Regional geometric differences between regurgitant and non-regurgitant mitral valves in patients with coronary artery disease.

OBJECTIVE: Demonstrate that regional geometric differences exist between regurgitant and non-regurgitant mitral valves (MV's) in patients with coronary artery disease and due to the heterogenous and regional nature of ischemic remodeling in patients with coronary artery disease (CAD), that the available anatomical reserve and likelihood of developing mitral regurgitation (MR) is variable in non-regurgitant MV's in patients with CAD. METHODS: In this retrospective, observational study intraoperative three-dimensional transesophageal echocardiographic data was analyzed in patients undergoing coronary revascularization with MR (IMR group) and without MR (NMR group). Regional geometric differences between both groups were assessed and MV reserve which was defined as the increase in antero-posterior (AP) annular diameter from baseline that would lead to coaptation failure was calculated in three zones of the MV from antero-lateral (zone 1), middle (zone 2), and posteromedial (zone 3). MEASUREMENTS AND MAIN RESULTS: There were 31 patients in the IMR group and 93 patients in the NMR group. Multiple regional geometric differences existed between both groups. Most significantly patients in the NMR group had significantly larger coaptation length and MV reserve than the IMR group in zones 1 (p-value = .005, .049) and 2 (p-value = .00, .00), comparable between the two groups in zone 3 (p-value = .436, .513). Depletion of the MV reserve was associated with posterior displacement of the coaptation point in zones 2 and 3. CONCLUSIONS: There are significant regional geometric differences between regurgitant and non-regurgitant MV's in patients with coronary artery disease. Due to regional variations in available anatomical reserve and the risk of coaptation failure in patients with CAD, absence of MR is not synonymous with normal MV function.

Should nasogastric tube be used routinely in patients undergoing cardiac surgery? A narrative review.

BACKGROUND AND AIM: Nasogastric tube (NGT) use has been common in the immediate postoperative period in surgical patients for decades. Potential advantages include the decompression of gastric contents and the early administration of time-sensitive medications. However, its routine use after cardiac surgery has not been established as a gold standard yet. The NGT use for prevention of postoperative nausea and vomiting has been a matter of debate in literature. Also, NGT use has also been associated with the incidence of some respiratory and gastrointestinal complications and it may be a source of significant pain and discomfort to patients. In this article, we review the current available literature regarding the use of NGT during and immediately after cardiac surgery, with particular emphasis on its potential role in enhanced postoperative recovery. METHODS: We performed a database search in October 2021 using Embase, Cochrane Library, and Medline to identify studies that examined the use of NGT in patients that underwent cardiac surgery. Data and literature about NGT's impact on post-operative nausea and vomiting, early administration of medications, interference with imaging, post-operative complications, respiratory complications, gastrointestinal complications, pain and discomfort, and enhanced recovery after surgery were examined. RESULTS: Three reports investigating the use of NGT to reduce post-operative nausea and vomiting were examined with sample sizes of 114, 104, and 202. The use of NGT did not significantly reduce the incidence of post-operative nausea and vomiting in 2/3 of the studies: a 2% nausea reduction with NGT (p < 0.05), a 7.7% nausea reduction with NGT (p = 0.6), and a 14% vomiting reduction with NGT (p = 0.007). The prevalence of pneumonia following NGT use has been shown to vary ranging from 4 to 95% with associated mortality rates of 17 to 62%. CONCLUSION: Based on our findings, there is currently not sufficient evidence to support the routine use of NGT during cardiac surgery. Further research is needed to establish the role of NGT in this patient population.

Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A Practical Echo-guided Approach Proposal.

Despite the valuable use of modern applications of perioperative ultrasound across multiple disciplines, there have been limitations to its implementation, restricting its impact on patient-based clinical outcomes. Point-of-care ultrasound evaluation of hypoxia and hypotension is an important tool to assess the underlying undifferentiated etiologies in a timely manner. However, there is a lack of consensus on the formal role of ultrasound during evaluation of perioperative hypoxia or hypotension. The previous ultrasound algorithms have adopted a complex technique that possibly ignore the pathophysiologic mechanisms underlying the conditions presenting in a similar fashion. The authors here propose a simple, sequential and focused multiorgan approach, applicable for the evaluation of perioperative hypotension and hypoxia in emergency scenarios. The authors believe this approach will enhance the care provided in the postanesthesia care unit, operating room, and intensive care unit.

Faculty-Focused Perioperative Ultrasound Training Program: A Single-Center Experience.

OBJECTIVE: Comprehensive educational initiatives in ultrasound for practicing physicians are lacking. We developed a perioperative ultrasound training program for faculty to offer a broad orientation to the principles and clinical applications of ultrasound. DESIGN AND SETTING: The program consisted of two phases. Phase one, which introduced ultrasound via didactic and hands-on components, had six live sessions. At the end of each, participants completed a knowledge quiz. During the sixth session, faculty participated in an objective structured clinical examination (OSCE). For phase two, faculty attended two to three sessions (8-10 hours each) of in-depth individualized training and demonstrated supervised performance of ultrasound-related procedures of their choice. PARTICIPANTS: Participants included Anesthesia faculty at Beth Israel Deaconess Medical Center. MEASUREMENTS AND MAIN RESULTS: On average 30 faculty members attended each live session for phase one; 12 completed phase two. There was a significant difference in quiz scores across the six sessions (p < 0.001) with scores for Session 6 being significantly higher than for Session 1 (p < 0.001). The average mean and median scores on the three OSCE stations were 95.63% and 98.33%, respectively. For phase two, the 8 participants who received training in regional anesthesia each performed > 10 blocks on patients over two days; 5 of the 7 participants who received training in transthoracic echocardiography each completed more than 15 examinations on simulators and 10 examinations on patients. CONCLUSION: It is possible to implement a departmental educational program for ultrasound to improve ultrasound knowledge and skills in practicing anesthesiologists.

Training Surgical Residents for Ultrasound-Guided Assessment and Management of Unstable Patients.

OBJECTIVE: Proficiency in the use of ultrasound is presently not an ACGME required core competency for accredited surgical training. There should be a basic unified ultrasound curriculum for surgical trainees. We developed a multimodal ultrasound-training program to ensure baseline proficiency and readiness for clinical performance without impacting trainee duty hours. DESIGN: We developed and implemented a multimodal curriculum for ultrasound education and its use as a supplement to clinical evaluation of unstable patients. SETTING: A single-center study was completed in a hospital setting. PARTICIPANTS: Post-graduate year-1 surgical residents at our institution were invited to participate in a multimodal perioperative course. RESULTS: 51 residents attended the course over the three sessions. The vignette exam as a whole demonstrated a Cronbach's alpha of 0.819 indicating good internal reliability of the entire test. There was significant improvement in their knowledge in clinical vignettes (55% ±â€¯12.4 on pre-test vs. 83% ±â€¯13.2% on post-test, p<0.001). CONCLUSION: It is feasible to incorporate a focused ultrasound curriculum to assess clinically unstable patients. The multimodal nature of the course aid in the development of preclinical proficiency and decreased the orientation phase of ultrasound use.

Improving Clinical Proficiency Using a 3-Dimensionally Printed and Patient-Specific Thoracic Spine Model as a Haptic Task Trainer.

BACKGROUND AND OBJECTIVES: Advanced haptic simulators for neuraxial training are expensive, have a finite life, and are not patient specific. We sought to demonstrate the feasibility of developing a custom-made, low-cost, 3-dimensionally printed thoracic spine simulator model from patient computed tomographic scan data. This study assessed the model's practicality, efficiency as a teaching tool, and the transfer of skill set into patient care. METHODS: A high-fidelity, patient-specific thoracic spine model was used for the study. Thirteen residents underwent a 1-hour 30-minute training session prior to performing thoracic epidural analgesia (TEA) on patients. We observed another group of 14 residents who were exposed to the traditional method of training during their regional anesthesia rotation for thoracic epidural placement. The TEA was placed for patients under the supervision of attending anesthesiologists, who were blinded to the composition of the study and control groups. As a primary outcome, data were collected on successful TEAs, which was defined as a TEA that provided full relief of sensation across the entire surgical area as assessed by both a pinprick and temperature test. Secondary outcomes included whether any assistance from the attending physician was required and failed epidurals. RESULTS: A total of 27 residents completed the study (14 in the traditional training, 13 in the study group). We found that the residents who underwent training with the simulator had a significantly higher success rate (11 vs 4 successful epidural attempts, P = 0.002) as compared with the traditional training group. The control group also required significantly more assistance from the supervising anesthesiologist compared with the study group (5 vs 1 attempt requiring guidance). The number needed to treat (NNT) for the traditional training group was 1.58 patients over the study period with a 95% confidence interval of 1.55 to 1.61. CONCLUSIONS: By using patient-specific, 3-dimensionally printed, thoracic spine models, we demonstrated a significant improvement in clinical proficiency as compared with traditional teaching models.

Summative Objective Structured Clinical Examination Assessment at the End of Anesthesia Residency for Perioperative Ultrasound.

While standardized examinations and data from simulators and phantom models can assess knowledge and manual skills for ultrasound, an Objective Structured Clinical Examination (OSCE) could assess workflow understanding. We recruited 8 experts to develop an OSCE to assess workflow understanding in perioperative ultrasound. The experts used a binary grading system to score 19 graduating anesthesia residents at 6 stations. Overall average performance was 86.2%, and 3 stations had an acceptable internal reliability (Kuder-Richardson formula 20 coefficient >0.5). After refinement, this OSCE can be combined with standardized examinations and data from simulators and phantom models to assess proficiency in ultrasound.

Mechanical discordance between left atrium and left atrial appendage.

During standard transesophageal echocardiographic examinations in sinus rhythm (SR) patients, the left atrial appendage (LAA) is not routinely assessed with Doppler. Despite having a SR, it is still possible to have irregular activity in the LAA. This situation is even more important for SR patients where assessment of the left atrium is often foregone. We describe a case where we encountered this situation and briefly review how to assess the left atrium and its appendage in such a case scenario.

Changes in Tricuspid Annular Geometry in Patients with Functional Tricuspid Regurgitation.

OBJECTIVE: To determine whether the indices of tricuspid annular dynamics that signify irreversible tricuspid valvular remodeling can improve surgical decision making by helping to better identify patients with functional tricuspid regurgitation who could benefit from annuloplasty. DESIGN: Retrospective analysis study. SETTING: Tertiary hospital. PARTICIPANTS: A total number of 55 patients were selected, 18 with functional tricuspid valve (TV) regurgitation and 37 normal nonregurgitant TVs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: When comparing the basal, mid, and longitudinal diameters of the right ventricle between the nonregurgitant valve (NTR) group and the functional tricuspid regurgitation (FTR) group, tricuspid annulus was more dilated (p < 0.001, p = 0.001, and p = 0.006, respectively) and less nonplanar (p < 0.001) in the FTR group. At end-systole (ES), the posterolateral-anteroseptal axis was significantly greater in the FTR group than in the NTR group (mean difference = 7.15 mm; p < 0.001). The right ventricle in the FTR group was also significantly dilated with greater leaflet restriction (p = 0.015). CONCLUSIONS: As compared to NTR TVs, FTR is associated with identifiable indices of tricuspid annular structural changes that are indicative of irreversible remodeling.

Dynamic Three-Dimensional Geometry of the Aortic Valve Apparatus-A Feasibility Study.

OBJECTIVE: To provide (1) an overview of the aortic valve (AV) apparatus anatomy and nomenclature, and (2) data regarding the normal AV apparatus geometry and dynamism during the cardiac cycle obtained from three-dimensional transesophageal echocardiography (3D TEE). DESIGN: Retrospective feasibility study. SETTING: A single-center university teaching hospital. PARTICIPANTS: The study was performed on data of 10 patients with a nonregurgitant, nonstenotic aortic valve undergoing cardiac surgery. INTERVENTIONS: Intraoperative 3D TEE was performed on all the participants using the Siemens ACUSON SC2000 ultrasound system and Z6Ms transducer (Siemens Medical Systems, Mountainview, CA). MEASUREMENTS AND MAIN RESULTS: Dynamic offline analyses were performed with Siemens eSie valve analytical software in a semiautomated fashion. Forty-five parameters were exported of which 13 were selected and analyzed. The cardiac cycle was divided into 4 quartiles to account for frame-rate variations. The annulus, sinus of Valsalva (SoV) and sinotubular junction (STJ) areas, diameter, perimeter and height, aortic leaflet height, leaflet coaptation height, and aortic valve-mitral valve angle changed significantly during the cardiac cycle (p < 0.001). STJ expanded more than both the annulus and the SoV (p < 0.001). The maximum aortic valve leaflet height change was greater in the left and right versus noncoronary leaflet (p < 0.001). CONCLUSIONS: The semiautomated AV apparatus dynamic assessment using eSie valve software is a clinically feasible technique and can be performed readily in the operating room. It has the potential to significantly impact intraoperative decision-making in cases suitable for AV repair. The AV apparatus is a dynamic structure and demonstrates significant changes during the cardiac cycle.

Percutaneous Valve in Valve Implantation for Dysfunctional Bioprosthetic Valves: A Case Report.

Percutaneous valve-in-valve therapy is a life-saving procedure for patients at high risk of reoperation due to dysfunctional bioprosthetic valves. We have reviewed 3 typical cases of a valve-in-valve procedure using high-quality images to demonstrate the suitability of this method for aortic, mitral, and tricuspid positions. Three-dimensional transesophageal echocardiography combined with other modalities such as computerized tomography and fluoroscopy are key elements for anesthesia and procedural guidance, especially as immediate tools to assess valvular function and specific procedure-related complications.

Artificial intelligence in mitral valve analysis.

BACKGROUND: Echocardiographic analysis of mitral valve (MV) has become essential for diagnosis and management of patients with MV disease. Currently, the various software used for MV analysis require manual input and are prone to interobserver variability in the measurements. AIM: The aim of this study is to determine the interobserver variability in an automated software that uses artificial intelligence for MV analysis. SETTINGS AND DESIGN: Retrospective analysis of intraoperative three-dimensional transesophageal echocardiography data acquired from four patients with normal MV undergoing coronary artery bypass graft surgery in a tertiary hospital. MATERIALS AND METHODS: Echocardiographic data were analyzed using the eSie Valve Software (Siemens Healthcare, Mountain View, CA, USA). Three examiners analyzed three end-systolic (ES) frames from each of the four patients. A total of 36 ES frames were analyzed and included in the study. STATISTICAL ANALYSIS: A multiple mixed-effects ANOVA model was constructed to determine if the examiner, the patient, and the loop had a significant effect on the average value of each parameter. A Bonferroni correction was used to correct for multiple comparisons, and P = 0.0083 was considered to be significant. RESULTS: Examiners did not have an effect on any of the six parameters tested. Patient and loop had an effect on the average parameter value for each of the six parameters as expected (P < 0.0083 for both). CONCLUSION: We were able to conclude that using automated analysis, it is possible to obtain results with good reproducibility, which only requires minimal user intervention.

Use of 3-Dimensional Printing to Create Patient-Specific Thoracic Spine Models as Task Trainers.

BACKGROUND AND OBJECTIVES: Thoracic epidural anesthesia is a technically challenging procedure with a high failure rate of 24% to 32% nationwide. Residents in anesthesiology have limited opportunities to practice this technique adequately, and there are no training tools available for this purpose. Our objective was to build a low-cost patient-specific thoracic epidural training model. METHODS: We obtained thoracic computed tomography scan data from patients with normal and kyphotic spine. The thoracic spine was segmented from the scan, and a 3-dimensional model of the spine was generated and printed. It was then placed in a customized wooden box and filled with different types of silicone to mimic human tissues. Attending physicians in our institution then tested the final model. They were asked to fill out a brief questionnaire after the identification of the landmarks and epidural space using ultrasound and real-time performance for a thoracic epidural on the model (Supplemental Digital Content 1, http://links.lww.com/AAP/A197). Likert scoring system was used for scoring. RESULTS: The time to develop this simulator model took less than 4 days, and the materials cost approximately $400. Fourteen physicians tested the model for determining the realistic sensation while palpating the spinous process, needle entry through the silicone, the "pop" sensation and ultrasound fidelity of the model. Whereas the tactile fidelity scores were "neutral" (3.08, 3.06, and 3.0, respectively), the ultrasound guidance and overall suitability for residents were highly rated as being the most realistic (4.85 and 4.0, respectively). CONCLUSIONS: It is possible to develop homemade, low-cost, patient-specific, and high-fidelity ultrasound guidance simulators for resident training in thoracic epidurals using 3-dimensional printing technology.

Hemodynamic Testing of Patient-Specific Mitral Valves Using a Pulse Duplicator: A Clinical Application of Three-Dimensional Printing.

OBJECTIVE: To evaluate the feasibility of obtaining hemodynamic metrics of echocardiographically derived 3-dimensional printed mitral valve models deployed in a pulse-duplicator chamber. DESIGN: Exploratory study. SETTING: Tertiary-care university hospital. PARTICIPANTS: Percutaneous MitraClip procedure patient. INTERVENTIONS: Three-dimensional R-wave gated, full-volume transesophageal echocardiography images were obtained after deployment of the MitraClip device. A high-quality diastolic frame of the mitral valve was segmented using Mimics Innovation Suite and merged with a flange. The data were exported as a stereolithography (.stl) file, and a rigid 3-dimensional model was printed using a MakerBot Replicator 2 printer. A flexible silicone cast then was created and deployed in the pulse-duplicator chamber filled with a blood-mimicking fluid. MEASUREMENTS AND MAIN RESULTS: The authors were able to obtain continuous-wave Doppler tracings of the valve inflow with a transesophageal echocardiography transducer. They also were able to generate diastolic ventricular and atrial pressure tracings. Pressure half-time and mitral valve area were computed from these measurements. CONCLUSION: This pulse duplicator shows promising applications in hemodynamic testing of patient-specific anatomy. Future modifications to the system may allow for visualization and data collection of gradients across the aortic valve.