Search

Continuous imaging of cardiac functions is highly desirable for the assessment of long-term cardiovascular health, detection of acute cardiac dysfunction and clinical management of critically ill or surgical patients1–4. However, conventional non-invasive approaches to image the cardiac function cannot provide continuous measurements owing to device bulkiness5–11, and existing wearable cardiac devices can only capture signals on the skin12–16. Here we report a wearable ultrasonic device for continuous, real-time and direct cardiac function assessment. We introduce innovations in device design and material fabrication that improve the mechanical coupling between the device and human skin, allowing the left ventricle to be examined from different views during motion. We also develop a deep learning model that automatically extracts the left ventricular volume from the continuous image recording, yielding waveforms of key cardiac performance indices such as stroke volume, cardiac output and ejection fraction. This technology enables dynamic wearable monitoring of cardiac performance with substantially improved accuracy in various environments.

To determine if patients with congenital heart disease are undergoing laparoscopic surgery requiring abdominal insufflation and to compare the outcomes of these procedures with those who underwent an open surgical approach.This was a retrospective study using the National Inpatient Sample from 2006 to 2014. Individuals with congenital heart disease who underwent at least one of six selected surgical procedures (laparoscopic or open) were included in the study. Subgroup analysis was performed on patients with Fontan palliation.The primary outcome was to determine the frequency with which congenital heart disease patients undergo laparoscopic surgery requiring abdominal insufflation compared with open surgery. Secondary outcomes included all-cause in-hospital mortality and in-hospital length of stay. Of the 5,527 patients included, nearly half underwent laparoscopic surgery (46.3%), and 128 (2.3%) had single-ventricle circulation. All-cause mortality was significantly higher for those who underwent open surgery compared with the laparoscopic approach (3.6% v 0.9%; odds ratio [OR], 4.0 [2.6-6.3]; p0.0001). Subgroup analysis of patients with Fontal palliation older than five years showed 30 (42%) underwent laparoscopic surgery and there was no mortality difference between the laparoscopic and open approaches (OR, 1.4 [0.2-21.3], p = 0.8). Length of stay was significantly shorter for patients undergoing laparoscopic compared with open surgery (median three days [interquartile range, two-five] v six days [three-13], p0.0001).Individuals with congenital heart disease are being offered laparoscopic surgery that requires abdominal insufflation. All-cause mortality and length of stay were higher for patients who underwent open surgical operations.

This article is the fifth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank Editor-in-Chief Dr. Kaplan and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

Congenital afibrinogenemia is a rare autosomal recessive hematologic disorder that results in coagulopathy due to the complete lack of fibrinogen production. While the common manifestation of the disease entails a bleeding diathesis, these patients are also at high risk of thromboembolic event due to abnormal coagulation cascade. We present a case in which a patient with congenital afibrinogenemia complicated by chronic thromboembolic pulmonary hypertension undergoes pulmonary thromboendarterectomy requiring cardiopulmonary bypass and deep hypothermic circulatory arrest. We discuss the clinical management technique with the use of human fibrinogen concentrate. We also discuss the potential safety implications and recent literature involving the use of human fibrinogen concentrate during cardiac surgery involving cardiopulmonary bypass and deep hypothermic circulatory arrest.

This article is the sixth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but, in some cases, these articles targeted the use of perioperative echocardiography in general.

This article is the fourth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board, for the opportunity to continue this series. In most cases, these were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles targetted the use of perioperative echocardiography in general.

This article is the third of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

This article is the first in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, the associate editor-in-chief, Dr. Augoustides, and the editorial board for the opportunity to start this series, namely the research highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This first article focuses on esophageal thermal injury during radiofrequency ablation, perioperative management of patients presenting for ablation procedures, left atrial appendage occlusion devices, and, finally, heart failure diagnostic devices.

This study sought to prospectively evaluate the prevalence, risk factors, and short-term major clinical outcomes of mobile thrombus detected on transvenous leads in patients undergoing lead extraction.The prevalence and clinical significance of thrombus on transvenous leads in patients undergoing lead extraction is not well characterized.Consecutive patients undergoing transvenous lead extraction for noninfectious indications were enrolled. Preoperative transesophageal echocardiograms were performed prospectively for all patients to examine for mobile thrombus. Anticoagulation was not started for thrombus unless other indications were present. Clinical endpoints of mortality and cardiovascular morbidity (symptomatic pulmonary embolism, myocardial infarction, or cerebrovascular accident) were assessed at a minimum of 2-month follow-up.A total of 108 patients underwent lead extraction for noninfectious indications. Lead thrombi were detected in 20 (18.5%) patients and all were

The management of heparin-induced thrombocytopenia (HIT) in the perioperative period for patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) can be a challenging clinical scenario. Once a diagnosis of HIT has been established, heparin products typically are avoided and alternative therapies for anticoagulation are started. Alternative anticoagulation strategies for CPB are limited and often have various pharmacokinetic profiles that may lead to increased perioperative bleeding. Historically the use of a GPIIb/IIIa inhibitor, such as tirofiban, followed by unfractionated heparin (UFH) is the typical alternative for surgeries requiring DHCA in patients with HIT at the authors' institution. This article presents a case in which cangrelor followed by UFH was used in a 20-year-old patient with suspected HIT and chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy surgery requiring CPB and DHCA. Due to the frequency of significant postoperative bleeding encountered when using tirofiban and UFH, it was decided to attempt to block platelet aggregation with significantly shorter-acting cangrelor. The authors hypothesized that cangrelor would reduce the risk of significant bleeding compared with tirofiban because of its favorable pharmacokinetics. Specifically, cangrelor has a short elimination half-life of 3 to 6 minutes, and its elimination is not altered by renal and hepatic impairment. This case report discusses the pathophysiology of HIT, the alternative anticoagulants used for HIT type II in pulmonary thromboendarterectomy, and the potential of cangrelor in conjunction with UFH to be a favorable option for patients in similar clinical scenarios.

Objective To compare pulmonary artery catheter (PAC) placement by transesophageal echocardiography combined with pressure waveform transduction versus the traditional technique of pressure waveform transduction alone. Design A prospective, randomized trial. Setting Single university hospital. Participants Forty-eight patients with chronic thromboembolic pulmonary hypertension (CTEPH) scheduled for pulmonary thromboendarterectomy. Interventions PACs were placed in 48 patients with CTEPH scheduled for pulmonary thromboendarterectomy by either a combined approach (eg, transesophageal echocardiography [TEE] and pressure waveform transduction) or by pressure waveform transduction alone. Measurements and Main Results Successful placement of the PAC via a combined technique or pressure waveform transduction alone was timed, number of attempts recorded, and final location noted. The final location of the pressure waveform-guided catheters was the proximal right pulmonary artery in 6 of 24 cases (25%), whereas the combined method resulted in successful placement in the proximal right pulmonary artery in 24 of 24 cases (100%). The pressure waveform technique resulted in a mean time to placement and mean number of attempts of 74 seconds and 1.70 attempts, respectively. The combined approach resulted in a mean time to placement and mean number of attempts of 89 seconds and 1.79 attempts, respectively. The combined method resulted in placement in the proximal right pulmonary artery significantly more often than the pressure-only method but did not reduce significantly the number of attempts or time required to place the catheter successfully. Additionally, among those cases that required more than 1 attempt or manipulation, there was no difference in the time to successful placement or the number of attempts required for successful placement. Conclusion TEE guidance during PAC insertion was hypothesized to result in a higher success rate, precise placement, and shorter times to placement. One hundred percent of the PACs inserted with TEE guidance were positioned successfully in the proximal right pulmonary artery, which is the institutional preference. Although the combined technique resulted in greater precision, the clinical significance of this is unknown. The time to placement benefit was not confirmed by this study.

This article is the second of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to start this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; however, in some cases, these articles will target the use of perioperative echocardiography in general.

Aortic rupture and transection are constituents of the acute aortic syndrome. Injury to the thoracic aorta during motor vehicle crashes is associated with blunt chest trauma and rapid deceleration mechanisms. Type A dissections and/or rupture of the aorta at the level of the aortic isthmus are the more common presentations of aortic injuries associated with motor vehicle crashes. We present the case of atypical echocardiographic findings of a nearly complete circumferential transection of the proximal ascending aorta injury after a motorcycle crash.

Objectives To assess the change in 3-dimensional (3D) echocardiography–derived right ventricular volumes before and after pulmonary thromboendarterectomy (PTE) and to evaluate the correlation of these variables with right heart catheterization–calculated pulmonary vascular resistance (PVR). Setting Single university hospitals. Participants Patients undergoing elective PTE surgery between November 2016 and February 2018. Methods All patients received a pulmonary artery catheter and arterial line, and transesophageal echocardiographic monitoring was performed. Transesophageal echocardiographic monitoring before surgery (pre-PTE) and postsurgery (post-PTE) included comprehensive 2D examinations and 3D right ventricular data set acquisition for offline volumetric analysis. Right ventricular fractional area of change (RVFAC) was measured from a right ventricular–focused midesophageal 4-chamber view. TomTec-Arena 4D RV-Function 2.0 offline software (TomTec Imaging Systems GmbH, Unterschlessheim, Germany) was used to measure right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV), and right ventricular ejection fraction (RVEF). Paired t tests were used to evaluate for differences before and after surgery, and echocardiographic variables versus PVR were analyzed with linear regression. Results Forty patients were scheduled for elective PTE surgery; 35 patients had complete hemodynamic profiles and echocardiographic data sets and were included in the evaluation. Mean pulmonary artery pressure decreased from 40 ± 11 to 28 ± 7 mmHg, and PVR decreased from 708 ± 432 to 285 ± 136 dynes*s/cm5 after PTE. RVEDV decreased from 106 ± 43 to 79 ± 35 cm3 (p Conclusion Even though RVEDV and RVESV displayed a statistically significant change after PTE, this study did not identify a correlation between those variables and PVR. In addition, markers of right ventricular systolic function (eg, RVFAC and RVEF) did not correlate with PVR. Therefore, the authors conclude that even though these echocardiographic measurements quantified a statistically significant change after PVR reduction, they cannot be reliably used as a surrogate marker of success immediately after PTE.

We appreciate the interest in our study [(1)][1] of short-term outcomes of incidental lead thrombi during lead extraction by Dr. Sadek and colleagues and read with great interest their experience using intracardiac echocardiography (ICE) to guide transvenous lead extraction [(2)][2]. Similar to our

Objective To evaluate the success and complication rates of a single center’s multidisciplinary approach to transvenous lead extraction. Setting One university hospital. Participants One hundred ninety-five patients scheduled for transvenous lead extraction. Interventions A multidisciplinary approach to transvenous lead extraction involving cardiac surgery, electrophysiology, perfusion, and cardiac anesthesiology. Measurements and Main Results A case series of 351 lead extractions performed in 195 patients over a 42-month period. Indications, success rates, and complication rates were tracked and retrospectively evaluated and reported. Indications for lead extraction included 53.3% because of lead malfunction, 36.9% because of infection, with the remaining 9.7% from other categories such as venous stenosis. The lead extraction rate was 99.7%, with complete removal in 97.7%. The overall major complication rate was 3.08%. After an initial 1-year period of performing lead extractions, the overall major complication rate reduced to 1.23%. Conclusions Transvenous lead extraction generally is a safe procedure, but not without complications. A multidisciplinary approach involving cardiac surgery, electrophysiology, and cardiac anesthesiology allows for successful management and the ability to rapidly manage major complications.

Objective To assess the feasibility of pulmonary artery catheter placement using transesophageal echocardiography inclusive of a description of the technique. Design A prospective, proof-of-concept study. Setting Single university hospital. Participants Twenty patients with chronic thromboembolic pulmonary hypertension scheduled for pulmonary thromboendarterectomy. Interventions Pulmonary artery catheters were placed in 20 patients solely by transesophageal echocardiographic guidance. Measurements and Main Results Placement of the pulmonary artery catheter in the pulmonary artery with transesophageal echocardiography guidance in fewer than 10 minutes was considered successful placement. The time to placement was measured from advancement of the pulmonary artery catheter in the superior vena cava (20 cm) to a final location at the junction of the right pulmonary artery and main pulmonary artery. All 20 pulmonary artery catheters were placed successfully using transesophageal echocardiography guidance and the median time to placement was 43 seconds. In 9 of the 20 patients (45%), the catheter was placed successfully on the first attempt without any adjustments. However, in 9 others (45%), the catheter required manipulation under transesophageal echocardiography vision. In 3 patients (15%), the pulmonary artery catheter was observed to be coiled in the right atrium and in 1 instance (5%) manipulation of the catheter in the right ventricle was required to enter the outflow tract. Conclusions Transesophageal echocardiography is a viable adjunctive method to conventional pressure waveform placement of pulmonary artery catheters in potentially difficult patients.

One of the most useful applications of intra-operative 2D transesophageal echocardiography (TEE) in noncardiac surgery is qualitative assessment of myocardial function in acutely unstable patients. When hemodynamic instability occurs intraoperatively, TEE can serve as an adjunct to other modalities in diagnosing or ruling out an ischemic event. In fact, compared to other monitoring methods, regional wall motion abnormality (RWMA) observed on echocardiography is the most sensitive method for early detection of ischemic changes in the heart. In noncardiac surgery, this can be especially useful in patients with no existing invasive or detailed monitoring that shows a sudden change in clinical status. Knowledge of normal coronary anatomy and its myocardial distribution is key in determining the location of an ischemic event. Recognizing the attributes of a wall motion abnormality such as decreased wall excursion or decreased wall thickening is key in diagnosing ischemic events, while recognizing that not all wall motion abnormalities are ischemic events (e.g., pacing effect).

Objectives To evaluate the accuracy, precision, and trending of a new endotracheally sourced impedance cardiography-based cardiac output (CO) monitor (ECOM; ConMed Corp, Irvine, CA). Setting Two university hospitals. Participants Thirty patients scheduled for elective coronary artery bypass graft (CABG) surgery. Interventions All patients received a pulmonary artery catheter (PAC), arterial catheter, endotracheal CO monitor (ECOM), endotracheal intubation, and transesophageal echocardiographic monitoring. ECOM CO was compared with CO measured with pulmonary artery thermodilution, and left ventricular CO measured with transesophageal echocardiography. Measurements One hundred forty-five pairs of triplicate CO measurements using intermittent bolus pulmonary artery thermodilution (TD) and ECOM were compared at 5 distinct time points: postinduction, postinduction passive leg raise, poststernotomy, post-CABG completion, and post–chest closure. Eighty-seven pairs of triplicate CO measurements using transesophageal echocardiography were obtained at 3 time points: postinduction, post-CABG completion, and post–chest closure and compared with ECOM- and PA-derived CO measurements. The measurements at each time point were compared by using Bland-Altman and polar plot analyses. Results The mean CO ranged from 2.16 to 9.41 L/min. ECOM CO, compared with TD CO, revealed a bias of 0.02 L/min, 95% limits of agreement of −2.26 to 2.30 L/min, and a percent error of 50%. ECOM CO showed trending with TD CO with 91% and 99% of values within 0.5L/min and 1 L/min limits of agreement, respectively. ECOM CO, compared with TEE CO, revealed a bias of −0.25 L/min, 95% limits of agreement of −2.41 to 1.92 L/min, and a percent error of 48%. ECOM CO showed trending with TEE CO with 83% and 95% of values within 0.5L/min and 1 L/min limits of agreement, respectively. Conclusion ECOM CO shows an acceptable bias with wide limits of agreement and a large percent error when compared with TD CO or TEE CO; however, it shows acceptable trending of CO to both modalities in patients undergoing cardiac surgery. Further studies are required to evaluate ECOM in other patient populations and clinical situations.