #739, Chicago, IL 60637. E-mail: kim.taub@gmail.com © 2016 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 MITRAL VALVE REPLACEMENT is a commonly performed operation with good success rates. The St. Jude Medical (SJM) prosthesis (St. Jude Medical, St. Paul, MN) has a long record of safety and very low incidence (0.06%) of mechanical failure. While failure of a mechanical valve is rare, most reports occur years after the initial surgery, usually involving an obstruction preventing the valve from fully closing. The authors present a case of immediate intraoperative mechanical mitral valve failure in which a robotically inserted valve did not open upon weaning from cardiopulmonary bypass (CPB).

Background Left ventricular dysfunction is often reversed after coronary artery bypass graft (CABG) surgery; however, this change is not easily predicted. The authors hypothesized that functional changes after a low dose of dobutamine (5 microgram. kg-1. min-1) intraoperatively would predict functional changes when complete revascularization was achieved. Methods The authors analyzed 560 segments in 40 patients scheduled for elective CABG surgery for regional wall motion (1-5 scoring system) at four stages: baseline (after induction and intubation), with administration of low-dose dobutamine before cardiopulmonary bypass, after separation from cardiopulmonary bypass (early), and after administration of protamine (late). Two independent observers scored the myocardial regions according to a 16-segment model in multiple imaging planes. For each segment, the response to dobutamine was dichotomized as improved or not improved from baseline and analyzed with logistic regression. The influence of covariates (ejection fraction, myocardial infarction, diabetes mellitus, and beta blockers) was also determined with logistic regression models. P < 0.05 was considered significant. Results Changes in myocardial function after low-dose dobutamine were highly predictive for early (P < 0.0001) and late (P < 0.0001) changes in myocardial function from baseline regional scores. The overall odds ratio for early and late improvement increased by 20.7 and 34.6, respectively, when improvement was observed after low-dose dobutamine was administered. The overall positive predictive value of improved regional wall motion after CABG did not vary with left ventricular ejection fraction, a history of myocardial infarction, or beta blocker use, and it varied little with diabetic status (range, 0.86-0.96) if regional wall motion improved with low-dose dobutamine before CABG. The overall negative predictive value was 0.70; however, the range varied with diabetic status (i.e., lowest in diabetic patients and highest in nondiabetic patients). Conclusion Intraoperative low-dose dobutamine is a reliable method to predict myocardial functional reserve and to determine functional recovery expected after coronary revascularization.

Esophageal surgery comprises a variety of procedures of differing complexity to treat functional and structural disorders of the esophagus. Local disease extension, surgical repair technique, and physical status of the patient primarily dictate anesthetic management of patients with esophageal pathology. Because the esophagus is in close proximity to vital organs and structures, a specific knowledge of the anatomy is essential to realize how esophageal pathology can compromise elemental physiological functions. A com prehensive anesthetic plan requires a detailed under standing of the surgical procedure in terms of approach, the extent of the operation, and associated complica tions. Consideration of comorbid conditions is equally important, as esophageal surgery is frequently per formed in debilitated and polytraumatized patients. The following article will review clinical manifestation, surgi cal therapy, and perioperative anesthetic management of the most commonly encountered esophageal disor ders. Specifically, anesthetic considerations in gastro esophageal reflux disease, esophageal carcinoma, esophageal perforation, and a variety of other esopha geal disorders will be discussed.

Background Recently, a novel real-time 3-dimensional (3D) matrix-array transesophageal echocardiographic (3D-MTEE) probe was found to be highly effective in the evaluation of native mitral valves (MVs) and other intracardiac structures, including the interatrial septum and left atrial appendage. However, the ability to visualize prosthetic valves using this transducer has not been evaluated. Moreover, the diagnostic accuracy of this new technology has never been validated against surgical findings. This study was designed to (1) assess the quality of 3D-MTEE images of prosthetic valves and (2) determine the potential value of 3D-MTEE imaging in the preoperative assessment of valvular pathology by comparing images with surgical findings. Methods Eighty-seven patients undergoing clinically indicated transesophageal echocardiography were studied. In 40 patients, 3D-MTEE images of prosthetic MVs, aortic valves (AVs), and tricuspid valves (TVs) were scored for the quality of visualization. For both MVs and AVs, mechanical and bioprosthetic valves, the rings and leaflets were scored individually. In 47 additional patients, intraoperative 3D-MTEE diagnoses of MV pathology obtained before initiating cardiopulmonary bypass were compared with surgical findings. Results For the visualization of prosthetic MVs and annuloplasty rings, quality was superior compared with AV and TV prostheses. In addition, 3D-MTEE imaging had 96% agreement with surgical findings. Conclusions Three-dimensional matrix-array transesophageal echocardiographic imaging provides superb imaging and accurate presurgical evaluation of native MV pathology and prostheses. However, the current technology is less accurate for the clinical assessment of AVs and TVs. Fast acquisition and immediate online display will make this the modality of choice for MV surgical planning and postsurgical follow-up.

With 99mTc-MIBI SPECT and a 4 h exercise (E: 150 MBq iv) and rest (R; 800 MBq iv) protocol, global and regional left ventricular (LV) myocardial uptake was determined in 70 patients with angiographically confirmed coronary heart disease (CHD) and in 10 controls. The aim was to establish an E/R ratio as a correlate to coronary vascular reserve, representing perfusion reserve (PR). E/R ratios, obtained from total LV myocardium or from normal or impaired regions, were greater than 1.19 under all conditions, indicating the presence of higher flow during exercise than at rest (even in areas of low flow). Global PR separated (P less than 0.01) controls (1.63 +/- 0.21; mean +/- SD) from severely diseased patients (1.29 +/- 0.14 in 2- or 3-vessel disease) only. Improved differential diagnosis was gained from calibrating the regional E/R ratio to regional differences (E minus R) of uptake. For the left ventricle regional PRs (RPR) for 25 ROIs of the target, framing the myocardium, were determined. RPR at the regional maximum of 99mTc-MIBI uptake was similar in both controls (1.66) and patients (1.63), indicating a high probability of meeting some areas with functionally normal perfusion in patients with CHD. RPR allowed sufficient separation (P less than 0.025) concerning the degree of coronary artery stenosis (RPR in occlusion, 0.26; stenosis greater than 75%, 0.39; less than 75%, 0.56). In controls, the overall value for RPR was 1.14 +/- 0.28 (P less than 0.001). LV global PR and RPR were useful in separating patients with CHD vs controls and in classifying the severity of vascular stenosis.

Transesophageal echocardiography (TEE) assists in the intraoperative decision-making process during cardiac anesthesia and cardiac surgery. Mechanical ventricular support may be necessary to support the circulatory system temporarily or serve as a bridge to heart transplantation. A left ventricular assist device (LVAD) is most commonly used.1 Biventricular failure necessitates the use of an LVAD along with a right ventricular assist device (RVAD) to form a biventricular assist device (BIVAD) (Fig 1). TEE plays a vital role in evaluating effective mechanical assistance of the circulation.1-3 This case describes a BIVAD placement in a patient and shows the roles and limitations of TEE in this scenario.

Objective: To investigate the influence of cardiopulmonary bypass (CPB) and fraction of inspired oxygen (F I O 2 ) on the contrast effect of Optison, a second-generation ultrasound contrast agent, in humans during coronary artery bypass graft (CABG) surgery with transesophageal echocardiography (TEE). Design: Prospective, observational, repeated-measures design. Setting: A single university hospital. Participants: Ten patients who underwent elective CABG surgery. Interventions: A transgastric, midpapillary, short-axis view of the left ventricle was obtained with TEE in the conventional imaging mode. A central injection of 0.3 mL of Optison was administered at 4 stages: after induction of anesthesia at F I O 2 = 1.0 and F I O 2 = 0.43 ± 0.02 and after protamine administration at F I O 2 = 1.0 and F I O 2 = 0.52 ± 0.09. Background-corrected maximal pixel intensity (PImax corr ) in the left ventricle was determined with videodensitometry. To estimate the magnitude of change in pixel intensities, point estimates of differences in PImax corr and their 95% and 99% confidence intervals were calculated after repeated measures analysis of variance. Measurements and Main Results: Decreasing the F I O 2 from 1.0 to corr significantly before or after CPB (mean change = −4.2 and 0.8; SE = 2.0 and 1.9; p = 0.06 and 0.68). Values for PImax corr before and after CPB were not significantly different at either F I O 2 = 1.0 or F I O 2 p = 0.26 and 0.54). Mean differences from initial values ranged from a 10% decrease to a 5% increase. Conclusion: In patients who undergo CABG surgery, the contrast opacification of Optison in the left ventricle is not changed by CPB or alterations in F I O 2 during intraoperative TEE. The application of Optison for enhancement of the endocardial border is not limited during cardiac surgery.

To determine factors that improve intraoperative myocardial perfusion assessment with conventional ultrasound imaging and intravenous ultrasound agents.Prospective cohort study with repeated interventions on each patient.Single university hospital.Fourteen patients scheduled for elective coronary artery bypass graft surgery.Myocardial perfusion was evaluated with contrast transesophageal echocardiography during conventional imaging after central venous injections of the contrast agent Optison (0.3 mL) before cardiopulmonary bypass. Eight patients received the injection during continuous sampling at each of 4 transducer frequency settings (3.5, 5.0, 6.0, 7.0 MHz). In another 6 patients, injections were administered during continuous and intermittent sampling (electrocardiogram-gated) at 3.5 and 5.0 MHz. Generalized estimating equations were used to compare mean responses, with por = 0.05 considered significant.All recorded images were analyzed with off-line videodensitometry. Background-corrected peak pixel intensity (PPI(corr)) and rate of change in pixel intensity (PPI(corr)/T(PPI)) were determined for each injection. PPI(corr) was greater at 3.5 MHz than at 5.0, 6.0, and 7.0 MHz (p0.001). PPI(corr)/T(PPI) was greater at 3.5 MHz than at 5.0 (p0.001), 6.0 (p = 0.003), and 7.0 MHz (p0.001). PPI(corr) was greater for gated than for nongated sampling conditions at 3.5 (p0.05) and 5.0 MHz (p0.05).To optimize myocardial contrast opacification, intraoperative transesophageal echocardiography should be performed with intermittent sampling at a transducer frequency close to the intrinsic frequency of the contrast agent.

A 52-YEAR-OLD African-American woman with coronary artery disease and a past medical history of hypertension and abuse of cocaine and heroin was scheduled for elective coronary artery bypass graft surgery. The coronary angiogram showed severe 2-vessel disease: occlusion of the proximal left anterior descending coronary artery and subtotal occlusion of the mid right coronary artery. Left ventricular systolic function was reported as normal with an ejection fraction of 73% and no regional wall motion abnormalities. The left ventricular end-diastolic pressure was elevated at 27 mmHg. A recent electrocardiogram showed normal sinus rhythm, and an inferior Q-wave myocardial infarction, also noticed on a previous electrocardiogram, could not be ruled out. After uneventful induction of general anesthesia and insertion of a pulmonary artery catheter, transesophageal echocardiography detected a left ventricular outpouching (Figs 1 and 2). Heart rate was 81 beats/min, blood pressure was 133/88 mmHg, and pulmonary artery pressure was 25/12 mmHg. What is the differential diagnosis?