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Objectives: Effects of temporary biventricular pacing after cardiopulmonary bypass are unpredictable, and the utility of speckle-tracking echocardiography in this setting is unclear. Accordingly, speckle-tracking analysis of transgastric echocardiograms taken during cardiac surgery was assessed as a potential tool to measure strain, synchrony, and twist as indices to predict response., Design: Prospective observational study, in part, with a randomized controlled study of temporary permanent biventricular pacing after cardiopulmonary bypass., Setting: Single-center study at university-affiliated tertiary care hospital., Participants: Twenty-one cardiac surgery candidates with ejection fraction ≤40% and QRS duration ≥100 ms or who were undergoing double-valve surgery., Interventions: Transgastric views of the basal, midpapillary, and apical levels of the left ventricle were acquired before and after bypass., Measurements and Main Results: Midpapillary sections were analyzable in 38% of patients. The remainder had epicardial borders extending beyond the field of view (24%) or inadequate image quality (38%). Only 9% of basal or apical sections were analyzable. Midpapillary radial strain and synchrony changed insignificantly after bypass. Variation in fractional area change correlated with changes in radial strain (p = 0.041) but not with synchrony., Conclusions: Intraoperative transgastric echocardiography is inadequate for speckle-tracking analysis with current techniques. Intraoperative predictors of temporary biventricular pacing response are lacking., (Copyright © 2014 Elsevier Inc. All rights reserved.)

We report a case of congenital inferior wall left ventricular diverticulum (LVD), atrial septal defect and mental retardation detected by intraoperative transesophageal echocardiography. The combination of three features strongly suggests that genetic factors play important role in the pathogenesis of the disorder. Most LVDs are asymptomatic. Echocardiographers and cardiac anesthesiologists should be aware of this anomaly, and include it in the differential diagnosis of abnormally shaped ventricular wall and seek other congenital abnormalities if LVD is detected.

Aortic valvular stenosis remains the most common debilitating valvular heart lesion. Despite the benefit of aortic valve (AV) replacement, many high-risk patients cannot tolerate surgery. AV implantation treats aortic stenosis without subjecting patients to sternotomy, cardiopulmonary bypass (CPB), and aorta cross-clamping. This transcatheter procedure is performed via puncture of the left ventricular (LV) apex or percutaneously, via the femoral artery or vein. Patients undergo general anesthesia, intense hemodynamic manipulation, and transesophageal echocardiography (TEE). To elucidate the role of the anesthesiologist in the management of transcatheter AV implantation, we review the literature and provide our experience, focusing on anesthetic care, intraoperative events, TEE, and perioperative complications. Two approaches to the aortic annulus are performed today: transfemoral retrograde and transapical antegrade. Iliac artery size and tortuosity, aortic arch atheroma, and pathology in the area of the (LV) apex help determine the preferred approach in each patient. A general anesthetic is tailored to achieve extubation after procedure completion, whereas IV access and pharmacological support allow for emergent sternotomy and initiation of CPB. Rapid ventricular pacing and cessation of mechanical ventilation interrupts cardiac ejection and minimizes heart translocation during valvuloplasty and prosthesis implantation. Although these maneuvers facilitate exact prosthesis positioning within the native annulus, they promote hypotension and arrhythmia. Vasopressor administration before pacing and cardioversion may restore adequate hemodynamics. TEE determines annulus size, aortic pathology, ventricular function, and mitral regurgitation. TEE and fluoroscopy are used for positioning the introducer catheter within the aortic annulus. The prosthesis, crimped on a valvuloplasty balloon catheter, is implanted by inflation. TEE immediately measures aortic regurgitation and assesses for aortic dissection. After repair of femoral vessels or LV apex, patients are allowed to emerge and assessed for extubation. Observed and published complications include aortic regurgitation, prosthesis embolization, mitral valve disruption, hemorrhage, aortic dissection, CPB, stroke, and death. Transcatheter AV implantation relies on intraoperative hemodynamic manipulation for success. Transfemoral and transapical approaches pose unique management challenges, but both require rapid ventricular pacing, the management of hypotension and arrhythmias during beating-heart valve implantation, and TEE. Anesthesiologists will care for debilitated patients with aortic stenosis receiving transcatheter AV implantation.

Detection of myocardial ischemia in the perioperative period is important because it allows for intervention that may prevent progression of ischemia to myocardial infarction. Perioperative ischemia is also an important predictor of adverse cardiovascular outcomes. Patients should first be stratified according to their risk of having cardiovascular disease by identifying major, intermediate, and minor predictors of adverse cardiovascular outcome. Electrocardiographic (ECG) monitoring for ischemia is inexpensive and noninvasive, but may not be applicable to all patients and is not perfectly sensitive or specific. Modern operating room monitors can automate ST segment monitoring and be set to alarm if changes occur. Increases in central venous pressure and pulmonary artery pressure can be caused by myocardial ischemia, but have been shown to be very insensitive compared to ECG. Also, detection of these hemodynamic changes requires insertion of invasive monitoring devices. Transesophageal echocardiography can be used to detect myocardial ischemia by identifying changes in regional wall motion. These transesophageal echocardiography changes occur sooner and more frequently than ECG changes, but require greater knowledge and skill to properly interpret.

Objective: Neurologic complications remain a significant cause of morbidity and mortality in cardiac surgery. Risk factors for neurologic injuries include the presence of atheromatous disease in the aorta. Epiaortic ultrasound has been shown to be superior in detecting the extent and location of atheromatous disease. The SonoSite Corporation (Bothell, WA) has recently introduced an affordable, portable, high-resolution ultrasound device. This new device was compared with the Hewlett-Packard Sonos 5550 ultrasound device (currently manufactured by Philips, Andover, MA) to determine suitability for this purpose., Design: Prospective, serial comparison of 2 devices., Setting: University hospital., Participants: Fifty consecutive cardiac surgery patients., Interventions: Intraoperative epiaortic ultrasound images were obtained using a SonoSite 180 Plus ultrasound device and a Hewlett-Packard Sonos 5500 ultrasound device. Three observers graded recorded images based on extent of atheromatous disease., Measurements and Main Results: Two patients were excluded because of errors in recording images. For the 48 remaining patients, consensus (median) grades had an observed agreement of 93.6% compared with a chance agreement of 67.7%. This correlates to a kappa value of 0.80 or near-excellent agreement., Conclusions: The near-excellent agreement of the 2 devices is acceptable, thus providing a unique opportunity to expand the use of epiaortic ultrasound imaging.

A 54-year-old man who underwent uneventful orthotopic heart transplantation 1 year previously had low-grade fever and dyspnea. Imaging studies revealed an ascending aortic pseudoaneurysm (AAP), which was repaired with a 5-mm polyester patch, with circulatory arrest and cardiopulmonary bypass. Intraoperative cultures of the AAP grew methicillin-resistant Staphylococcus aureus, and the pseudoaneurysm recurred after 6 weeks despite intravenously administered antibiotic therapy. A 28.5-mm x 3.3-cm Gore Excluder aortic cuff was deployed in the ascending aorta through a left axillary artery cutdown with use of combined transesophageal echocardiography and fluoroscopy. In addition, controlled hypotension and asystole were established with administration of adenosine to facilitate precise device deployment. Postoperative imaging with transesophageal echocardiography and magnetic resonance angiography revealed complete resolution of the AAP, and the patient had done well at 7-month follow-up. Treatment of a mycotic aortic pseudoaneurysm with an endoprosthesis in a patient without other treatment alternatives can be performed safely, with acceptable short-term results.

Left ventricular outflow tract (LVOT) obstruction caused by systolic anterior motion is a cause of failed mitral valve repair. Intraoperative transesophageal echocardiography has been very helpful in diagnosing problems with mitral valve repairs intraoperatively, allowing immediate correction. We report an unusual cause of LVOT obstruction attributed to prolapse of the annuloplasty ring into the LVOT. Intraoperative hemodynamics were normal, and the diagnosis would not have been made before leaving the operative suite without the transesophageal echocardiography.

In recent years, there has been much interest in performing coronary artery bypass graft (CABG) surgery without the aid of cardiopulmonary bypass (CPB). Initial efforts focused on "minimally invasive" direct coronary artery bypass, wherein the left anterior descending artery is bypassed with an in situ left internal mammary artery graft through a small left anterior thoracotomy. A more widely adopted approach however, is off-pump CABG (OPCAB), in which CABG surgery is performed on one or more vessels through the usual median sternotomy approach without the aid of CPB. This article reviews the differences in the anesthetic considerations of OPCAB compared to conventional CABG using CPB.

Unlabelled: A key element in developing a process to determine knowledge and ability in applying perioperative echocardiography has included an examination. We report on the development of a certifying examination in perioperative echocardiography. In addition, we tested the hypothesis that examination performance is related to clinical experience in echocardiography. Since 1995, more than 1200 participants have taken the examination, and more than 70% have passed. Overall examination performance was related positively to longer than 3 mo of training (or equivalent) in echocardiography and performance and interpretation of at least six examinations a week. We concluded that the certifying examination in perioperative echocardiography is a valid tool to help determine individual knowledge in perioperative echocardiography application., Implications: This report describes the process involved in developing the certifying transesophageal echocardiography examination and identifies correlates with examination performance.

Transesophageal echocardiographic (TEE) examination is a powerful and informative cardiac monitor and an important diagnostic tool for use during cardiac surgery. This article reviews how to perform a comprehensive TEE examination on a patient in the operating room and the important clinical uses of TEE during critical events.

We report 3 patients who sustained intrathoracic esophageal perforations due to transesophageal echocardiography encountered during the past 2 years. Lack of suspicion of this complication led to delay in diagnosis. Surgical management led to survival of all 3 patients.

Background: The echocardiographic contrast agent Optison may be useful in patients undergoing cardiac surgery. This study investigates its effects on hemodynamics, cardiac performance, and oxygenation in this group of patients., Methods: Parameters of hemodynamic stability, cardiac performance, and oxygenation were measured in 57 patients by transesophageal echocardiography, electrocardiography, invasive arterial blood pressure and central venous pressure monitoring, capnography, pulsoximetry, and pulmonary artery catheter before and 5 and 10 minutes after an intravenous bolus of 0.3 mL of Optison., Results: No statistically significant differences in ST-segment changes, heart rate, arterial and central venous pressure, peripheral oxygen saturation, cardiac index, left ventricular ejection fraction, and regional wall motion were seen 5 and 10 minutes after injection of Optison compared with baseline parameters., Conclusions: Optison did not cause clinically important changes in parameters of hemodynamic stability, cardiac performance, and oxygenation in our patients. The intraoperative use of intravenous Optison appears to be safe in patients undergoing cardiac surgery, including in the use of cardiopulmonary bypass.

Background: Hemodynamic instability during multivessel off-pump coronary artery bypass grafting can lead to hypotension, progressive myocardial ischemia, further hypotension, and the need for urgent cardiopulmonary bypass., Methods: In 10 patients undergoing off-pump coronary artery bypass grafting, a novel technique of pressure-controlled blood delivery has been used that allows the immediate restoration of arterial blood to distal coronary beds after distal coronary anastomosis. This technique utilizes a servo-controlled pump to allow delivery of blood at systemic or suprasystemic pressures, and provides the option for infusion of supplemental additives for myocardial resuscitation, myocardial vasodilation, and enhancement of myocardial performance., Results: Myocardial perfusion was successfully enhanced via one or two grafts in all 10 patients with an average graft flow of 98+/-8 mL/min. In 3 patients, a 27% increase in perfusion pressure led to a 59% increase in perfusate flow. All patients were hemodynamically stable after initiation of selective graft perfusion., Conclusions: Based on this preliminary patient series, the selective perfusion of grafted vessels seems to facilitate multivessel off-pump coronary artery bypass grafting by promoting rapid recovery of grafted segments, by enhanced hemodynamic stability during subsequent anastomoses, and by providing increased flexibility in the sequence of grafting.

Background: The aim of this study was to evaluate the efficacy of 1.5 mg/kg bolus of amrinone on low cardiac output (CO) state following emergence from cardiopulmonary bypass (CPB) in cardiac surgical patients., Methods: Immediately after emergency from CPB, 14 patients with a cardiac index (CI) less than 2.2 l.min-1.m-2 despite administration of inotropes and nitroglycerin, received 1.5 mg/kg amrinone over 3 min without changing catecholamine infusion rates (amrinone group). Hemodynamics and left ventricular short axis views with transesophageal echocardiography were recorded at baseline, 3, 4, and 10 min following amrinone administration. Left ventricular filling volumes were maintained constant by volume reinfusion from the CPB reservoir. We matched the data of the amrinone group with the other 14 patients who did not receive amrinone (non-amrinone group) to evaluate the efficacy of amrinone in low CO state., Results: At baseline, CI (1.8 +/- 0.1 l.min-1.m-2) in the amrinone group was significantly lower than CI (3.0 +/- 0.2) in the non-amrinone group. Following amrinone administration, CI and velocity of circumferential fibershortening corrected for heart rate (Vcfc) significantly increased, and systemic vascular resistance index and pulmonary vascular resistance index significantly decreased from the baseline within 10 min without changes in heart rate, mean arterial blood pressure, or pulmonary artery occlusion pressure, and became equivalent with those of the non-amrinone group., Conclusions: A 1.5 mg/kg amrinone loading dose to patients in a low CO state, despite catecholamine therapy immediately after emergence from CPB, effectively improves ventricular function when loading conditions are maintained constant.

Objectives: Reoperative coronary artery bypass grafting presents unique challenges for myocardial preservation. The purpose of this study was to compare oxygenated blood cardioplegia with oxygenated crystalloid cardioplegia during reoperative coronary artery bypass grafting using transesophageal echocardiography to assess regional wall motion of the left ventricle before and after cardiopulmonary bypass., Methods: Sixty-one patients undergoing reoperative coronary artery bypass grafting were prospectively randomized to receive oxygenated blood cardioplegia or oxygenated crystalloid cardioplegia delivered with a combined antegrade-retrograde technique. Transgastric short axis views of the left ventricle were made with transesophageal echocardiography during the operation before cardiopulmonary bypass and immediately after cardiopulmonary bypass. Regional wall motion was graded by a blinded observer, and before cardiopulmonary bypass scores were compared with after cardiopulmonary bypass scores., Results: No significant differences were found in the change in regional wall motion score from before cardiopulmonary bypass to after cardiopulmonary bypass between the blood and crystalloid cardioplegia groups., Conclusions: This study found blood and crystalloid cardioplegia to be equally efficacious for myocardial preservation during reoperative coronary artery bypass grafting.

Although milrinone effectively increases cardiac function, few studies have specifically evaluated its efficacy during cardiac surgery. We investigated the effects of milrinone on hemodynamics and left ventricular function in cardiac surgical patients who were already treated with catecholamines. Thirty-seven patients undergoing cardiac surgery were studied. Immediately after emergence from cardiopulmonary bypass (CPB), patients were randomly assigned to a control group (n = 10) or to one of these milrinone groups: milrinone 50 microg/kg intravenously (n = 8), 50 microg/kg + 0.5 microg x kg(-1) x min(-1) (n = 10), or 75 microg/kg + 0.75 microg x kg(-1) x min(-1) (n = 9). Hemodynamics and transesophageal echocardiogram were recorded while constant filling pressures were maintained by volume reinfusion from the CPB reservoir. Arterial blood samples were obtained for the measurement of milrinone plasma concentrations and to determine the dose response curve. In all three milrinone groups, cardiac index and velocity of circumferential fiber shortening (Vcfc) significantly increased from the baseline, and both were significantly higher at 5 and 10 min than those in the control group. The plasma concentration of milrinone with half of maximum increase in Vcfc was 139.3 ng/mL based on the dose-response curve. Thus, milrinone improves hemodynamics and left ventricular function when constant loading conditions are maintained.

Closure of the fibrillating left atrial appendage has been recommended during mitral valve operations to help prevent thrombus formation and systemic embolization postoperatively. We report recanalization of the appendage orifice in 6 patients after surgical closure by pursestring suturing at the time of mitral valve replacement. Transesophageal echocardiography demonstrated disruption of the closure line and partial recanalization of the sutured orifice with relatively high velocity flow between the left atrial body and the appendage.

Eighteen patients (3 men and 15 women; mean age 63 years) with right-sided tumors were evaluated by both transthoracic and transesophageal echocardiography from 1989 to 1996. The indications for echocardiographic studies included evaluation for a presumed mass and further evaluation of ventricular function and valvular function. Fifteen patients had right atrial tumors. These included 5 hypernephromas, 4 myxomas, 2 angiosarcomas, 1 lipoma, 1 cavernous hemangioma, 1 hepatoma, and 1 chondrosarcoma. Three patients had right ventricular (RV) tumors: 1 metastatic olfactory neuroblastoma, a leiomyosarcoma, a chondrosarcoma, and a fourth patient had infiltration of the RV free wall of unknown etiology. Biopsy of either right atrial or RV masses was performed with transesophageal echocardiographic guidance in 2 patients, and allowed histologic diagnosis before surgical resection. These findings indicate that tumors are more often found in the right atrium than in the right ventricle, and females predominate. Most tumors arising within the right atrium are benign, whereas those extending into the right atrium from outside are malignant. RV tumors are rarely encountered; when present, they are likely to be malignant.

TEE offers many benefits in the evaluation of patients with IE. It provides increased sensitivity as compared to TTE in the detection of this disease, and is better able to identify and delineate many of the associated complications and hemodynamic aberrancies. TEE also has helped expand our knowledge of the pathophysiology and natural history of IE. Continued advances in the technology of TEE instrumentation undoubtedly will lead to further improvements in our ability to assess and to treat patients stricken with this serious infection. Nevertheless, IE continues to exact a significant toll on its victims, and our efforts to diagnose, to treat, and to prevent it must not weaken.