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Real-time three-dimensional echocardiography (RT3DE) is increasingly available in the veterinary field due to continuous reduction in costs and improvement of equipment. Much like its motion-mode and bi-dimensional counterparts, acquisition and analysis of RT3DE images and datasets is greatly improved by a thorough understanding of the technological aspects, basic physic principles, and knowledge of available modalities with their advantages and drawbacks. In this review, the authors aim to describe how the currently available RT3DE technology has evolved, explain technical aspects of the equipment, and illustrate the most commonly available modalities for image acquisition and visualization. [ABSTRACT FROM AUTHOR]

Diagnosing childhood tuberculosis (TB) is challenging, and novel diagnostic tools are urgently needed. Mediastinal lymphadenopathy is a hallmark of primary pulmonary TB (PTB) in children. We aimed to summarise available methodological and diagnostic data of transthoracic mediastinal ultrasound for childhood TB. Literature review identified two prospective and three retrospective studies, a case report, and a technical report including cases. All reported on suprasternal scanning of the mediastinum; additional parasternal scanning was reported by five studies. The proportion of children with lymphadenopathy detected by mediastinal ultrasound ranged between 15% and 85%, with studies including both supra- and parasternal scanning achieving higher detection ratios. Three retrospective studies reported mediastinal lymphadenopathy on ultrasound for most cases presenting with a normal or inconclusive CXR. Data on ultrasound for mediastinal lymphadenopathy in children are limited but indicate that mediastinal ultrasound can successfully detect mediastinal lymphadenopathy in children with TB. [ABSTRACT FROM AUTHOR]

The use of intraoperative transesophageal echocardiography (TEE) has become the standard of care for most cardiac surgical procedures. There are guidelines established for training, practice, and quality improvement in perioperative TEE by the joint efforts of the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists. Cardiac point-of-care ultrasound (POCUS) increasingly is being incorporated into anesthesiologists' training and practice. While a special "certification in Critical Care Echocardiography" was created by the National Board of Echocardiography in 2019, there currently exist no guidelines for training, certification, and practice of perioperative TTE by anesthesiologists. In this review, the authors describe the categories, indications and applications of perioperative TTE and provide a recommended sequence for performing an examination tailored to the evaluation of perioperative patients. Although the authors describe a protocol utilized at their institution, there are no standards described in the literature for PTTE. Cardiac anesthesiologists and cardiac anesthesia societies (Society of Cardiovascular Anesthesiologists, European Association of Cardiothoracic Anesthesiologists) must come forward to establish standards working in collaboration with echocardiography societies (American Society of Echocardiography, European Society of Cardiology). [ABSTRACT FROM AUTHOR]

In this paper, the authors report their experience of perioperative transthoracic echocardiography (TTE) practice and its impact on perioperative patient management. Retrospective case series. Single institution, tertiary university hospital. A total of 101 adult ASA II-V male and female patients >18 years old who were scheduled for or having surgery were included in this retrospective case series. All patients underwent a focused perioperative TTE exam performed by cardiac anesthesiologists with significant TTE experience, and further clinical management was based on echocardiography findings discussed with the anesthesia care team. Significant echocardiographic findings and changes in patient management were reported. Step-up management was a new intervention that was executed based on echocardiographic findings (volume infusion, inotropic therapy, cardiology consultation, and other interventions), and step-down management was avoidance of an unnecessary intervention based on echocardiographic findings (proceeding to surgery without cancellation, delay, cardiology consultation, and additional investigations/interventions). Fifty-three percent of TTEs were performed in the preoperative setting, 34% were intra-operative, and 13% were postoperative. No significant findings were detected in 38 patients, leading to step-down management in all of them. Among patients with positive findings, left ventricular dysfunction (12.8%), hypovolemia (10.8%), and right ventricular dysfunction (7.9%) were the most common. Step-up therapy included inotropic/vasopressor therapy (24.8%), intensive care admission after surgery for further management (13.8%), volume infusion (12.8%), and other interventions (additional monitoring, surgical delay, cardiology consultation, and modification of surgical technique). Perioperative focused TTE examination is useful in the diagnosis of new cardiac conditions for anesthesia management (intraoperative monitoring and hemodynamic therapy) and postoperative care (intensive care unit admissions). Perioperative TTE performed by anesthesiologists can also help avoid procedural delays and unnecessary consults. [ABSTRACT FROM AUTHOR]

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. Herein a customized pulsatile left-sided heart model that uses patient-specific 3-dimensional printed valves under physiological intracardiac pressures as a TEE task trainer is described. With this model, dynamic patient-specific valvular anatomy can be visualized with actual TEE machines by trainees to familiarize themselves with the surgery equipment and the imaging protocol. [ABSTRACT FROM AUTHOR]

Longitudinal shortening constitutes most of the right ventricle (RV) contraction in the normal heart. However, after even uncomplicated cardiac surgery with preserved RV function a significant and sustained decrease in longitudinal contraction expressed as a reduction in tricuspid annular plane systolic excursion (TAPSE) has been observed. Why and exactly when this happens remains unsettled. The aim of this study was to evaluate the magnitude and timing of changes in TAPSE in relation to sternotomy, pericardial opening, cardiopulmonary bypass (CPB), and chest closure. Fifty patients with normal preoperative ejection fraction and no valvulopathy, who underwent coronary artery bypass grafting with the use of CPB, were included. TAPSE was assessed using transthoracic echocardiography (TTE) at baseline and immediately after chest closure. Transesophageal echocardiography was performed at the following time points: after (1) anesthesia induction and transthoracic echocardiography; (2) sternotomy; (3) pericardiotomy; (4) completion of CPB; and (5) chest closure. TAPSE was significantly reduced to approximately half of its initial value in all patients (from 22 [95% confidence interval, 21-23 mm] after anesthesia induction to 9 [95% confidence interval, 8-10 mm] after chest closure). No change was seen after pericardiotomy. The most prominent reduction (30%-40%) was observed after weaning from CPB. An additional significant decrease of 13% to 16% was seen after chest closure. TAPSE was consistently reduced to approximately half of its initial value after uncomplicated coronary artery bypass grafting surgery. The reduction happened mainly after weaning from CPB, possibly reflecting conformational change of the RV. [ABSTRACT FROM AUTHOR]

Ultrasonography is increasingly being viewed as an everyday tool in obstetric anesthesia. For the administration of spinal or epidural anesthesia, it reduces needle redirection attempts in patients with difficult anatomy. In the less frequent scenario of a collapsed patient, it helps with assessment in the form of transthoracic echocardiography. Abdominal blocks require ultrasound guidance for safe and anatomically correct placement. Accurate assessment of gastric volume status with ultrasound would be a useful everyday skill if it is adopted into mainstream practice. We provide a summary of current opinions on the role of ultrasound in practice and highlight the potential for its future use in obstetric anesthesia. [ABSTRACT FROM AUTHOR]

Background Cardiac masses are uncommon in the canine population. When present, an attempt should be made to obtain a definitive diagnosis. Our goal with this case series was to report that as long as anatomic location permits, obtaining fine needle aspirates (FNAs) for cytological evaluation is practical, safe, and may provide a definitive diagnosis. Methods Our database has been retrospectively searched for cases where FNA of cardiac masses have been performed. Results A total of six cases were retrieved. Four dogs were under general anaesthesia and two were sedated. Ultrasound guided transthoracic FNAs were obtained in all cases with only minor complications: mild self-limiting pericardial effusion (n = 1) and one ventricular ectopic complex (n = 1). All dogs were closely monitored during the procedure (pulse oximetry, electrocardiography and blood pressure). A diagnosis was obtained in all cases: inflammation (n = 1), haemangiosarcoma (n = 2), sarcoma (n = 2) and chemodectoma (n = 1). Conclusion A cytological diagnosis allows clinicians to make appropriate clinical decisions, has dramatic impact on treatment recommendations and gives information about prognosis. [ABSTRACT FROM AUTHOR]

Ventricular tachycardias (VTs) can usually be treated by endocardial catheter ablation. However, some VTs can arise from the epicardial surface, and their substrate can be altered only by epicardial catheter ablation. There are two approaches to epicardial catheter ablation: transvenous and transthoracic. The transvenous approach through the coronary venous system (CVS) has been commonly used because it is easily accessible. However, this approach may be limited by the distribution of the CVS and insufficient radiofrequency energy delivery. Transthoracic epicardial catheter ablation has been developed to overcome these limitations of the transvenous approach. It is a useful supplemental or even preferred strategy to eliminate epicardial VTs in the electrophysiology laboratory. This technique has been applied for scar-related VTs secondary to often non-ischemic cardiomyopathy and sometimes ischemic cardiomyopathy, and idiopathic VTs as the epicardial substrates of these VTs have become increasingly recognized. When endocardial ablation and epicardial ablation through the CVS are unsuccessful, transthoracic epicardial ablation should be the next option. Intrapericardial access is usually obtained through a subxiphoidal pericardial puncture. This approach might not be possible in patients with pericardial adhesions caused by prior cardiac surgery or pericarditis. In such cases, a hybrid procedure involving surgical access with a subxiphoid pericardial window and a limited anterior or lateral thoracotomy might be a feasible and safe method of performing an epicardial catheter ablation in the electrophysiology laboratory. Potential complications associated with this technique include bleeding and collateral damage to the coronary arteries and phrenic nerve. Although the risk of these complications is low, electrophysiologists who attempt epicardial catheter ablation should know the complications associated with this technique, how to minimize their occurrence, and how to rapidly recognize and treat the complications that they encounter. This review discusses the indications, techniques, and complications of the transvenous and transthoracic epicardial catheter ablation of VTs. [ABSTRACT FROM AUTHOR]

Background: Mechanisms of the pseudonormalization (PN) of the transmitral flow (TMF) velocity pattern have been mainly attributed to left ventricular diastolic function. Purpose: To assess the influence of left atrial (LA) function on the PN with two-dimensional tissue tracking technique. Methods: The subjects consisted of 21 healthy volunteers and 70 patients with various cardiac dis-eases. Images of one cardiac cycle in the apical four-chamber view were stored by the HIVIS10N 900 (Hitachi Medico, Chiba, Japan). The LA volume (LAV) loop was created using two-dimensional tissue tracking technique and LAV index (LAVI) at a given cardiac phase was calculated. A preload of 90 mmHg was applied using a customized lower body positive pressure (LBPP) system. Patients were divided into the PN group (n = 18) with their early diastolic TMF velocity (£) increased and late diastolic TMF velocity (A) decreased, and the non-(N)-PN group (n = 52) with both ? and A wave velocities increased by LBPP. Results: (1) During LBPP, the LAVImax in both the groups increased significantly. (2) In the N-PN group, the LAVlpass (p< 0.001), LAVIact (p<0.01), and LAVItotai (p< 0.0001) increased significantly. The dV/dts (p<0.0001) and dV/dtE (p< 0.0001) increased significantly with an increase in the dV/dtA. On the other hand, there was no change in those parameters except LAVIpass (p < 0.05) and dV/dtE (p < 0.05) significantly increased in the PN group. (3) As a result, the LAVImin was significantly greater in the PN group than in the N-PN group (p < 0.0001 ) during LBPP. The ratio of ? velocity to early diastolic mitral annular velocity (£/£') during LBPP was significantly greater in the PN group than in the N-PN group (p < 0.0001 ). Conclusions: The lack of an increase in active LA emptying volume in response to an increase of preload leads to elevated LA pressure and the pseudonormalization of the TMF velocity pattern in patients with various cardiac diseases. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to assess the risk and predictive value of cardiac pathology detected on an anesthesiologist-performed focused transthoracic echocardiogram with adverse cardiac outcomes in the perioperative period. Design: A retrospective review of 222 patients having a focused transthoracic echocardiogram and evaluating the incidence and echocardiographic risk factors associated with perioperative adverse cardiac events. Setting: A single tertiary referral university teaching hospital. Participants: Two hundred twenty patients who had a focused transthoracic echocardiogram performed by an anesthesiologist. Interventions: All patients who had a focused transthoracic echocardiogram had their discharge summary and any perioperative troponin levels reviewed, looking for evidence of adverse cardiac events, including cardiac death before discharge, myocardial infarction, pulmonary edema, hypotension requiring vasoactive drug infusion, or new arrhythmia. Measurements and Main Results: Data were collected on the 222 patients who had an anesthesiologist-performed focused transthoracic echocardiogram, with 39 (18%) having an adverse cardiac event. There were 24 (11%) myocardial infarctions, 6 (2.7%) new arrhythmias, 5 (2.3%) deaths, and 4 (1.8%) episodes of severe hypotension. High-risk pathology detected on echocardiography included adverse cardiac events in 64% of the patients with pulmonary hypertension, 56% of the patients with left or right ventricular dysfunction, and 17% of the patients with stenotic valvular disease. In particular, patients with a combination of pulmonary hypertension, ventricular dysfunction, and/or stenotic valvular disease had a 77% risk of an adverse cardiac event. In contrast, no patients with a completely normal study, flow murmur, or isolated regurgitant valvular disease had adverse cardiac events. Conclusions: Anesthesiologist-performed focused transthoracic echocardiography predicts perioperative adverse cardiac events in noncardiac surgical patients. [Copyright &y& Elsevier]

Background: To evaluate the left atrial (LA) volume and function of obese patients with/without obstruc-tive sleep apnea (OSA) and its association with left ventricular (LV) diastolic function independent of obesity. Methods: LA volumetric and functional parameters were measured by 2-dimensional and strain echocar-diography in 49 obese (body mass index≥25 kg/m2) subjects (24 non-OSA and 25 OSA). Results: OSA group showed larger maximal LA volume indexed for body surface area, larger volume before atrial contraction, a reduction in the LA passive emptying fraction, and an increase in the LA active emptying fraction with no significant change in LA total emptying fraction. Mitral annular early diastolic velocity (Ea) was significantly reduced, whereas the ratio of mitral valve early diastolic velocity (E) to Ea (ElEa) and late diastolic velocity (Aa) were significantly increased in OSA group. Although the mean peak late diastolic strain rate had not shown any differences, the LA mean peak systolic strain/strain rate, and mean peak early diastolic strain rate were significantly lower in the OSA group. Apnea-hypopnea index (AH1) of the OSA patients was significantly correlated with £/Ea (r=0.67, p < 0.001). There is a significant correlation between LA active emptying volume index and E/Ea (r=0.77, p< 0.001), and between LA passive emptying volume index and E/Ea (r= -0.51, p = 0.009). Conclusion: LA structural and functional remodeling was significantly correlated with the severity of OSA and LV diastolic filling pressure. OSA impaired LA wall compliance and passive contraction independent of obesity. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: We have previously demonstrated deterioration in cardiac function at term in human pregnancy. To explore further, we investigated central arterial hemodynamics and association with maternal weight during gestation. Study design: Primiparous women (n =32) were recruited in a tertiary referral obstetric hospital and a longitudinal cohort study with analyses at median 16 and 37weeks gestation undertaken. Subgroups of normal body mass index, <25kg/m2, and overweight, ⩾25kg/m2, at 16weeks were created. Main outcome measures: We performed 2D speckle tracking echocardiography strain analysis and tonometric measures of central arterial pressures, waveforms and pulse wave velocity. Results: A reduction in cardiac strain (2P =0.002) from 16 to 37weeks gestation was associated with increased systemic vascular resistance (2P =0.008), reduced arterial compliance (2P =0.004) and increased central arterial pressures (2P <0.001) and augmentation index (2P =0.001). Conclusions: By 37weeks, compared with values in earlier pregnancy, overweight women had higher systemic vascular resistance (2P <0.05). Additionally, their central diastolic pressure was higher (2P <0.05) and their ventricular strain was lower (2P <0.05) than in normal weight pregnant women. An increase in systemic vascular resistance and central arterial pressures by term may contribute to the observed deterioration in cardiac function. This appears more prominent in overweight women. [Copyright &y& Elsevier]

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Abstract: Primary tuberculosis often occurs in children with the main types of hilar lymphonode tuberculosis or Ghon complex. When pulmonary tuberculosis aggravates and tubercule bacillus invades pulmonary veins, a disseminated disease may occur clinically. One 8-year-old girl presented with hypodynamia and emaciation. CT indicated the disseminated disease and extensive mediastinal and hilar lymphadenopathy. But she had negative sputum smears and negative PPD test. The bronchi showed inflammatory change in fiberoptic bronchoscopy. Percutaneous transthoracic needle biopsy (PTNB) guided by CT was used as a means for the diagnosis of pulmonary tuberculosis. The case was rapidly diagnosed as sub-acute disseminated pulmonary tuberculosis with the help of combined CT imagine and histology. [Copyright &y& Elsevier]

Summary: A 19-year-old male was admitted to the emergency room of our hospital after a motor vehicle accident. During his first physical examination, a holosystolic murmur was heard at the fourth left parasternal border. Transthoracic echocardiography showed severe tricuspid insufficiency, but the cause of tricuspid insufficiency was unclear. Therefore, three-dimensional echocardiography was performed and demonstrated flail anterior, posterior and septal leaflets of the tricuspid valve. The diagnosis was tricuspid insufficiency due to papillary muscle rupture secondary to chest blunt trauma. Surgical repair of the tricuspid valve was performed in this patient. After surgery, the signs and symptoms of right ventricular heart failure were relieved. In this case, three-dimensional echocardiography was very useful for the evaluation of spatial destruction of the tricuspid valve and papillary muscle. [Copyright &y& Elsevier]

Summary: Background and objective: Plasma B-type natriuretic peptide (BNP) levels are determined by several factors. The presence of atrial fibrillation (AF) is one of these factors. Meanwhile, plasma BNP levels are well correlated with left ventricular (LV) filling pressure in patients with sinus rhythm. Furthermore, LV filling pressure can be estimated by the ratio of early diastolic transmitral velocity to early diastolic mitral annular velocity (E/e′ ratio) in patients with sinus rhythm or with AF. However, it is still unclear if elevated plasma BNP levels reflect increases in LV filling pressure in patients with AF, especially with preserved LV systolic function. This study was designed to examine which factors determine plasma BNP levels in patients with persistent nonvalvular AF and preserved LV systolic function. Methods and results: We examined 195 clinically stable outpatients with persistent nonvalvular AF and preserved LV systolic function. They underwent comprehensive 2-dimensional and Doppler echocardiography, plasma BNP and creatinine levels, clinical history, and heart rate were determined. Then we statistically analyzed the correlation between plasma BNP levels and several variables including E/e′ ratio. On univariate analyses, plasma BNP levels were significantly correlated with age, LV diastolic diameter (LVDd), E/e′ ratio, and mitral E wave deceleration time. In addition, plasma BNP levels were significantly higher in males and in patients with a history of congestive heart failure and those who had been administered a β-blocker. On multiple linear regression analyses, E/e′ ratio, age, LVDd, and administration of β-blocker were independent determinant factors of plasma BNP levels. Conclusions: Plasma BNP levels in patients with persistent AF and preserved LV systolic function are affected by E/e′ ratio, age, LVDd, and administration of β-blockers. [Copyright &y& Elsevier]

The use of echocardiography in anaesthesia and critical care started with transoesophageal echocardiography, whereas transthoracic echocardiography was largely the domain of the cardiologist. In recent times, there has been a change in focus towards transthoracic echocardiography owing to the development of small and portable, yet high-fidelity, echocardiography machines. The cost has reduced, thereby increasing the availability of equipment. A parallel development has been the concept of limited transthoracic echocardiography that can be performed by practitioners with limited experience. The basis of these examinations is to provide the practising clinician with immediate information to help guide management with a focus on haemodynamic evaluation, and limited structural (valve) assessment to categorise whether there is a valve disorder that may or may not cause haemodynamic instability. The limited examination is therefore goal directed. A number of named examinations exist which differ in their scope and views. All of these require a limited knowledge base, and are designed for the clinician to recognise patterns consistent with haemodynamic or anatomical abnormalities. They range from very limited two-dimensional assessments of ventricular function to more complex (yet presently limited) studies such as HEART (haemodynamic echocardiography assessment in real time) scan, which is designed to provide haemodynamic state, as well as basic valvular and pericardial assessment. It is suitable for goal-directed examination in the operating theatre, emergency department or intensive care unit (ICU) and for preoperative screening. [ABSTRACT FROM AUTHOR]

Abstract: Two major surgical strategies to improve survival rates after oesophagectomy for oesophageal cancer have emerged during the past decades; (limited) transhiatal oesophagectomy and (extended) transthoracic oesophagectomy with two-field lymphadenectomy. This overview describes short and long-term advantages of these two strategies. In the short term, transhiatal oesophagectomy is accompanied by less morbidity. In the long term, this strategy is only preferable for patients with tumours located at the gastro-oesophageal junction, without involved lymph nodes in the proximal compartment of the chest. For patients with tumours located in the oesophagus, the transthoracic route with extended lymphadenectomy is probably preferred, because of improved long-term survival. [Copyright &y& Elsevier]

Objective: This study was designed to assess the clinical applicability of a small, handheld, portable transthoracic echocardiography device by noncardiologist intensivists. Design: Prospective, observational study. After 10 one-hour tutorials, intensivists performed a limited transthoracic echocardiography (TTE) (2–4 views, without Doppler or M-mode) examination with the 5.6-lb SonoHeart Echo System (SonoSite, Bethell, WA) on critically ill patients admitted to the surgical intensive care unit. After initial cardiac clinical assessment in 90 patients, a limited TTE was performed by an intensivist to assess left ventricular (LV) function and LV volume status. Each study was immediately reviewed and repeated by an echocardiographer to determine the technical quality of the TTE and the accuracy of the intensivist’s interpretation. Data were analyzed and presented in proportions using descriptive statistics. Setting: Surgical intensive care unit of an academic medical center. Participants: Ninety critically ill adult patients. Interventions: After initial cardiac clinical assessment, a limited TTE was performed by an intensivist to assess LV size and function, to rule out significant pericardial effusions, and to estimate circulatory volume. Results: Intensivists successfully performed a diagnostic limited TTE in 94% of patients and interpreted their studies correctly in 84%. Limited TTE provided new cardiac information and changed management in 37% of patients. TTE added useful information in an additional 47% of patients but did not alter immediate management. The mean “goal-directed TTE” acquisition time was 10.5 ± 4.2 minutes. Conclusion: After a brief formal training in using this handheld echocardiographic system in intensive care unit patients, surgical intensivists successfully performed and correctly interpreted a limited TTE in critically ill patients. Limited TTE provided new information and altered management in a significant number of patients. This study supports incorporating bedside goal-directed, limited TTE into intensivists’ training programs. [Copyright &y& Elsevier]

Objective: To create the Saudi Arabian Society of Echocardiography Accreditation Commission Guidelines and Standards. Method: A review of available the North American and European accreditation guidelines was conducted and a model, locally appropriate for Saudi echocardiography laboratories and applicable in the current settings, was developed. Results: The document specifies the organizational setting as well as the following categories of personnel: medical director, technical director, medical staff, and technical staff. The guideline team also examined aspects related to the facility and the facility safety policies and protocols. Examination and procedural issues for Adult transthoracic echocardiography including instrumentation, archiving media, examination interpretation and reports are also included as well as the required components for the Adult transthoracic echocardiography report. The last section of the guidelines focuses on Key Performance Indicators. A similar approach was taken regarding the Adult Stress Echocardiography, Transesophageal Echo, and monitoring of the patients during the procedures. Conclusion: The development of the Saudi Echocardiography Guidelines and Standards is a basic requirement for accreditation and also mandatory to improve the quality and utilization of such an important investigation. [ABSTRACT FROM AUTHOR]