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A Free-Access Online Interactive Simulator to Enhance Perioperative Transesophageal Echocardiography Training Using a High-Fidelity Human Heart 3D Model
The clinical uses of perioperative transesophageal echocardiography have grown exponentially in recent years for both cardiac and noncardiac surgical patients. Yet, echocardiography is a complex skill that also requires an advanced understanding of human cardiac anatomy. Although simulation has changed the way echocardiography is taught, most available systems are still limited by investment costs, accessibility, and qualities of the input cardiac 3-dimensional models. In this report, the authors discuss the development of an online simulator using a high-resolution human heart scan that accurately represents real cardiac anatomies, and that should be accessible to a wide range of learners without space or time limitations.A High-Resolution Virtual Reality-Based Simulator to Enhance Perioperative Echocardiography Training
Perioperative echocardiography requires an advanced understanding of the complex human cardiac anatomy. Currently, conventional training simulators rely on handcrafted heart models that lack accuracy and details and undermine the complexities of the cardiac anatomy, both actual and relative. These simulators are expensive and difficult to transport, creating barriers to widespread implementation. In this report, the authors describe a realistic, virtual reality simulator using high-resolution human heart scans that accurately represent the healthy and pathologic cardiac anatomies in ways that can be standardized and made accessible to a wide range of learners at the cost of a virtual reality headset.Temporary Epicardial Pacing After Cardiac Surgery
Temporary epicardial pacing frequently is employed after cardiac surgery, and can have a significant impact on a patient's hemodynamics, arrhythmias, and valvulopathies. Given that anesthesiologists often are involved intimately in the initial programming and subsequent management of epicardial pacing in the operating room and intensive care unit, it is important for practitioners to have a detailed understanding of the modes, modifiable intervals, and potential complications that can occur after cardiac surgery.Where Should We Leave the Wild “Raa Raa” During Cardiopulmonary Bypass?
THE PULMONARY artery catheter (PAC), the Raa Raa, the noisy, wild lion in a British stop-motion animated children's television program1 (Fig 1), also known as the Swan-Ganz catheter, is used frequently during cardiac surgery. The PAC might provide clinicians with important information on the preload, afterload, and contractility through the measured and derived parameters for risks stratification and guide perioperative management, particularly in patients with advanced heart failure, pulmonary hypertension, cardiogenic shock, and those who undergo heart and lung transplantation and left ventricular assist device implantation.Porcine Orthotopic Cardiac Xenotransplantation: The Role and Perspective of Anesthesiologists
ON JANUARY SEVENTH, 2022, the first genetically modified porcine cardiac xenograft was transplanted into a patient at the University of Maryland Medical Center. As members of the xenotransplant team and division of cardiac anesthesiology at the University of Maryland School of Medicine, the authors here had a role in this historic event. Cardiac xenotransplantation could become a common occurrence if it proves to be a viable answer for the limited supply of donor hearts to treat end-stage heart failure.Right Heart Failure Management: Focus on Mechanical Support Options
Millions of American adults suffer from right heart failure (RHF), a condition associated with high rates of hospitalization, organ failure, and death. There is a multitude of etiologies and mechanisms that lead to RHF, often in a feedforward spiral of decline. The management of advanced cases of RHF can be particularly difficult. For patients who are refractory to the medical optimization of volume status, hemodynamic and pharmacologic support, and rhythm control, mechanical therapies may be warranted.A Sequential Approach for Echocardiographic Guidance of Transseptal Puncture: The PITLOC Protocol
With advancements in technology and progress in interventional procedures, left-sided structural heart disease (SHD) interventions have become part of everyday clinical practice. One of the most important steps for a successful left-sided structural heart intervention is the transseptal puncture (TSP). Appropriate transesophageal echocardiographic (TEE) guidance of TSP requires extensive supervised hands-on experience prior to attaining proficiency. Whereas some TEE skills are acquired during cardiac anesthesia fellowships, continuous procedural guidance during SHD interventions requires substantial hands-on experience.Dynamic Geometric Tricuspid Valve Assessment: Extending from Bench to Bedside
SURGICAL AND PERCUTANEOUS procedures on the tricuspid valve (TV) are becoming more prevalent due to the improved outcomes associated with intervention in these patients with functional tricuspid regurgitation (TR). Although the decision to intervene on other cardiac structures, such as the mitral valve, often is based on dynamic geometric indices; this is not the case with the TV where the decision to intervene often is based on the degree of TR or static 2-dimensional measurements. To identify patients accurately in whom TV intervention may confer clinical benefit, it is important to assess geometric indices throughout the cardiac cycle.Echocardiographic Assessment of the Mitral Valve for Suitability of Repair: An Intraoperative Approach From a Mitral Center
Intraoperative echocardiography of the mitral valve in the precardiopulmonary bypass period is an integral part of the surgical decision-making process for assessment of suitability for repair. Although there are comprehensive reviews in the literature regarding echocardiographic examination of the mitral valve, the authors present a practical stepwise algorithmic workflow to make objective recommendations. Advances in echocardiography allow for quantitative geometric analyses of the mitral valve, along with precise assessment of the valvular apparatus with three-dimensional echocardiography.Fluoroscopic Imaging for the Interventional Echocardiographer
Procedural guidance during structural heart disease (SHD) interventions is achieved with both two-dimensional and three-dimensional transesophageal echocardiography as well as real-time fluoroscopic imaging. Although both image the cardiac anatomy, they are based on different principles of image acquisition. In the era of multimodality imaging with coregistration of anatomic landmarks and simultaneous real-time display, it is essential to have cross-disciplinary imaging knowledge. Besides improving communication, it also enhances patient care and, possibly, outcomes.Three-Dimensional Transesophageal Echocardiography Simulator: New Learning Tool for Advanced Imaging Techniques
The use of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) has grown exponentially in recent years. Three-dimensional TEE technology has evolved to allow for real-time display of 3D images and, thus, has become the standard of care for the evaluation of cardiac anatomy and function. Its use has provided a new dimension of clinical insight when managing patients for cardiac surgery or structural heart interventions. While the intraoperative utility of 3D TEE has expanded, there has been a slower advancement in the area of training and, specifically, simulator-based training in 3D TEE.Selective Lobe Ventilation and a Novel Platform for Pulmonary Drug Delivery
The current methods of mechanical ventilation and pulmonary drug delivery do not account for the heterogeneity of acute respiratory distress syndrome or its dependence on gravity. The severe lung disease caused by severe acute respiratory distress syndrome coronavirus 2, coronavirus disease 2019, is one of the many causes of acute respiratory distress syndrome. Severe acute respiratory distress syndrome coronavirus 2 has caused more than three million deaths worldwide and has challenged all therapeutic options for mechanical ventilation.Contrast-Enhanced Echocardiography Application in Patients Supported by Extracorporeal Membrane Oxygenation (ECMO): A Narrative Review
Extracorporeal membrane oxygenation (ECMO) is a lifesaving intervention increasingly used to support patients with severe respiratory and cardiac dysfunction. Echocardiography is an important tool, aiding implantation and monitoring during ECMO therapy, but often its use is limited by poor acoustic windows. This limitation may be overcome by the use of echocardiography contrast agents to improve diagnostic yield and reduce the need for other imaging modalities that may require patient transfer, involve ionizing radiation and, occasionally, nephrotoxic radio-opaque contrast medium.Artificial Intelligence for Dynamic Echocardiographic Tricuspid Valve Analysis: A New Tool in Echocardiography
There has been a resurgence of interest in the structure and function of the tricuspid valve (TV) with the established prognostic impact of functional tricuspid regurgitation. Current 3-dimensional transesophageal echocardiography prototype software is limited to exploration of the mitral and aortic valves exclusively. Thus, newer analytical software is required for dynamic geometric analysis of the TV morphology for remodeling. This article presents a preliminary experience with novel artificial intelligence-based semiautomated software for TV analysis.Perioperative and Echocardiographic Considerations for the Inspiris Resilia Aortic Valve--Current and Future
SURGICAL AORTIC valve replacement (SAVR) remains the currently recommended standard therapy for patients with aortic stenosis and low or intermediate surgical risk, and may be considered in patients at high surgical risk.1 SAVR with a bioprosthetic aortic valve (AV) eliminates the need for therapeutic anticoagulation but is associated with structural valve deterioration (SVD).2,3 Recent American College of Cardiology/American Heart Association guidelines have lowered the age that is “reasonable” to implant a bioprosthetic SAVR from 60 to 50 years old, and multiple studies have demonstrated increasing bioprosthetic valve implantation in younger patient populations.Intraoperative and Early Postoperative Management of Patients Undergoing Minimally Invasive Left Ventricular Assist Device Implantation
Minimally invasive approaches for left ventricular assist device (LVAD) implantation have grown in popularity and have many potential advantages, including less bleeding, shorter recovery time, and improved postoperative right ventricular function compared with traditional implantation. Centrifugal flow LVADs are easily implanted via a minimally invasive approach. In this article, the authors review intraoperive considerations for minimally invasive LVAD implantation and hemodynamic management principles for patients with centrifugal flow LVADs.Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation
Venoarterial extracorporeal membrane oxygenation (ECMO) is a well-established technique to rescue patients experiencing cardiogenic shock. As a form of temporary mechanical circulatory support, venoarterial ECMO can be life-saving, but it is resource intensive and associated with substantial morbidity and mortality. Optimal clinical outcomes require specific expertise in the principles and nuances of ECMO physiology and management. Key considerations discussed in this review include hemodynamic assessment and goals; pharmacologic anticoagulation; ECMO weaning strategies; and the prevention, evaluation, and treatment of common complications.Strain Imaging: An Everyday Tool for the Perioperative Echocardiographer
Strain analysis allows for global and regional analysis of myocardial function and has been shown to be an independent predictor of outcomes after cardiac surgery. Strain imaging offers advantages over traditional EF measurements in that it is relatively angle independent, it is less dependent upon loading conditions, it is reproducible, it does not rely on geometric assumptions, and it can detect subclinical systolic dysfunction. Limitations of strain analysis include high temporal resolution requirements, a strong dependence on image quality, and inter-vendor variability.Three-Dimensional Printing and Transesophageal Echocardiographic Imaging of Patient-Specific Mitral Valve Models in a Pulsatile Phantom Model
Three-dimensional printing is increasingly used in the health care industry. Making patient-specific anatomic task trainers has been one of the more commonly described uses of this technique specifically, allowing surgeons to perform complex procedures on patient-specific models in a nonoperative setting. With regard to transesophageal echocardiography (TEE) training, commercially available simulators have been increasingly used. Even though these simulators are haptic in nature and anatomically near realistic, they lack patient specificity and the training of the dynamic workflow and imaging protocol used in the operative setting.The Use of Subcostal Echocardiographic Views to Guide the Insertion of a Right Ventricular Temporary Transvenous Pacemaker—Description of the Technique
The need for temporary cardiac pacing may occur in emergency and elective situations and may require transvenous right ventricular lead placement. The treatment of bradyarrhythmias presents the most common perioperative emergency indication. Intraoperatively, temporary rapid right ventricular pacing is accepted as a safe, titratable, and highly reliable method to achieve deliberate hypotension, and it has become a routine practice in the anesthetic management of cardiovascular interventions. The navigation of the lead into the right ventricle often requires fluoroscopy to guide placement and to confirm position.Transesophageal Echocardiography for Impella Placement and Management
ACUTE CARDIOGENIC SHOCK is a common problem encountered by cardiac anesthesiologists. Current methods of treatment include pharmacologic and mechanical circulatory support (MCS). MCS is used for temporary or long-term treatment of cardiogenic shock. Temporary MCS is used as a bridge to myocardial recovery, a bridge to a more durable therapy (durable MCS or heart transplantation), or a bridge to decision-making.1 Temporary MCS is becoming more common in cardiogenic shock in multiple scenarios including postcardiotomy shock, high-risk percutaneous cardiac intervention, acute decompensated heart failure, and ventricular tachycardia ablation, and for percutaneous venting of the left ventricle during peripheral venoarterial extracorporeal membrane oxygenation.Ultrasound Imaging for Diaphragm Dysfunction: A Narrative Literature Review
Of the various muscles that make up the respiratory system, the diaphragm is the prima donna. In the past, only specialist research centers were able to estimate and challenge the effort of this muscle; this was achieved by measuring transdiaphragmatic pressure—an invasive technique involving a double-balloon probe inserted through the esophagus—or by measuring twitch pressure (ie, the pressure generated at the outside tip of the endotracheal tube). However, the prevalence of diaphragm dysfunction in critically ill patients requiring intubation can exceed 60% (at the time of hospital admission) and may rise to as high as 80% in patients requiring prolonged mechanical ventilation and experiencing difficult weaning.Expiratory Central Airway Collapse in Adults: Anesthetic Implications (Part 1)
Expiratory central airway collapse (ECAC) is a general term that incorporates tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC). TBM and EDAC are progressive, degenerative disorders of the tracheobronchial tree, causing airway collapse. Induction of general anesthesia can trigger intraoperative airway collapse in patients with these conditions. This crisis presents as the sudden inability to ventilate, which can lead to life-threatening hypoxemia and hypercapnia. This article reviews the definition, pathophysiology, diagnosis, and anesthetic implications of ECAC.The MitraClip Procedure—A Comprehensive Review for the Cardiac Anesthesiologist
R.T. Hahn is a speaker for Edwards Lifesciences, Irvine CA; Abbott Vascular, Abbott Park, IL; Boston Scientific, Marlborough, MA; Philips Healthcare, Best, Netherlands; and GE Healthcare, Little Chalfont, UK; is an unpaid national principal investigator for the Percutaneous Tricuspid Valve Annuloplasty System for Symptomatic Chronic Functional Tricuspid Regurgitation SCOUT trial; and is the director of the Echo Core Lab at the Cardiovascular Research Foundation for multiple industry-sponsored trials for which she receives no direct compensation.Ultrasonic Enhancing Agents for the Cardiothoracic Anesthesiologist: A Focused Review of the 2018 American Society of Echocardiography Guidelines Update
INTRAVENOUS (IV) INJECTION of substances to improve visualization of anatomic structures has long been used in noninvasive imaging techniques. Ultrasonic enhancing agents (UEAs), previously known as ultrasound contrast agents, have been an essential part of echocardiography since their safety profile was established. In 2018, the American Society of Echocardiography (ASE) incorporated new data from numerous clinical trials and updated its 2008 consensus statement for the clinical applications of UEAs in echocardiography.
