Mitral Stenosis on TEE

Sometimes you need a refresher on measurements of the mitral valve via TEE.  Here’s a great 2D TEE walk through for mitral stenosis.

http://tele.med.ru/book/cardiac_anesthesia/text/pe/pe009.htm


Methods of Determining MVA

Severity of MS

Ventricular Assist Devices: Impella

“There’s an emergent case coming for impella placement.”

Impella?  I’ve read about these devices and I’m familiar with managing patients on LVADs as well as providing anesthesia for LVAD placement.  But, I’ve never done an Impella on a critically unstable patient.

YouTube video describing the purpose and placement of the Impella

Cath Lab Digest: Overview of Impella 5.0

home-graphic-role

Anesthesia & Analgesia; January 2012. Echo rounds: The Use of TEE for Confirmation of Appropriate Impella 5.0 Device Placement.

From A&A Echo Rounds

 YouTube video similar to our axillary artery conduit (we had to go left sided bc of a prior AICD in the patient’s right chest) for Impella 5.0

JCVA, June 2010. Review Articles: Percutaneous LVAD: Clinical Uses, Future Applications, and Anesthetic Considerations.

Left Atrial Occlusion Devices

Our hospital is starting to do more left atrial occlusion devices for people who have afib and aren’t able to tolerate blood thinners. Currently, two types are offered by our cardiologists: Watchman procedure (endocardial) vs Lariat procedure (epicardial).

Lariat

It look and acts similar to a lariat or lasso.  An external guide wire with a magnet at its tip is introduced outside the heart towards the left atrial appendage (LAA). Another wire with a magnet at its tip is introduced from a groin vein and it traverses the interatrial septum to sit at the most distal point inside the LAA. The magnets “connect” and the lariat is introduced along the external guide wire and essentially lassos the LAA.

Lariat procedure
Watchman

A large occlusion device is inserted via a groin vein and traverses the interatrial septum into the proximal (base or largest opening) left atrial appendage. The device gets deployed and successfully occludes the LAA.

Watchman

PPT on Watchman from Boston Scientific

Is one better than the other?

Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications.  Pillarisetti J, et al. Heart Rhythm. 2015.

CONCLUSION: The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Anesthesia

For these cases, we typically have a good flowing peripheral IV and intubate these patients for general anesthesia. There’s a fair amount of TEE required for placement and verification of correct positioning of the device. Both procedures require transseptal access. Watch for hypotension as there is a risk for pericardial effusion.

TEE for Lariat

TEE for Lariat


TEE for Watchman

Watchman TEE

Echo Essentials for Endoluminal LAA Closure: April 2014 Cardiac Interventions Today

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation: J Vis Exp. 2012; (60): 3671

Anesthesia and Transesophageal Echocardiography for WATCHMAN Device Implantation: December 2016Volume 30, Issue 6, Pages 1685–1692.

f4-large
From JACC: Cardiovascular Interventions
PDF Article

Percutaneous Left Atrial Appendage Closure
Procedural Techniques and Outcomes

3D Echo inside the Cath Lab – A must in LAA Closure. London, 2016.

ECHONOMY:Tools for Echocardiographic Calculations

YouTube: LEFT ATRIAL APPENDAGE CLOSURE PROCEDURE : Role of Transesophageal Echocardiography

YouTube: TCTAP 2015 SHD Live Case Session: LAA Closure

YouTube: How to image the inter-atrial septum using 3D-TEE “RATLe-90 maneuver”

YouTube: TOE in LA Appendage Assessment by Jason Sharp

**ASEcho.org 2017**

WATCHMAN:
 
Baseline TEE:
·       Full Scripps TEE protocol
·       Measure the LAA at the following views:
o   0°, 45°, 90°, 135°
·       Report the LAA maximal orifice, as well as the LAA dimensions at each angle using the following Xcelera drop-downs under “Left Atrium”:
 
·       Comment on presence or absence of atrial thrombus or “smoke”
·       Optional: Comment on LAA shape (ie: cauliflower, chicken wing, windsock, cactus)
 

 

Intra-Procedural TEE:
·       Comment on presence or absence of atrial thrombus

·       Report the LAA maximal orifice using the following Xcelera drop-down under “Left Atrium”:

·       Enter LAA device size and implantation date under the “History” section in Xcelera
·       Comment on the presence or absence of a residual leak using the following Xcelera drop-down under “Left Atrium”:
 
·       If a residual leak is present, comment on the size (mm) of the leak using the following Xcelera drop-down under “Left Atrium”:
 
·       Iatrogenic ASD with direction of shunting
·       Comment on any post-procedure pericardial effusion (compare to baseline)

 

 
Post-Procedure Discharge TTE (pt. in hospital):
·       LIMITED 2D TTE to rule out pericardial effusion (unless order specifies otherwise)
·       Spectral Doppler for respirophasic flow changes if an effusion is present

 

 
45-Day, 6 Month, 1 year and 2 year F/U TEEs:
·       Comment on presence or absence of atrial thrombus
·       Comment on the presence or absence of a residual leak using the following Xcelera drop-down under “Left Atrium”:
 
·       If a residual leak is present, comment on the size (mm) of the leak using the following Xcelera drop-down under “Left Atrium”:
 
·       Carry over LAA device size and implantation date under the “History” section in Xcelera

·       Comment on Iatrogenic ASD with direction of shunting, if still present

Left atrial occlusion devices

Our hospital is starting to do more left atrial occlusion devices for people who have afib and aren’t able to tolerate blood thinners. Currently, two types are offered by our cardiologists: Watchman procedure (endocardial) vs Lariat procedure (epicardial).

Lariat

It look and acts similar to a lariat or lasso.  An external guide wire with a magnet at its tip is introduced outside the heart towards the left atrial appendage (LAA). Another wire with a magnet at its tip is introduced from a groin vein and it traverses the interatrial septum to sit at the most distal point inside the LAA. The magnets “connect” and the lariat is introduced along the external guide wire and essentially lassos the LAA.

Lariat procedure
Watchman

A large occlusion device is inserted via a groin vein and traverses the interatrial septum into the proximal (base or largest opening) left atrial appendage. The device gets deployed and successfully occludes the LAA.

Watchman

PPT on Watchman from Boston Scientific

Is one better than the other?

Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications.  Pillarisetti J, et al. Heart Rhythm. 2015.

CONCLUSION: The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Anesthesia

For these cases, we typically have a good flowing peripheral IV and intubate these patients for general anesthesia. There’s a fair amount of TEE required for placement and verification of correct positioning of the device. Both procedures require transseptal access. Watch for hypotension as there is a risk for pericardial effusion.

TEE for Lariat

TEE for Lariat


TEE for Watchman

Watchman TEE

Echo Essentials for Endoluminal LAA Closure: April 2014 Cardiac Interventions Today

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation: J Vis Exp. 2012; (60): 3671

Anesthesia and Transesophageal Echocardiography for WATCHMAN Device Implantation: December 2016Volume 30, Issue 6, Pages 1685–1692.

f4-large
From JACC: Cardiovascular Interventions
PDF Article

Percutaneous Left Atrial Appendage Closure
Procedural Techniques and Outcomes

3D Echo inside the Cath Lab – A must in LAA Closure. London, 2016.

ECHONOMY:Tools for Echocardiographic Calculations

YouTube: LEFT ATRIAL APPENDAGE CLOSURE PROCEDURE : Role of Transesophageal Echocardiography

YouTube: TCTAP 2015 SHD Live Case Session: LAA Closure

YouTube: How to image the inter-atrial septum using 3D-TEE “RATLe-90 maneuver”

YouTube: TOE in LA Appendage Assessment by Jason Sharp

 

Minimally invasive mitral valve surgery from an anesthesiologist’s perspective. #cardiac #mitral #tee #minimallyinvasive #robot #anesthesia #meded

Surgically, more and more cases are performed through tiny incisions for minimal scarring.  Don’t let that underestimate the size of the procedure.  For example, mitral valve surgery is still a common procedure that involves a sternotomy (“cracking the chest”) and stopping the heart — it’s a big procedure.  However, surgeons have become adept at making smaller incisions while still undergoing the big procedure.

Innovations; 2011: Vol 6, No. 2.  Minimally invasive vs. Conventional open mitral valve surgery: A meta-analysis and systematic review.

Robotic mitral valve repair: anatomic considerations

Journal of Heart Valve Disease: August 2006. 2D Echo measurements alone do not provide accurate non-invasive selection of annuloplasty band size for robotic mitral valve repair

Annals of Cardiothoracic Surgery: 2013;2(6): 796-802. Value of TEE guidance in minimally invasive mitral valve surgery.

Multimedia-Manual of Cardiothoracic Surgery: Vol 2009; Issue 0122. Minimally invasive mitral valve surgery via right minithoracotomy

Cardiac Anesthesia: Principles and Clinical Practice; Chapter 25: Anesthesia for minimally invasive cardiac surgery.

Mitral Valve Repair Center: Post-Repair TEE Assessment.

Medtronic: Echo and surgical techniques for retrograde cardioplegia-coronary sinus cannulation during minimally invasive cardiac valve surgery.

OA Anaesthetics; 2014 Feb 25;2(1):3. Anaesthetics considerations for robotic-assisted cardiac surgery.

A modified anaesthesia protocol for patients undergoing minimally invasive cardiac surgery by thoracotomy – a single center experience.

HSR Proceedings in Intensive Care and Cardiovascular Anesthesia; 2013. Current concepts for minimally invasive mitral valve repair.

2014 Clinical vignette from the surgical prospective

Chauhan S, Sukesan S. Anesthesia for robotic cardiac surgery: An amalgam of technology and skill. Ann Card Anaesth [serial online] 2010 [cited 2016 Apr 12];13:169-75. Available from: http://www.annals.in/text.asp?2010/13/2/169/62947

When the bark is louder than the bite

In residency, you learn to deal with many different personalities.  This ranges from super sweet and helpful to utterly cruel and egotistical.  At MGH, our CA-3 year was spent running the call schedule on night call (the first-call experience).  It’s a terrific experience in prioritizing as well as organizing your team to prepare for what rolls through the OR doors.  Fast forward 4 years and now I’m in private practice.

While running the schedule on call, I get a call from the trauma surgeon saying a patient with an epidural hematoma needs to come to the OR emergently and couldn’t wait for another anesthesiologist to be called in from home (home call gives an anesthesiologist 30 minutes to come into the hospital for an emergency).  So, I made the executive decision to pull the anesthesiologist from the elective suboccipital craniotomy case to do the emergency.  It was a crani to crani and neuro to neuro switch… meaning the neuro team and crani trays were already open and ready to go.  It made the most sense in my mind.  Of course, without missing a beat, the “elective” neurosurgeon showed complete disdain of my decision.  To add fuel to the fire, he proceeded to berate the OR nurses, myself, and staff to make sure his displeasure was known.  I stood by my decision because it was the best decision for the emergency craniotomy patient who could have potentially died.  Secondly, I chose not to call in my final anesthesiologist for an elective case as we would have gone on “trauma bypass”.  This means that no traumas or emergencies could come to our hospital.  The “elective” neurosurgeon became more livid by the minute.  2.5 hours after he was supposed to start his case, I finished my first case and was able to get his case started.

Now, who does an elective suboccipital craniotomy for tumor case on a Saturday?  Secondly, he decides to do this in a sitting position — this has it’s own sets of risks.  He needed a precordial doppler, which our hospital did not have, so we called for it from our neighboring sister hospital.  In the meantime, I had another plan…that was to put down a TEE probe to monitor for venous air embolism (VAE).  After speaking to the patient and family, I proceeded to explain the risks/benefits of arterial line, central venous line, transesophageal echo, mechanical ventilation, blood transfusion, and intensive care unit stay.  It’s always a lot for the family to comprehend, especially while meeting them for the first time.  However, it is our job as anesthesiologists to make them comfortable and calm their fears.

**This picture taken from a google search for “precordial doppler”.  It is not my own.**

IndianJAnaesth_2012_56_5_502_103979_u2

**This picture taken from a google search for “precordial doppler”.  It is not my own.**

We get to the room and proceed with vital signs monitoring.  Uneventful induction and intubation.  A right internal jugular vein central venous line is placed (mainly to use as a Bunegin-Albin catheter).   TEE probe placed to look for air in RV and possibly air lock and RV failure –> VAE.  Radial arterial line placed and transduced at the level of the head.  Pt was placed in Mayfield pins and positioned in steep sitting position with reverse Trendelenberg and flexing the legs up.  Neuromonitoring commenced looking for changes in sensory and motor signaling.

All throughout the case, the TEE showed various amounts of air coming through the right side of the heart:

IMG_6787.PNGWith greater amounts of air, there would be a detectable decrease in blood pressure as well as end-tidal CO2.  While the right ventricle was still capable of pushing blood forward, I simply increased the blood pressure pharmacologically and increased the patient’s volume with normal saline from the IV.  Rarely does one get to see this TEE view as most of these cases are monitored non-invasively via pre-cordial doppler or ETCO2 and BP.

Lastly, this patient had a great outcome.  A 2cm x 2 cm hemangioma was resected with minimal disruption or trauma to surrounding tissue.  2 hours after a lengthy 4 hour surgery, the patient was sitting with their family… communicating and interacting with them.  All motor and sensory intact.

Pearls from this case:

1) Always do what is best for the patient.  When a life-and-death situation presents itself, it gets priority.  Period.  It doesn’t matter what pressure or temper tantrums you get from outside parties.  Make the best clinical decision. Organize a plan.  Stick with it.

2) Find out the surgeon’s plan.  This case was not booked in sitting position.  Some of these cases are done in prone position, which makes the likelihood of VAE significantly lower than in sitting position.  Knowing the surgeon’s plan of attack is critical to an anesthetic plan.

3) Read. Read. And read more.  Although I’ve been out of residency and fellowship for 4 years, cases will always test your knowledge as well as make you learn new skills/techniques to better your plan.  Take the time to do your best.  Always review.  Medicine is a lifelong learning career.

4) Don’t sweat the small stuff.  The “elective” neurosurgeon who raised such hell at the beginning of the case was thanking me for my help and expertise by the end of the case.  Learn as much as you can from your residency.  Take the knowledge gained and let your clinical acumen do the talking.  There is no room for ego when taking care of a patient.  Your ability to be well-read, well-trained, and well-respected will dictate the tone.  No fluff is needed when you bring 100% to the table.  Don’t be intimidated by the loud bark.

Aortic valve replacement

Gross pathology of rheumatic heart disease: ao...
Image via Wikipedia

As people get older, there’s a tendency for their valves to become calcified.  The calcifications cause narrowing of the main valve for blood flow out of the heart to the rest of the body.

We took care of a patient the other day that had a very, very stenotic aortic valve.  The transthoracic echo stated an ejection fraction of 10% with global hypokinesis and estimated aortic valve area of 0.6.  (I can’t remember the peak/mean of aortic valve gradient…with an EF10%, I’m not sure that it’ll be that impressive).  The cath report stated an aortic valve area of 0.3!  Additionally, systolic PA pressures were 50s-60s with a mean in the 40s.

That information alone is enough to be a scary anesthesia candidate!  On arrival to the OR, the patient was tough in just about every way (except his demeanor; he was a total sweetheart).  IV placement was difficult, arterial line was difficult (even with U/S).  Prior to induction we were finally able to obtain 18g PIV and 20g brachial a-line…with a little help of our friend midazolam.

Induction: 4mg midazolam worked in…  phenylephrine running at 40mcg/min peripherally prior to induction meds.  The patient’s poor EF was pretty evident based on his poor radial pulses and scarily low BP (90s/60s).  Prior to pushing the induction agents, I administered roughly 200mcg of phenylephrine (in 50mcg increments)… then 250 mcg fentanyl… then 10mg etomidate… then 250mcg fentanyl… then 10 mg etomidate.  Yes, small…slow… careful induction.  This was one of the times that I definitely wanted the surgeon in the room ready to go prior to induction.  The patient was rock-solid stable, despite my internal anxiety of what may have transpired if the induction had gone awry.  After the resident was able to easily mask the patient, I pushed 100mg of rocuronium.  He secured the ETT and I breathed a huge sigh of relief.  This was definitely my scariest induction – but with appropriate planning and setup, I was thrilled that everything occurred by the book.

By TEE, I calculated a AVA of 0.8 under anesthesia via planimetry and continuity equation.  I reported an annulus size of 27mm… the surgeon ended up going with a 25.  The LV was globally hypokinetic – it was just a poor functioning chamber.  It almost appeared as just a “quiver” of tissue.  (My thoughts for coming off CPB: “this guy needs squeeze – must grab epi!).  The RV appeared to be moving ok (not hypertrophic or dilated; mild hypokinesis; no tricuspid annular dilation) and PA looked okay (not dilated).  In retrospect, I probably should’ve used Bernoulli’s equation to calculate pressure gradient for the R heart.

Upon re-warming, I decided to start an epinephrine infusion.  This just made sense to me.  He needed as much beta activity to get his heart going!  Sure, we had dopamine, but I wanted him to FLY off CPB!  So, I started him on just baby epi to see how his heart would respond:  Epi 2mcg/min.  I think his heart was so happy that the obstruction (stenotic aortic valve) was opened he really took off and was able to generate the afterload for pressure.  Also, I was concerned about his pulmonary hypertension, which seemed to be attributed mainly to the decreased forward flow from the stenotic aortic valve causing left heart failure.  His pulmonary pressures decreased after the new valve was placed.  My main concern was to make sure he had the contractility (the squeeze) to maintain a decent forward flow (cardiac output).  I’m really glad we didnt’ go the IABP route.

Postop, the patient was doing well.  The surgeon had him on both dopamine and epinephrine (I’m still trying to figure out that one).  Post-op day #1, the patient was extubated and had been weaned off epinephrine, but was still on dopamine.  My guess is that the surgical team is more comfortable managing dopamine in the ICU.

Any thoughts?  What would you do differently?