Mitral Valve analysis

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

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%