Utility of E Point Septal Separation as Screening Tool for Left Ventricular Ejection Fraction in Perioperative Settings by Anesthetists

Background and Aims:Left ventricular (LV) systolic dysfunction is a common cause of hemodynamic disturbance perioperatively and is associated with increased morbidity and mortality. Echocardiographic evaluation of left ventricular systolic function (LVSF) has great clinical utility. This study was aimed to test the hypothesis that LVSF assessed by an anesthetist using mitral valve E Point Septal Separation (EPSS) has a significant correlation with that assessed using modified Simpson’s method perioperatively. Methods: This prospective observational study included 100 patients scheduled for elective surgeries. Transthoracic echocardiography (TTE) was performed preoperatively within 24 hours of surgery by an anesthetist as per American Society of Echocardiography (ASE) guidelines.EPSS measurements were obtained in parasternal long?axis view while volumetric assessment of LV ejection fraction (EF) used apical four?chamber view.Bivariate analysis of EPSS and LV EF was done by testing Pearson correlation coefficient.Receiver Operating Characteristic (ROC) curve constructed to obtain area under curve (AUC) and Youden’s Index. Results: The mean value of mitral valve EPSS was 7.18 ± 3.95 mm. The calculated mean LV EF value using volumetric analysis was 56.31 ± 11.92%. LV dysfunction as per ASE guidelines is present in 28% of patients. EPSS was statistically significantly related to LV EF negatively with a Pearson coefficient of ?0.74 (P < 0.0001).AUC of ROC curve 0.950 (P < 0.0001) suggesting a statistically significant correlation between EPSS and LV EF.Youden’s index of EPSS value 7 mm was obtained to predict LV systolic dysfunction. Conclusion: Mitral valve EPSS shows a significant negative correlation with gold standard LVEF measurement for LVSF estimation. It can very well be used to assess LVSF perioperatively by anesthetists with brief training.

Utilidad de la ecocardiografía transtorácica focalizada en emergencias hemodinámicas intraoperatorias / Usefulness of Focalized transthoracic ecocardiography in intraoperative hemodynamic emergencys

INTRODUCTION: Echocardiography represents one of the most important advances in the monitoring of critical patients. Initially available only in cardiovascular surgery, currently, there is transesophageal echocardiography (TEE) and transthoracic echocardiography (ETT) in non-cardiac surgery, for anesthesiologists. The advantages of ETT is a non-invasive tool, of lower cost than the transesophageal transducer and therefore more feasible to be overcrowded and available in the pavilion. OBJECTIVE: To evaluate the usefulness of TTE in patients with hemodynamic compromise during non-cardiac surgery. NATERIAL AND METHODS: In a prospective manner between April 2016 and September 2018, patients were studied who during their intraoperative period presented a compromise of their hemodynamic state, defined as an average blood pressure under 55 mm Hg, for more than 3 minutes and without response to the usual therapy based on vasopressors and volume. Each of these patients had a prospective protocol for focused ETT looking for the cause of this disorder, by a duly trained operator. RESULTS: 124 patients, with an average age of 67 years (range 42 to 93 years) were evaluated. In all cases, at least one echocardiographic window was obtained that allowed a diagnosis to be made and/or to guide the therapy. The main causes of hemodynamic compromise were hypovolemia (52%), poor left ventricular function (21%) and other causes such as pericardial effusion, suspected pulmonary thromboembolism, pulmonary pathology and suspected myocardial ischemia. DISCUSSION: The ETT could be a feasible tool to use in acute hemodynamic events, since it offers good quality windows that allow new decisions based on the diagnosis and also allows to guide the selected therapies. In addition, it has been shown to positively impact clinical behaviors in the perioperative period. ETT is a non-invasive monitor, reasonably easy to learn to use; In addition to directly visualizing cardiac structures, it allows differential diagnoses of the causes of intraoperative hypotension. The therapies can also be decided according to the echocardiographic images and control how they generate changes in the cardiac cavities and in the hemodynamic state of the patient.

INTRODUCCIÓN: La ecocardiografía representa uno de los más importantes avances en la monitorización de pacientes críticos. Inicialmente disponible sólo en cirugía cardiovascular, en la actualidad, se cuenta con ecocardiografía transesofágica (ETE) y ecocardiografía transtorácica (ETT) en cirugía no cardíaca, para los anestesiólogos. Las ventajas del ETT están en ser una herramienta no invasiva, de menor costo que el transductor transesofágico y, por lo tanto, más factible de ser masificada y estar disponible en pabellón. OBJETIVO: Evaluar la utilidad de ETT en pacientes con compromiso hemodinámico durante cirugía no cardiaca. MATERIAL Y MÉTODOS: En forma prospectiva entre abril de 2016 y septiembre del 2018, se estudiaron enfermos que durante su intraoperatorio presentaron compromiso de su estado hemodinámico, definido como una presión arterial media bajo 55 mm Hg, por más de 3 minutos y sin respuesta a la terapia habitual basada en vasopresores y volumen. A cada uno de estos enfermos se le realizó un protocolo prospectivo de ETT focalizado buscando la causa de esta alteración, por un operador debidamente entrenado. RESULTADOS: 124 pacientes, con edad promedio de 67 años (rango 42 a 93 años) fueron evaluados. En todos los casos se obtuvo al menos una ventana ecocardiográfica que permitió realizar un diagnóstico y/o guiar la terapia. Las principales causas de compromiso hemodinámico fueron hipovolemia (52%), mala función del ventrículo izquierdo (21%) y otras causas como derrame pericárdico, sospecha de tromboembolismo pulmonar, patología pulmonar y sospecha de isquemia miocárdica. La ETT podría ser una herramienta factible de utilizar en eventos hemodinámicos agudos, ya que ofrece ventanas de buena calidad que permiten tomar decisiones nuevas basadas en el diagnóstico y, además, permite guiar las terapias seleccionadas. Además, ha mostrado impactar de forma positiva las conductas clínicas en el perioperatorio. DISCUSIÓN: La ETT es un monitor no invasivo, razonablemente fácil de aprender a utilizar que además de visualizar de manera directa las estructuras cardíacas, permite realizar diagnósticos diferenciales de las causas de hipotensión intraoperatoria. Además, se puede decidir las terapias de acuerdo a las imágenes ecocardiográficas y controlar cómo éstas generan cambios en las cavidades cardíacas y en el estado hemodinámico del paciente.

Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care

Transthoracic echocardiography is a potent and appealing diagnostic tool by virtue of rapidity, noninvasiveness, and repeatability. Focus-assessed transthoracic echocardiography (FATE) forms quick guidance to interpret the echocardiographic information and relates it to the clinical context. It can be applied in the perioperative period, intensive care units (ICUs), and emergency situations, in trauma and as resuscitation aids. FATE intents to assess cardiac function including contractility, chamber size and hypertrophy, valvular dysfunction, cardiac tamponade, and pericardial and pleural effusions. Thence, FATE has become a quintessential scanning tool perioperatively and in ICUs.