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ABSTRACT: Intraoperative real-time three-dimensional transesophageal echocardiography (RT-3D TEE) was used to examine the geometric changes that occur in the mitral annulus immediately after aortic valve replacement (AVR).
A total of 35 patients undergoing elective surgical AVR under cardiopulmonary bypass was enrolled in the study. Intraoperative RT-3D TEE was used prospectively to acquire volumetric echocardiographic datasets immediately before and after AVR. The 3D echocardiographic data were analyzed offline using TomTec Mitral Valve Assessment software to assess changes in specific mitral annular geometric parameters.
Datasets were successfully acquired and analyzed for all patients. A significant reduction was noted in the mitral annular area (-16.3%, p < 0.001), circumference (-8.9%, p < 0.001) and the anteroposterior (-6.3%, p = 0.019) and anterolateral-posteromedial (-10.5%, p < 0.001) diameters. A greater reduction was noted in the anterior annulus length compared to the posterior annulus length (10.5% versus 6.2%, p < 0.05) after AVR. No significant change was seen in the non-planarity angle, coaptation depth, and closure line length. During the period of data acquisition before and after AVR, no significant change was noted in the central venous pressure or left ventricular end-diastolic diameter.
The mitral annulus undergoes significant geometric changes immediately after AVR. Notably, a 16.3% reduction was observed in the mitral annular area. The anterior annulus underwent a greater reduction in length compared to the posterior annulus, which suggested the existence of a mechanical compression by the prosthetic valve.
The Journal of heart valve disease 11/2012; 21(6):696-701. · 0.81 Impact Factor
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ABSTRACT: BACKGROUND: Mitral valve (MV) annular dynamics have been well described in animal models of functional mitral regurgitation (FMR). Despite this, little if any data exist regarding the dynamic MV annular geometry in humans with FMR. In the current study we hypothesized that 3-dimensional (3D) echocardiography, in conjunction with commercially available software, could be used to quantify the dynamic changes in MV annular geometry associated with FMR. METHODS: Intraoperative 3D transesophageal echocardiographic data obtained from 34 patients with FMR and 15 controls undergoing cardiac operations were dynamically analyzed for differences in mitral annular geometry with TomTec 4D MV Assessment 2.0 software (TomTec Imaging Systems GmbH, Munich, Germany). RESULTS: In patients with FMR, the mean mitral annular area (14.6 cm(2) versus 9.6 cm(2)), circumference (14.1 cm versus 11.4 cm), anteroposterior (4.0 cm versus 3.0 cm) and anterolateral-posteromedial (4.3 cm versus 3.6 cm) diameters, tenting volume (6.2 mm(3) versus 3.5 mm(3)) and nonplanarity angle (NPA) (154 degrees ± 15 versus 136 degrees ± 11) were greater at all points during systole compared with controls (p < 0.01). Vertical mitral annular displacement (5.8 mm versus 8.3 mm) was reduced in FMR compared with controls (p < 0.01). CONCLUSIONS: There are significant differences in dynamic mitral annular geometry between patients with FMR and those without. We were able to analyze these changes in a clinically feasible fashion. Ready availability of this information has the potential to aid comprehensive quantification of mitral annular function and possibly assist in both clinical decision making and annuloplasty ring selection.
The Annals of thoracic surgery 10/2012; · 3.74 Impact Factor
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ABSTRACT: A 3-dimensional echocardiographic view of the mitral valve, called the "en face" or "surgical view," presents a view of the mitral valve similar to that seen by the surgeon from a left atrial perspective. Although the anatomical landmarks of this view are well defined, no comprehensive echocardiographic definition has been presented. After reviewing the literature, we provide a definition of the left atrial and left ventricular en face views of the mitral valve. Techniques used to acquire this view are also discussed.
Anesthesia and analgesia 08/2012; 115(4):779-84. · 3.08 Impact Factor
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Anesthesia and analgesia 04/2011; 112(6):1300-2. · 3.08 Impact Factor
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ABSTRACT: We present the case of a 78-year-old woman who presented with acute anterior myocardial infraction. An intraoperative transesophageal echocardiogram revealed an akinetic apex with hyperkinesis of the basal segments causing systolic anterior motion of the mitral valve. The patient was immediately placed on cardiopulmonary bypass. Her postoperative course was uneventful. We present transesophageal and transthoracic echocardiographic videos showing this unique complication and describing the challenge of managing a patient who required opposing therapies.
The Annals of thoracic surgery 03/2011; 91(3):e39-40. · 3.74 Impact Factor
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ABSTRACT: Low tidal volumes have been associated with improved outcomes in patients with established acute lung injury. The role of low tidal volume ventilation in patients without lung injury is still unresolved. We hypothesized that such a strategy in patients undergoing elective surgery would reduce ventilator-associated lung injury and that this improvement would lead to a shortened time to extubation
A single-center randomized controlled trial was undertaken in 149 patients undergoing elective cardiac surgery. Ventilation with 6 versus 10 ml/kg tidal volume was compared. Ventilator settings were applied immediately after anesthesia induction and continued throughout surgery and the subsequent intensive care unit stay. The primary endpoint of the study was time to extubation. Secondary endpoints included the proportion of patients extubated at 6 h and indices of lung mechanics and gas exchange as well as patient clinical outcomes.
Median ventilation time was not significantly different in the low tidal volume group; a median (interquartile range) of 450 (264-1,044) min was achieved compared with 643 (417-1,032) min in the control group (P = 0.10). However, a higher proportion of patients in the low tidal volume group was free of any ventilation at 6 h: 37.3% compared with 20.3% in the control group (P = 0.02). In addition, fewer patients in the low tidal volume group required reintubation (1.3 vs. 9.5%; P = 0.03).
Although reduction of tidal volume in mechanically ventilated patients undergoing elective cardiac surgery did not significantly shorten time to extubation, several improvements were observed in secondary outcomes. When these data are combined with a lack of observed complications, a strategy of reduced tidal volume could still be beneficial in this patient population.
Anesthesiology 03/2011; 114(5):1102-10. · 5.36 Impact Factor
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ABSTRACT: We present the case of a 72-year-old male who was diagnosed with a saphenous vein graft pseudoaneurysm, detected on routine chest echocardiogram 13 years after undergoing coronary artery bypass graft surgery. Intraoperative transesophageal echocardiography revealed the pseudoaneurysm to be causing functional tricuspid stenosis, which was relieved after surgical excision of the mass.
Journal of Cardiac Surgery 02/2011; 26(2):177-80. · 0.87 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 10/2010; 25(1):177-81. · 1.06 Impact Factor
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International anesthesiology clinics 01/2010; 48(1):87-100.
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Journal of the American College of Cardiology 12/2009; 55(1):e1. · 14.16 Impact Factor
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Anesthesia and analgesia 06/2009; 108(5):1467-9. · 3.08 Impact Factor
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Balachundhar Subramaniam, Peter J Panzica,
Victor Novack,
Feroze Mahmood,
Robina Matyal,
John D Mitchell,
Eswar Sundar,
Ruma Bose,
Frank Pomposelli,
Judy R Kersten,
Daniel S Talmor
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ABSTRACT: A growing body of evidence suggests that hyperglycemia is an independent predictor of increased cardiovascular risk. Aggressive glycemic control in the intensive care decreases mortality. The benefit of glycemic control in noncardiac surgery is unknown.
In a single-center, prospective, unblinded, active-control study, 236 patients were randomly assigned to continuous insulin infusion (target glucose 100-150 mg/dl) or to a standard intermittent insulin bolus (treat glucose > 150 mg/dl) in patients undergoing peripheral vascular bypass, abdominal aortic aneurysm repair, or below- or above-knee amputation. The treatments began at the start of surgery and continued for 48 h. The primary endpoint was a composite of all-cause death, myocardial infarction, and acute congestive heart failure. The secondary endpoints were blood glucose concentrations, rates of hypoglycemia (< 60 mg/dl) and hyperglycemia (> 150 mg/dl), graft failure or reintervention, wound infection, acute renal insufficiency, and duration of stay.
The groups were well balanced for baseline characteristics, except for older age in the intervention group. There was a significant reduction in primary endpoint (3.5%) in the intervention group compared with the control group (12.3%) (relative risk, 0.29; 95% confidence interval, 0.10-0.83; P = 0.013). The secondary endpoints were similar. Hypoglycemia occurred in 8.8% of the intervention group compared with 4.1% of the control group (P = 0.14). Multivariate analysis demonstrated that continuous insulin infusion was a negative independent predictor (odds ratio, 0.28; 95% confidence interval, 0.09-0.87; P = 0.027), whereas previous coronary artery disease was a positive predictor of adverse events.
Continuous insulin infusion reduces perioperative myocardial infarction after vascular surgery.
Anesthesiology 06/2009; 110(5):970-7. · 5.36 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 04/2009; 23(4):544-8. · 1.06 Impact Factor
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ABSTRACT: Perioperative measurement of the myocardial performance index (MPI) with transesophageal echocardiography in patients undergoing elective abdominal aortic aneurysm repair and its association with outcome.
A prospective observational study.
A tertiary care university hospital.
Patients undergoing elective abdominal aortic aneurysm repair.
Perioperative transesophageal echocardiography.
Fifty-one consecutive patients undergoing elective abdominal aortic aneurysm repair were enrolled in the study. The MPI was calculated by using pulse-wave Doppler from the midesophageal window and the deep transgastric position of the probe. In addition, diastolic function was measured as the slope of the transmitral flow propagation velocity, and ejection fraction was calculated as a measure of ventricular systolic function. Comparisons between subjects with uncomplicated versus adverse outcomes were made by using a Mann-Whitney U test. Comparison of the incidence of adverse outcome among subjects with normal and elevated MPIs was made by using a Fisher exact test. Statistical significance was set at p < 0.05.
It was possible to calculate MPI in all patients with transesophageal echocardiography perioperatively. Patients with adverse postoperative outcomes had an elevated MPI as compared with those without any adverse outcome (0.50 v 0.30, p < 0.001). Also, an MPI of > or = 0.36 was associated with a statistically significant higher incidence of complications (congestive heart failure/prolonged intubation) (p < 0.001).
The MPI is an easily obtained echocardiographic measure of global ventricular performance, which can be measured perioperatively and may be useful as a prospective risk stratification index for patients undergoing elective abdominal aortic aneurysm surgery.
Journal of cardiothoracic and vascular anesthesia 10/2008; 22(5):706-12. · 1.06 Impact Factor
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ABSTRACT: Beta-adrenergic-blocking medications may have a cardioprotective effect after high-risk vascular surgery. This effect has been shown primarily in men and has not been independently shown in women.
Retrospective data were collected from vascular surgery (primarily infrainguinal) patients. Adverse outcome was defined as myocardial infarction, new-onset congestive heart failure (CHF), significant arrhythmia, renal failure, or death. The incidence of adverse outcomes was compared independently for both men and women based on the administration of perioperative beta-blockade. Analysis was performed for the whole population and for the subset of patients who were not on preoperative beta-blockers (beta-blocker naïve). Risk-stratified analysis was used to determine which group received any effect from beta-blockade. Logistic regression was performed to determine the independent effect of perioperative beta-blockade in both sexes.
There were 594 men and 366 women. The incidence of adverse outcomes was lower when beta-blockers were administered in men (12.6% v 18.9%, p = 0.04) but not in women (17.8% v 13.7%, p = 0.37). Among beta-blocker-naïve subjects, men had significant reductions in myocardial infarction and renal failure, whereas women did not have a reduction in the incidence of any outcome. After risk-stratification, the high-risk women who received beta-blockade had a statistically worse outcome (36.8% v 5.9%, p = 0.02) because of an increased incidence of CHF. By logistic regression, beta-blockade improved outcomes in men but not women.
In this retrospective analysis, women did not benefit from perioperative beta-blockade. Women at high risk appeared to have a worse outcome because of a higher incidence of CHF.
Journal of cardiothoracic and vascular anesthesia 07/2008; 22(3):354-60. · 1.06 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 07/2008; 22(3):431-4. · 1.06 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 01/2008; 23(2):208-10. · 1.06 Impact Factor
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ABSTRACT: We report a case in which flow-directed placement of the pulmonary artery catheter led to its inadvertent placement in the coronary sinus, in the absence of congenital anomalies. Incorrect placement was diagnosed by use of the transesophageal echocardiography. If unrecognized, the catheter might have provided misleading information and led to mismanagement of the patient.
Anesthesia and analgesia 03/2006; 102(2):363-5. · 3.08 Impact Factor
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ABSTRACT: Patients with severe left ventricular systolic dysfunction (LVSD) undergoing coronary artery bypass grafting (CABG) have an increased risk for morbidity and mortality. The purpose of this study was to assess the association of pre-CABG right ventricular (RV) function with outcome for patients with severe LVSD. We performed a retrospective evaluation of 41 patients with severe LVSD (left ventricular ejection fraction [LVEF] < or =25%) scheduled for nonemergent CABG. Data were obtained from review of medical records, transesophageal echocardiography tapes, and phone interview. The pre- and post-cardiopulmonary bypass (CPB) LVEF and the RV fractional area of contraction (RVFAC) were calculated by using intraoperative transesophageal echocardiography. Group 1 patients had an RVFAC < or =35% (n = 7), whereas Group 2 patients had RVFAC >35% (n = 34). The durations of mechanical ventilation and of intensive care unit and hospital stays are presented as the median. Pre-CABG LVEF was similar between Groups 1 and 2 (15.8% +/- 3.3% versus 17.8% +/- 3.9%). Compared with Group 2, Group 1 patients required greater duration of mechanical ventilation (12 days versus 1 day; P < 0.01), longer intensive care unit (14 versus 2 days; P < 0.01) and hospital (14 versus 7 days; P = 0.02) stays, had a more frequent incidence and severity of LV diastolic dysfunction, and had a smaller change in LVEF immediately after CPB (4.1% +/- 8.3% versus 12.5% +/- 9.2%; P = 0.03). All Group 1 patients died of cardiac causes within 2 yr of surgery; five died during the same hospital admission. Three Group 2 patients died: one of colon cancer at 18 mo after CABG and two of cardiac causes 24 and 48 mo after surgery. A fourth patient was awaiting cardiac transplantation 4 yr after surgery. The remaining Group 2 patients were New York Heart Association Classification I or II. For patients with severe LVSD undergoing CABG, pre-CPB RV dysfunction was associated with poor outcome. Patients with RVFAC >35% had a relatively uneventful perioperative course and good long-term survival, whereas patients with RVFAC < or =35% had a poor early and late outcome. Assessment of RV function is useful to further assess the risk of CABG. IMPLICATIONS: Right ventricular function before cardiopulmonary bypass is associated with poor outcome after coronary artery surgery in patients with poor left ventricular function.
Anesthesia & Analgesia 01/2003; 95(6):1507-18, table of contents. · 3.29 Impact Factor
