TEE – Sleepy Time

Tricuspid Clip

Updated: August 2021

Echocardiographic Imaging for Transcatheter Tricuspid Edge‐to‐Edge Repair. Journal of the American Heart Association. 2020;9:e015682.

State of the Art Review of Echocardiographic Imaging in the Evaluation and Treatment of Functional Tricuspid Regurgitation. Circ Cardiovasc Imaging.2016;9:e005332.

Screening TEE for Transcatheter Tricuspid Valve Repair. Cardiac Interventions Today. May/June 2020.

Echocardiography for Tricuspid Valve Intervention. Cardiac Interventions Today. July/August 2018.

Tricuspid Clip in Tricuspid Regurgitation. Amer Coll of Card, Feb 2020.

Percutaneous management of tricuspid regurgitation. Image-guided step-by-step MitraClip procedure. REC Interv Cardiol. 2020;2:118-128.

Intraprocedural Imaging of Transcatheter Tricuspid Valve Interventions. JACC: Cardiovascular Imaging,Volume 12, Issue 3, March 2019, Pages 532-553.

Transcatheter Tricuspid Valve Intervention: Coaptation Devices. Front. Cardiovasc. Med., 13 August 2020.

Transcatheter treatment of severe tricuspid regurgitation with the MitraClip system.

European Heart Journal (2016) 37, 849–853.

Echocardiography of the tricuspid valve. Ann Cardiothorac Surg. 2017 May; 6(3): 223–239.

Echocardiographic Evaluation of Tricuspid Valve. PPT. 2017 SOTA.

Use of Echocardiography for Guiding Percutaneous Tricuspid Valve Procedures. JACC: Cardiovascular Imaging. March 2017.

Tricuspid Interventions. PPT. Oct 2016.

Prosthetic Heart Valves

ASE Guidelines: Recommendations For Evaluation of Prosthetic Valves with Two-Dimensional and Doppler Echocardiography.

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound. A Report From the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, Endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. JASE Guidelines and Standards| Volume 22, ISSUE 9, P975-1014, September 01, 2009.

Recommendations for the imaging assessment of prosthetic heart valves: a report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging. European Heart Journal – Cardiovascular Imaging, Volume 17, Issue 6, June 2016, Pages 589–590, https://doi.org/10.1093/ehjci/jew025

Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.

Evaluation of Aortic Prosthetic Valves. JASE 2018. PPT.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72–e227.

Prosthetic Heart Valves: Selection of the Optimal Prosthesis and Long-Term Management. Circulation. 2009;119:1034–1048.

On-X heart valve echo. Slideshare, Jan 2016.

Myxoma is the most common primary benign cardiac tumor, which could lead to some fatal complications because of its strategic position. Although any age can be affected, it predominates in the age group of 30-60 years of age with more than 75% of the affected being women. The occurrence of myxomas in left and right atrium are 75% and 20% respectively.The majority of myxomas present with systemic emboli, fever and/or weight loss, or intracardiac obstruction to blood flow.¹ A ‘tumor plop’ is a sound that typically occurs during early diastole and is believed to be caused by motion of the tumor striking the wall of the endocardium. The treatment is surgical excision and key aims of anesthesia care include constant monitoring of systemic blood pressure, adequate IV fluids, and judicious use of vasoactive medications to prevent a fall in systemic vascular resistance.³

Preop

A-line/CVP
Assess patient symptomatology: SOB, chest pain, changes in pulse pressure/CVP with positioning, heart sounds
Adequate PIV access
Vasopressors to help with SVR and heart rate control – mass can act as stenotic valve

Intraop

Induction: maintain SVR and consider slowing heart rate if mass blocking valves

Postop

2D TEE: X-plane

2D TEE: color flow through mitral valve

2D TEE: LA myxoma

2D TEE: LA myxoma w color

3D TEE: LA myxoma

From OpenAnaesthesia

References:

Surgical approach

Cardiac myxomas: 24 years of experience in 49 patients. European Journal of Cardio-thoracic Surgery 22 (2002) 971–977.

Anesthesia management

Hemodynamic management of a patient with a huge right atrium myxoma during thoracic vertebral surgery: A case report. Medicine (Baltimore). 2018 Sep; 97(39): e12543.

Anesthetic Management of a Patient With a Giant Right Atrial Myxoma. Semin Cardiothorac Vasc Anesth. 2016 Mar;20(1):104-9.

Anesthetic management of a patient with asymptomatic atrial myxoma for hernia repair. Anaesth Pain & Intensive Care 2016;20(2):246-248

Giant Left Atrial Myxoma Obstructing Mitral Valve Bloodflow. Anesthesiology 7 2019, Vol.131, 151-152.

Anesthetic Management of a Voluminous Left Atrial Myxoma Resection in a 19 Weeks Pregnant with Atypical Clinical Presentation. Case Reports in Anesthesiology, Volume 2019, Article ID 4181502, 6 pages.

Large myxoma causing cardiac arrest during surgery. A Clinical Reports volume 1, Article number: 24 (2015).

Atrial myxomas causing severe left and right ventricular dysfunction. Annals of Cardiac Anaesthesia. Case Report: Year : 2017 | Volume : 20 | Issue : 4 | Page : 450-452.

Intraoperative Diagnosis of Left Atrial Myxoma. Anesthesia & Analgesia: January 1995 – Volume 80 – Issue 1 – p 183-184

Anesthetic experiences of myxoma removal surgery in two patients with Carney complex -A report of two cases-. Korean J Anesthesiol. 2011 Dec; 61(6): 528–532.

Echocardiography

Virtual TEE: Cardiac Myxoma

Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan. Ann Card Anaesth 2014;17:306-8.

ERAS for Cardiac Surgery

ERAS for cardiac surgery. #eras #pain #multimodal #opioids #surgery #cardiac #perfusion #perfusionist

I have been utilizing ERAS in general surgery, OB, and ortho cases. Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery. Careful what you look for my friends. There’s actually a good amount of information out there!

Updated: Dec 2021

Up-To-Date: Anesthetic management for enhanced recovery after cardiac surgery (ERACS). Nov 2021.

Guidelines for Perioperative Care in Cardiac SurgeryEnhanced Recovery After Surgery Society Recommendations. JAMA Surg. 2019;154(8):755-766. doi:10.1001/jamasurg.2019.1153

ERAS CS: Opioid Reduction Strategies in Cardiac Surgery – STS 8 in 8 Series. Sept 2020.

ERAS CS: Standardizing Evidence Based Best Practice in Periopertive Cardiac Surgical Care. Nov 2020.

CTSNet: “Cardiac Surgery Re-start and Beyond – Optimizing ICU Resource Utilization and Patient Safety”. Sept 2020.

CTSNet: “Enhanced Recovery After Cardiac Surgery Part II: Intraoperative and Postoperative.” June 2019.

CTSNet: ERAS Guidelines for Perioperative Care in Cardiac Surgery. July 2019.

ACCRAC podcast: ERAS for Cardiac Surgery

ERAS Cardiac Consensus Abstract – April 2018

Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. European Journal of Cardio-Thoracic Surgery, Volume 54, Issue 3, 1 September 2018, Pages 491–497, https://doi.org/10.1093/ejcts/ezy100

** Audio PPT ** American Association for Thoracic Surgery: Enhanced Recovery After Cardiac Surgery. April 2018

The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. The Journal of Thoracic and Cardiovascular Surgery. April 2018Volume 155, Issue 4, Pages 1843–1852.

Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018 Jan 31. pii: S1053-0770(18)30049-1. DOI: https://doi.org/10.1053/j.jvca.2018.01.045

Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients. 2016 Jun;30(3):665-70. doi: 10.1053/j.jvca.2016.01.017. Epub 2016 Jan 16.

A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2017 Jan;153(1):118-125.e1. doi: 10.1016/j.jtcvs.2016.09.016. Epub 2016 Sep 19.

Clinical Trial: The Safety and Efficacy of the Enhanced Recovery After Surgery(ERAS) Applied on Cardiac Surgery With Cardiopulmonary Bypass: a Single Center, Randomized, Controlled Clinical Study. May 2017.

A Multidisciplinary Protocol-Driven Approach to Improve Extubation Times After Cardiac Surgery. Ann Thorac Surg 2018;105:1684–90.

Enhanced Recovery After Cardiac Surgery Society

**Enhanced Recovery After Cardiac Surgery Society Expert Recommendations**

My blog posts:

Key Points

Level 1 (Class of recommendation=Strong Benefit):
- Tranexamic acid or epsilon aminocaproic acid should be administered for on-pump cardiac surgical procedures to reduce blood loss.
- Perioperative glycemic control is recommended (BS 70-180; [110-150]).
- A care bundle of best practices should be performed to reduce surgical site infection.
- Goal-directed therapy should be performed to reduce postoperative complications.
- A multimodal, opioid-sparing, pain management plan is recommended postoperatively
- Persistent hypothermia (T<35o C) after CPB should be avoided in the early postoperative period. Additionally, hyperthermia (T>38oC) should be avoided in the early postoperative period.
- Active maintenance of chest tube patency is effective at preventing retained blood syndrome.
- Post-operative systematic delirium screening is recommended at least once per nursing shift.
- An ICU liberation bundle should be implemented including delirium screening, appropriate sedation and early mobilization.
- Screening and treatment for excessive alcohol and cigarette smoking should be performed preoperatively when feasible.
Level IIa (Class of recommendation=Moderate Benefit)
- Biomarkers can be beneficial in identifying patients at risk for acute kidney injury.
- Rigid sternal fixation can be useful to reduce mediastinal wound complications.
- Prehabilitation is beneficial for patients undergoing elective cardiac surgery with multiple comorbidities or significant deconditioning.
- Insulin infusion is reasonable to be performed to treat hyperglycemia in all patients in the perioperative period.
- Early extubation strategies after surgery are reasonable to be employed.
- Patient engagement through online or application-based systems to promote education, compliance, and patient reported outcomes can be useful.
- Chemical thromboprophylaxis can be beneficial following cardiac surgery.
- Preoperative assessment of hemoglobin A1c and albumin is reasonable to be performed.
- Correction of nutritional deficiency, when feasible, can be beneficial.
Level IIb (Class of recommendation=Weak Benefit)
- A clear liquid diet may be considered to be continued up until 4 hours before general anesthesia.
- Carbohydrate loading may be considered before surgery.

ERAS for cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia

Volume 32, Issue 6, December 2018, Pages 2760-2770.

grant.eracs_.jtcvs-002.pdf

multimodal-analgesia-protocol-pocket-card.pdf

Cardiac ERAS. JCVA 2020. PDF.

**Guidelines for Perioperative Care in Cardiac SurgeryEnhanced Recovery After Surgery Society Recommendations. JAMA, May 2019.**

What would you suggest? AVR or not?

60-something y/o male patient who isn’t physically active but does ADLs. Scheduled for CABG but has AI, PVD, EF 40%, HTN, HLD. Would you suggest an AVR or not…. along with the CABG?

What would you suggest?

Transcatheter Mitral Valve Replacement

Our hospital will be partaking in the Medtronic APOLLO study.

The data so far from other hospitals in an easy to read format.

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PPT from Duke 2017

Peri-procedural imaging for transcatheter mitral valve replacement. Cardiovasc Diagn Ther. 2016 Apr; 6(2): 144–159.

Role of echocardiography for catheter-based management of valvular heart disease. Journal of Cardiology 69 (2017) 66–73.

EAE/ASE Recommendations for the Use of Echocardiography in New Transcatheter Interventions for Valvular Heart Disease. J ASE Sept 2011.

Multimodality Imaging in the Context of Transcatheter Mitral Valve Replacement. JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 10, 2015.

Echo in mitral valve intervention. ESC 2012.

Mitral Valve Morphology Assessment: Three-Dimensional Transesophageal Echocardiography Versus Computed Tomography. Ann Thorac Surg 2010;90:1922–9.

Transcatheter Mitral Valve Replacement for Patients With Symptomatic Mitral Regurgitation. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 69, NO. 4, 2017.

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Transcatheter Mitral Valve Intervention, An Issue of Interventional Cardiology Clinics, E-Book.

Quantification of Mitral Valve Morphology With Three-Dimensional Echocardiography. Can Measurement Lead to Better Management? Circulation Journal Official Journal of the Japanese Circulation Society http://www.j-circ.or.jp. 2014.

Transcatheter valve replacement and valve repair: Review of procedures and intraprocedural echocardiographic imaging. Circ Res. 2016;119:341-356.

Philips: TMVR

Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64.

Transcatheter Mitral Valve Repair. Summer 2014Volume 19, Issue 2, Pages 219–237.

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Mitraclip and TEE for MR

Transthoracic Echocardiography (TTE)

Transthoracic echo: a beginner’s guide #tte #cardiac #echo #meded

Knowing how to do a quick focused echo exam can be instrumental in diagnosis as well as treatment. This has helped me determine how severe cardiac tamponade has been in an emergent case prior to induction when there was no prior echo. There are so many more useful answers that a bedside echo can provide. Time to get acquainted.

Helpful links: