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.

Mitral Valve analysis

Review article: TEE of Mitral Valve. International Journal of Perioperative Ultrasound and Applied Technologies, September-December 2013;2(3):122-130.

New Concepts for Mitral Valve Imaging. Ann Cardiothorac Surg. 2013 Nov; 2(6): 787–795.

A Quantification Approach to Echocardiography of Mitral Valve for Repair. Anesthesia & Analgesia 12(1):34-58 · July 2015

4D-transesophageal echocardiography and emerging imaging modalities for guiding mitral valve repair. Ann Cardiothorac Surg 2015;4(5):461-462.

Quantification of Mitral Regurgitation by the Proximal Flow Convergence

Method—Comparison of Transthoracic and Transesophageal Echocardiography. Clin. Cardiol. 25, 517–524 (2002)

Virtual TEE: spectral Mitral valve

Echocardiographic atlas of the mitral regurgitation. J Saudi Heart Assoc. 2011 Jul; 23(3): 163–170.

Intraoperative transesophageal echocardiographic assessment of the mitral valve repair. Ann Card Anaesth 2010;13:79-85.

Anatomy of the Mitral Valve and Quantification of Mitral Regurgitation. Mayo Clinic PPT 2016.

Automated Quantitative 3-D Echo To Guide Mitral Valve Repair in Functional Mitral Regurgitation.

Computer-based comparison of different methods for selecting mitral annuloplasty ring size. Journal of Cardiothoracic Surgeryvolume 12, Article number: 8 (2017)

Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography. Eur J Echocardiogr. 2011 Jun; 12(6): 445–453.

Sizing for Mitral Annuloplasty: Where Does Science Stop and Voodoo Begin? Ann Thorac Surg 2013;95:1475–83

Guidance of Mitral and Tricuspid Interventions: Role of 3D Echo. Chicago 2018 PPT.

Mitral Annular Evaluation With CT in the Context of Transcatheter Mitral Valve Replacement. JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 5, 2015.

MAY 2015:612–5.

The choice of mitral annuloplastic ring—beyond “surgeon’s preference”. Ann Cardiothorac Surg 2015;4(3):261-265

Gold Standard to Measure MR – PPT 2016 U of Wash.

IABP

There’s always a good reason to review the physiology and reasons for placement of an Intra Aortic Balloon Pump (IABP). We come across these a couple of times a month in our cardiac patients. They’re a great temporary measure to stabilizing and treating the patient.

Contemporary Clinical Niche for Intra-Aortic Balloon Counterpulsation in Perioperative Cardiovascular Practice: An Evidence-Based Review for the Cardiovascular Anesthesiologist. JCVA, February 2017. Volume 31, Issue 1, Pages 309–320.

One of the best explanations that I have ever seen for the IABP is from Dr. Rishi Kumar. He’s a board certified anesthesiologist and is ICU fellowship trained and is pursuing a cardiac anesthesia fellowship as well. This lovely human is no joke. I’ve read his blog and his instagram posts, and he’s a wonderful teacher and mentor to those he reaches. Please click his link for an entry regarding IABPs on his blog.

RKMD.com: Intra-Aortic Balloon Pump, Arterial Line, and EKG Waveforms. April 2018.

TEE for placement of IABP

Anesthesia & Analgesia, July 2011. Vol 113, No. 1.

Want the tip 1-2 cm from left subclavian artery (LSCA)
X-plane aortic arch down to descending aorta to see the left subclavian artery
Visible during systole when the IABP balloon is deflated

Good visualization of the LSCA

A Novel Technique for Intra-aortic Balloon Positioning in the Intensive Care Unit. J Extra Corpor Technol. 2012 Sep; 44(3): 160–162.

Cardiac anesthesiologists and LVAD patients: Pro vs Cons

There’s been a big debate re: who should care for LVAD patients… a general anesthesiologist or a cardiac anesthesiologist? See below for pros and cons of each. Ultimately, I think all anesthesiologists should be comfortable caring for these patients as we’ll see more and more LVAD patients undergoing procedures.

Troubleshooting the Left Ventricular Assist Device. Emergency Medicine. 2016 February;48(2):58-63.

LVAD Parameter Abnormalities:

High power, low-pulsatility index and fluctuating pump speed: Consider pump thrombosis or hypotension, vasodilation, initial response to exercise.
High power with high pulsatility index: Consider fluid overload, normal physiological response to increased demand; myocardial recovery.
Low power, low pulsatility index, and unchanging speed: Consider hypertension or inflow/outflow obstruction, LV failure, dysrhythmia.
Low power with normal or high pulsatility index: Consider suction event.

Pro: Cardiothoracic Anesthesiologists Should Provide Anesthetic Care for Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. JCVA, February 2017. Volume 31, Issue 1, Pages 378–381

Con: Cardiothoracic Anesthesiologists Are Not Necessary for the Management of Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. JCVA, February 2017. Volume 31, Issue 1, Pages 382–387.

Ventricular assist devices and non-cardiac surgery. BMC Anesthesiology201515:185

Goals of care for LVAD patients undergoing non-cardiac surgery should be directed at maintaining forward flow and adequate perfusion. Three main factors that affect LVAD flow are preload, RV function, and afterload.
The right ventricle is the primary means of LVAD filling; therefore, maintaining RV function is imperative.
Marked increases in systemic vascular resistance should be avoided.
Generally, decreases in pump flow should first be treated with a fluid challenge. Hypovolemia should be avoided and intraoperative losses should be replaced aggressively. Second line treatment should include inotropic support for the right ventricle.
Low-dose vasopressin (<2.4 U/h) may be the vasopressor of choice due to its minimal effect on pulmonary vascular resistance.
Standard Advanced Cardiovascular Life Support Guidelines should be followed; however, external chest compressions should be avoided during cardiac arrest.
Steep Trendelenburg may increase venous return, risking RV strain. Peritoneal insufflation for laparoscopic surgery also increases afterload and has detrimental effects on preload. Insufflation should utilize minimum pressures and be increased in a gradual, step-wise fashion.
TEE can be extremely valuable in diagnosing the cause of obstruction.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery. Annals of cardiac anaesthesia 2016. Vol 19, Issue 4: 676-686.

LVAD: What Should I report? Feb 2017 ASE conference. **ECHO**

Higher the RPMs (pump speed)
- More LV compression, smaller LV size
- Less functional MR
- More AI, less AV opening
- Less LVED diameter
De Novo Aortic Regurgitation Post LVAD
- Proposed mechanisms
  - Aortic valve remains closed during systole
  - Commissural fusion of the aortic valve from disuse
  - Subsequent degeneration of valve
  - Turbulent blood backflow from small outflow cannula onto a closed valve
  - Persistent elevation of aortic root pressure –> aortic root dilation and valve incompetence
- Treatment
  - Lower LVAD speed (but that may worsen mitral regurgitation)
  - Aortic valve surgery or percutaneous intervention
  - Heart transplant
RV Fractional Area Change (RV FAC)
- RVFAC is a rough measure of RV systolic function (4 chamber view)
- RVFAC = (RVEDA – RVESA) / RVEDA
- Normal RVFAC = 35 – 63%

Ventricular Assist Device (VAD). LifeInTheFastLane.com. December 11, 2016.

Care of the LVAD patient PPT. Summit 2014.

Pulsatility Index:
- normally decrease as pump speed is increased

LVAD: Understanding equipment and Alarms. Duke Heart Center PPT.

LVAD Management in the ICU. Crit Care Med 2014; 42:158–168.

Screen Shot 2018-11-26 at 11.20.26 AM — From Left Ventricular Assist Device Management in the ICU Pratt, Alexandra K. MD1; Shah, Nimesh S. MD1; Boyce, Steven W. MD2 Critical Care Medicine: January 2014 – Volume 42 – Issue 1 – p 158–168 doi: 10.1097/01.ccm.0000435675.91305.76 Concise Definitive Review

Screen Shot 2018-11-26 at 11.20.47 AM — Left Ventricular Assist Device Management in the ICU Pratt, Alexandra K. MD1; Shah, Nimesh S. MD1; Boyce, Steven W. MD2 Critical Care Medicine: January 2014 – Volume 42 – Issue 1 – p 158–168 doi: 10.1097/01.ccm.0000435675.91305.76 Concise Definitive Review

Anesthesia for Left Ventricular Assist Device Insertion: A Case Series and Review. Ochsner J. 2011 Spring; 11(1): 70–77.

Medical Management of Patients With Continuous-Flow Left Ventricular Assist Devices. Curr Treat Options Cardiovasc Med. 2014 Feb; 16(2): 283.

My blog posts:

HeartWare vs. HeartMate LVAD

Ventricular Assist Devices: Impella

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?

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: