Elastic recoil signal on tissue doppler imaging of mitral annulus as a qualitative test to identify left ventricular diastolic function.

Introduction: Left ventricular (LV) diastolic dysfunction is common on preoperative screening among patients undergoing surgery. There is no simple screening test at present to suspect LV diastolic dysfunction. This study was aimed to test the hypothesis, whether elastic recoil signal (ERS) on tissue Doppler imaging of mitral annulus (MA TDI) can be used as a qualitative test to differentiate patients from normal LV diastolic function versus patients with LV diastolic dysfunction. Methods: This was a prospective cross-sectional observational study of patients admitted for elective surgeries. Normal diastolic function and categorization of LV diastolic dysfunction into severity grades I, II, or III were performed as per the American Society of Echocardiography/ European Associationof Cardio Vascular Imaging (ASE/EACVI) recommendations for LV diastolic dysfunction. Results: There were 41 (61%) patients with normal LV diastolic function and 26 (39%) patients with various grades of LV diastolic dysfunction. In 38 out of 41 patients with normal LV diastolic function, the characteristic ERS was identified. The ERS was absent in all the patients with any grade of LV diastolic dysfunction. Consistency of identification of ERS on echocardiography was tested with a good interobserver variability coefficient of 0.94 (P-value <0.001). The presence of ERS demonstrated an excellent differentiation to rule out any LV diastolic dysfunction with an area under the receiver operating characteristics curve (AUROC) of 0.96 (CI 0.88-0.99; P value <0.001). Conclusions: To conclude, in a mixed surgical population, the anesthetist could successfully assess LV diastolic dysfunction in the preoperative period and the characteristic ERS on MA TDI signal can be used as a qualitative test to differentiate patients from normal LV diastolic function versus patients with LV diastolic dysfunction using the transthoracic echocardiography (TTE).

Use of a Video Laryngoscope to Reduce Complications of Transesophageal Echocardiography Probe Insertion: A Multicenter Randomized Study.

OBJECTIVE: The objective of this multicenter study was to test the hypothesis of whether the use of a video laryngoscope (VL) reduces complications related to transesophageal echocardiography (TEE) probe insertion. DESIGN: A multicenter randomized control study. SETTING: At 5 tertiary care level hospitals. PARTICIPANTS: Three hundred sixty-three adult patients undergoing elective cardiac surgery. INTERVENTIONS: The patients were randomized into 2 groups-the conventional group (C group; n = 177) and the VL group (n = 186) for TEE probe insertion. MEASUREMENTS AND MAIN RESULTS: The primary endpoint of the study was the incidence of oropharyngeal injury, which was defined as blood at the tip of the TEE probe at the end of surgery and/or evidence of injury on VL examination at the end of surgery. The secondary endpoints of the study were the number of attempts required for successful TEE probe insertion and the relation between the esophageal inlet and the larynx. There was a higher incidence of injuries in the C group (n = 26; 14.7%) compared to the VL group (n = 14; 7.5%; p = 0.029). The number of attempts for probe insertion was significantly lower in the VL group (p = 0.0023). The most common relation between the esophageal inlet and the larynx was posterolateral (n = 88; 47%), followed by posterior (n = 77; 41%) and lateral (n = 21;12%). CONCLUSION: The use of VL was associated with a lesser incidence of injury compared to the conventional technique, and its use for this purpose is recommended. The use of VL for probe insertion resulted in fewer attempts compared with the conventional technique. Significant variations do exist in the relation between the esophageal inlet and the larynx, and direct visualization with VL may contribute to better safety.

Normative Transesophageal Echocardiographic Values of Cardiac Structures in the Indian Population-Indian Normative TEE Measurements (INTEEM) Study.

OBJECTIVES: Information on normative reference values for cardiac structures is critical for the accurate application of echocardiography for guiding clinical decision-making. Many studies using transthoracic echocardiography (TTE) have shown that Indians have smaller diameters of various cardiac structures. There are no normative studies for transesophageal echocardiography (TEE). The authors observed dimensions of various cardiac structures in healthy Indian patients under general anesthesia using TEE and compared them with existing guidelines from non-Indian data. DESIGN: The Indian Normative TEE Measurements study was a multicenter, prospective observational study conducted in India. SETTING: Operating rooms for noncardiac surgeries in tertiary care-level hospitals. PARTICIPANTS: Adult patients undergoing noncardiac surgery who were free from any cardiac, respiratory, and renal diseases and had no contraindications for TEE. INTERVENTIONS: After inducing general anesthesia and achieving stable hemodynamic conditions, a comprehensive TEE examination was performed and various measurements were made. MEASUREMENTS AND MAIN RESULTS: For each of the 83 patients undergoing noncardiac surgery, 39 various measurements for left ventricle, right ventricle, both atria, and all valves were made. This included diameters and functional parameters. They were analyzed in a vendor-neutral software off-line. The absolute values of many of the measurements were higher in men, but when indexed to body surface area (BSA) they were similar in both sexes. The values were lower than most of the Western data but matched previous Indian studies using TTE. CONCLUSIONS: The authors present normative values of various echocardiographic parameters using TEE. Because of its variations, it is recommended to use India-specific data to make decisions in Indian patients. It may be prudent to use BSA-indexed values during decision-making.

Temporary mechanical circulatory support: insights and evolving strategies.

PURPOSE: The goal of this study is to evaluate the utilization and outcomes of temporary mechanical circulatory support (MCS) among patients listed for cardiac transplantation (CT). There is a constant threat of sudden clinical deterioration in these patients that could necessitate emergent MCS. All advanced heart failure and transplant centers in India are plagued by issues of late referrals, low organ donation rates, and financial constraints. Here, we share our experience and explain our evolving strategies tailored to improve outcomes. METHODS: Single-center retrospective analysis of temporary MCS implanted in patients listed for CT from January 1, 2015, to December 31, 2019. RESULTS: A total of 35 patients had 41 MCS implantations. Twenty-four cases were pre-transplant and 11 cases were post-transplant. Veno-arterial extracorporeal membrane oxygenator was the most commonly (20 cases, 44.4%) used MCS modality. Primary outcome of in-hospital mortality was noted in 17 patients (48.5%) in this high-risk profile. All but 2 of the 12 patients that underwent pre-transplant MCS, and were bridged to cardiac transplant, survived the index hospitalization accounting for 90% survival in this subset of patients. The secondary outcome of MCS-related vascular injury was observed in 9 patients (25.7%). CONCLUSION: This single-center observational study demonstrates that early planning and timely institution of MCS improves outcomes in high-risk MCS patients bridged to cardiac transplant. The incidence of MCS-related vascular complications can be improved with development of standard operating protocols.

Left Atrial Strain as a Single Parameter to Predict Left Ventricular Diastolic Dysfunction and Elevated Left Ventricular Filling Pressure in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting.

OBJECTIVE: Left ventricular diastolic dysfunction (LVDD) is very common among patients undergoing cardiac surgery and is associated with increased mortality and morbidity. The present study tested the hypothesis of whether left atrial strain (LAS) can be used as a single parameter to predict LVDD (per 2016 LVDD evaluation guidelines) and elevated left ventricular filling pressure (LVFP) (ie, LVDD grades II and III) in patients scheduled for off-pump coronary artery bypass grafting (OPCABG) surgery. DESIGN: A prospective observational study. SETTINGS: Tertiary-care level hospital. PARTICIPANTS: The study comprised 60 patients undergoing elective OPCABG. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Transthoracic echocardiography was performed within 24 hours of surgery by an anesthesiologist. LVDD was graded per American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations for 2016 LVDD guidelines. Left atrial (LA) function was evaluated using two-dimensional strain measurements obtained with the speckle-tracking echocardiography technique. Receiver operating characteristic curves were constructed, and the area under the curve was derived for the prediction of elevated LVFP by LAS. Fourteen (23.3%) patients had elevated LVFP. Global LA reservoir strain (LASr) reduced significantly as the LVDD grade worsened (28.9% ± 8.3%, 21.8% ± 7.2%, 15.6% ± 4.5% and 11.9% ± 1.3%, respectively, for normal LV diastolic function and grades I, II, and III LVDD; p < 0.0001). Similar trends were noted for other components of LAS; namely, global LA conduction, global LA contraction strain, and LAS rate. The ability to predict high LVFP with LASr was statistically significant, with an area under the receiver operating characteristic curve of 0.92 (confidence interval 0.82-0.97; p < 0.001), and a Youden's index for LASr of 19% was obtained with 85.71% sensitivity and 84.78% specificity. The ability of LAS and its components to predict increased LVFP in various subpopulations (normal v reduced ejection fraction) yielded statistically significant results. CONCLUSIONS: In patients scheduled for OPCABG, cardiac anesthesiologists successfully could measure LAS with speckle-tracking echocardiography in the preoperative period. LAS as a single parameter was significantly associated with the grade of LVDD. LASr decreased significantly with worsening grade of LVDD. Furthermore, an LASr value <19% significantly predicted a high LVFP, and LASr predicted high LVFP in both preserved and reduced ejection fraction equally well.

A comparative study of safety and efficacy of ultrasound-guided infra-clavicular axillary vein cannulation versus ultrasound-guided internal jugular vein cannulation in adult cardiac surgical patients.

Background: Ultrasound (US)-guided internal jugular vein (IJV) cannulation is a widely accepted standard procedure. The axillary vein (AV) in comparison to the subclavian vein is easily visualized, but its cannulation is not extensively studied in cardiac patients. Aims: This study is an attempt to study the efficacy of real-time US-guided axillary venous cannulation as a safe alternative for the time-tested US-guided IJV cannulation. Design: This is a prospective randomized controlled study. Materials and Methods: A total of 100 adult patients scheduled for cardiac surgery were divided equally in Group A-US-guided IJV cannulation, and Group B-US-guided axillary venous cannulation. Under local anesthesia and real-time US guidance the IJV or AV was secured. The access time, guidewire time, and procedure time were noted. Furthermore, the number of needle attempts, malposition, change of site, and complications were noted. Results: The data were analyzed for 49 patients in Group A and 48 patients in the Group B due to exclusions. The access time and the guidewire time were comparable in both groups. The first attempt needle puncture was successful for the IJV group in 98% of patients in comparison to 95% of patients in Group B. Guidewire was passed in the first attempt in 94% in Group A and 89% in the Group B. Except for arterial puncture in one case in group A, the complications were insignificant in both groups. Conclusion: The study shows that the US-guided AV cannulation may serve as an effective alternative to the IJV cannulation in cardiac surgery.