[Transesophageal echocardiography for non-cardiac surgery patients: superfluous luxury or essential diagnostic tool?].
Jörg BrederlauMarkus KredelThomas WurmbJerald F. DirksUlrich SchwemmerJens BroscheitNorbert RoewerGreim Ca
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Intravascular volume status
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Echocardiography is one of the diagnostic tools that can be applied at the bedside, along with avoiding transporting critically ill patients. This prospective observational study was designed to assess the clinical applicability of the transthoracic echocardiography (TTE) device by noncardiologist intensivists.Intensivists performed a limited TTE examination on critically ill patients admitted to the surgical intensive care unit (ICU). After initial cardiac clinical assessment in 85 critically ill adult patients, a limited TTE was performed by an intensivist to assess left ventricular (LV) function and LV volume status as well as valvular function and qualitative factors. Data were analyzed and presented in proportions using descriptive statistics. The setting was in surgical ICU of an academic medical center.Valvular abnormalities (44.8%) as well as qualitative indices (68.3%) were the most frequently detected abnormalities. The ejection fraction was the only alteration, which was affected by the risk factors (P = 0.05, mean = 55.57).Transthoracic approach can provide useful information on cardiac anatomy and function in most ICU patients along with detecting severe previously unknown conditions in some patients.
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The purpose of this report is to review the role of echocardiography in the selection of patients for percutaneous mitral commissurotomy (PMC). Echocardiography has become the standard for the assessment of the severity of mitral stenosis and of its consequences. PMC is usually performed only in patients with a valve area of < 1.5 cm 2 , whereas pulmonary hypertension or spontaneous echo contrast in the left atrium may lead to intervention in patients with few symptoms. The next step of the echocardiographic evaluation is to eliminate contraindications: left atrial thrombosis (by the systematic performance of a transesophageal examination before PMC), mitral regurgitation ≥ 2/4, severe aortic valve disease, mixed tricuspid valve disease, and massive or bicommissural calcification. Finally, echocardiography allows the classification of patients into different anatomic groups for prognostic consideration. There is controversy regarding the best echo score system in the prediction of the results of PMC. Scores using a global evaluation of the valve anatomy are the most widely used, whereas more recently, scores taking into account the uneven distribution of the disease have had promising preliminary results. Overall, echo scores are useful criteria for selecting candidates for PMC, but they should be considered together with the other clinical and procedural variables. Thus, echocardiography has an important role in the selection of patients for PMC, as well as for the guidance of the procedure, the evaluation of the results, and surveillance.
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Aims and objectives: To prospectively evaluate the impact of cardiopulmonary ultrasound (CPUS) on etiological diagnosis and treatment of critically ill acute respiratory failure (ARF) patients.Design: This is a prospective observational study conducted in a general intensive care unit (ICU) of a tertiary care center in India.Patients over 18 years old with presence of one of the objective criteria of ARF.Patients either consecutively admitted for ARF to ICU or already admitted to ICU for a different reason but later developed ARF during their hospital stay.Written informed consent in local language was obtained from next of kin.Interventions: All included patients underwent bedside CPUS including lung ultrasound (US) and transthoracic echocardiography plus targeted venous US by single investigator, blinded to clinical data.The US diagnosis of ARF etiology was shared with treating intensivist.Initial clinical diagnosis (ICD) and treatment plan (made before US) of each patient were compared with post-US clinical diagnosis and treatment plan.The changes in diagnosis and treatment up to 24 hours post-US were considered as impact of US.Results: Mean age of 108 included patients was 45.7 ± 20.4 years (standard deviation).The ICD was correct in 67.5% (73/108) cases, whereas the combined CPUS yielded correct etiological diagnosis in 88% (95/108) cases.Among the 108 included patients, etiological diagnosis of ARF was altered after CPUS in 40 (37%) patients, which included "diagnosis changed" in 18 (17%) and "diagnosis added" in 22 (20%).Treatment plan was changed in 39 (36%) patients after CPUS, which included surgical interventions in 17 (16%), changes in medical therapy in 12 (11%), and changes in ventilation strategy in 4 (3.5%)patients. Conclusion:This study demonstrates that use of combined US approach as an initial test in ARF, improves diagnostic accuracy for identification of underlying etiology, and frequently changes clinical diagnosis and/or treatment.
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Lutembacher syndrome (LS) is a rare cardiac abnormality characterized by any combination of a congenital or iatrogenic atrial septal defect (ASD) and a congenital or acquired mitral stenosis (MS). Clinical features and hemodynamic effects of LS depend on the balance of effects of the MS and the ASD. Prognosis is influenced by several factors [pulmonary vascular resistance, right ventricle (RV) compliance, size of ASD and MS severity] but the occurrence of secondary pulmonary hypertension and congestive heart failure is commonly associated with poor outcome. Echocardiography remains the gold standard for diagnosis and evaluation of LS. Timely diagnosis is critical for modifying the natural course, by allowing patients to benefit from currently available percutaneous trans-catheter therapies with favorable effects on the outcomes. This article is a review of published literature on the current diagnostic and therapeutic modalities for LS, focusing on the pivotal role of echocardiography as the key diagnostic tool. Clinical suspicion of LS should prompt extensive investigation with non-invasive and where possible, invasive technics. Multicenter registers have a potential to assist the evaluation of long term outcomes of percutaneous trans-catheter therapies in patients with LS.
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Objectives: To assess focused cardiac ultrasound impact on clinician hemodynamic characterization of patients with suspected septic shock as well as expert-generated focused cardiac ultrasound algorithm performance. Design: Retrospective, observational study. Setting: Single-center, noncardiac PICU. Patients: Less than 18 years old receiving focused cardiac ultrasound study within 72 hours of sepsis pathway initiation from January 2014 to December 2016. Interventions: Hemodynamics of patients with suspected septic shock were characterized as fluid responsive, myocardial dysfunction, obstructive physiology, and/or reduced systemic vascular resistance by a bedside clinician before and immediately following focused cardiac ultrasound performance. The clinician’s post-focused cardiac ultrasound hemodynamic assessments were compared with an expert-derived focused cardiac ultrasound algorithmic hemodynamic interpretation. Subsequent clinical management was assessed for alignment with focused cardiac ultrasound characterization and association with patient outcomes. Measurements and Main Results: Seventy-one patients with suspected septic shock (median, 4.7 yr; interquartile range, 1.6–8.1) received clinician performed focused cardiac ultrasound study within 72 hours of sepsis pathway initiation (median, 2.1 hr; interquartile range, –1.5 to 11.8 hr). Two patients did not have pre-focused cardiac ultrasound and 23 patients did not have post-focused cardiac ultrasound hemodynamic characterization by clinicians resulting in exclusion from related analyses. Post-focused cardiac ultrasound clinician hemodynamic characterization differed from pre-focused cardiac ultrasound characterization in 67% of patients (31/46). There was substantial concordance between clinician’s post-focused cardiac ultrasound and algorithm hemodynamic characterization (33/48; κ = 0.66; CI, 0.51–0.80). Fluid responsive (κ = 0.62; CI, 0.40–0.84), obstructive physiology (к = 0.87; CI, 0.64–1.00), and myocardial dysfunction (1.00; CI, 1.00–1.00) demonstrated substantial to perfect concordance. Management within 4 hours of focused cardiac ultrasound aligned with algorithm characterization in 53 of 71 patients (75%). Patients with aligned management were less likely to have a complicated course (14/52, 27%) compared with misaligned management (8/19, 42%; p = 0.25). Conclusions: Incorporation of focused cardiac ultrasound in the evaluation of patients with suspected septic shock frequently changed a clinician’s characterization of hemodynamics. An expert-developed algorithm had substantial concordance with a clinician’s post-focused cardiac ultrasound hemodynamic characterization. Management aligned with algorithm characterization may improve outcomes in children with suspected septic shock.
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Few obstetric-specific guidelines detail the indications for screening echocardiography in pregnancy. The objective of the study is to examine the association of common indications for maternal echocardiography with the likelihood of abnormality identification, pregnancy management alteration, and conformity with current American College of Cardiology Foundation (ACCF) guidelines.This retrospective cohort analysis categorized all echocardiograms performed within pregnancy and the first month postpartum within a tertiary health system to correlate indications with abnormal findings.Data from 226 echocardiograms were analyzed from 205 women. The most common indication for initial echocardiography was cardiac symptoms (34.6%). History of cardiac disease was the only indication demonstrating a significant association with an abnormal finding on initial echocardiography (odds ratio [OR]: 2.6; p = 0.006). Postpartum status (OR: 4.9; p < 0.001), multiparity (p < 0.001), and tobacco use (OR: 2.2; p = 0.011) were demographic characteristics associated with the identification of abnormal findings on initial echocardiography. Abnormal echocardiographic findings were associated with changes in clinical management but did not correlate with adverse obstetric or neonatal outcomes, which may support the impact of a multidisciplinary programmatic approach. ACCF appropriateness criteria correlated well with identification of abnormal echocardiographic results (p = 0.034).Although the presence of cardiac symptoms or history of diabetes failed to demonstrate association with abnormal echocardiographic findings, a history of prior cardiac disease, tobacco use, multiparity, and postpartum status were factors associated with identification of abnormal findings on initial maternal echocardiography. The ACCF appropriateness criteria for obtaining echocardiography can be applied to pregnant women with consideration for these additional risk factors.· The ACCF criteria are applicable in pregnancy for appropriateness of echocardiography indications.. · Several clinical factors often prompt performance of echocardiography in pregnancy without merit.. · Consideration for multiparty, tobacco abuse, and postpartum state should coincide with ACCF criteria..
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To assess the accuracy of findings from the clinical history, symptoms, signs and diagnostic tests (ECG, CXR and natriuretic peptides) in relation to the diagnosis of left ventricular systolic dysfunction (LVSD) in a primary care setting.Diagnostic accuracy systematic review, we searched Medline (1966 to March 2008), EMBASE (1988 to March 2008), Central, Cochrane and ZETOC using a diagnostic accuracy search filter. We included cross-sectional or cohort studies that assess the diagnostic utility of clinical history, symptoms, signs and diagnostic tests, against a reference standard of echocardiography. We calculated pooled positive and negative likelihood ratios and assessed heterogeneity using the I2 index.24 studies incorporating 10,710 patients were included. The median prevalence of LVSD was 29.9% (inter-quartile range 14% to 37%). No item from the clinical history or symptoms provided sufficient diagnostic information to "rule in" or "rule out" LVSD. Displaced apex beat shows a convincing diagnostic effect with a pooled positive likelihood ratio of 16.0 (8.2-30.9) but this finding occurs infrequently in patients. ECG was the most widely studied diagnostic test, the negative likelihood ratio ranging from 0.06 to 0.6. Natriuretic peptide results were strongly heterogeneous, with negative likelihood ratios ranging from 0.02 to 0.80.Findings from the clinical history and examination are insufficient to "rule in" or "rule out" a diagnosis of LVSD in primary care settings. BNP and ECG measurement appear to have similar diagnostic utility and are most useful in "ruling out" LVSD with a normal test result when the probability of LVSD is in the intermediate range.
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Thallium-201 myocardial perfusion scintigraphy assists in detecting coronary artery disease and assessing the significance of known stenoses. An adenosine infusion protocol is discussed in conjunction with presentation of results obtained in a community hospital setting. Primary indications for pharmacologic stress maneuvers include: Evaluation of patients unable or unwilling to exercise to adequate levels of workload and patients undergoing preoperative evaluation (particularly in patients undergoing vascular surgery). Experience in a community hospital setting attests to the safety of this pharmacologic protocol while showing a diagnostic accuracy similar to results reported in peer review literature. The method has been readily received by referring internists and cardiologists and is associated with a 21% increase in nuclear myocardial perfusion stress tests during the first six months of 1991.
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