Intraoperative Transesophageal Echocardiography for the Evaluation and Management of Diastolic Dysfunction in Patients Undergoing Cardiac Surgery: A Survey of Current Practice

doi:10.1053/j.jvca.2015.11.002

Journal of Cardiothoracic and Vascular Anesthesia

Volume 30, Issue 2, April 2016, Pages 389-397

https://doi.org/10.1053/j.jvca.2015.11.002 Get rights and content

Objectives

To characterize existing practice patterns for intraoperative evaluation and grading of diastolic dysfunction in patients undergoing cardiac surgery.

Design

A 14-question, multiple-choice survey of current practice for patients with diastolic dysfunction and the use of intraoperative transesophageal echocardiography (TEE) to evaluate, grade, and monitor changes in diastolic function.

Setting

Online survey.

Participants

Members of the Society of Cardiovascular Anesthesiologists.

Interventions

None.

Measurements and Main Results

Of 515 respondents, there was a near-even spread between those based in an academic setting (53%) and those based in private practice (43%). Most respondents (81%) had completed training with certification in TEE. Most respondents (86%) currently modified their intraoperative management, at least some of the time, if they believed a patient was experiencing diastolic dysfunction, with 72% varying the nature of any modification according to the identified grade of diastolic dysfunction. Although 62% of respondents usually evaluated diastolic dysfunction in the pre-bypass period, only 59% of those evaluating diastolic dysfunction typically graded the dysfunction, with a variety of algorithms used for this purpose. The majority of respondents (62%) typically did not re-evaluate diastolic function using TEE in the post-bypass period. In 2 sample patients with Doppler data provided, there was marked variation in grading of diastolic dysfunction by respondents; this variation remained marked even within subgroups of respondents who typically used the same grading algorithm.

Conclusions

Marked variation currently exists in how intraoperative TEE is used to evaluate, grade, and monitor diastolic function during cardiac surgery. This suggests clinically important knowledge gaps that should be addressed.

Section snippets

Materials and Methods

The Human Research and Ethics Committee of the authors’ institution approved the survey before distribution with a waiver of the requirement for written informed consent.

Results

The survey was completed, in whole or in part, by 515 respondents. A slight majority of respondents (53%) identified their predominant cardiac anesthesia practice as academic or university based, whereas 43% identified their predominant cardiac anesthesia practice as private practice. The great majority of respondents (81%) had completed training with advanced TEE training and certification; annual cardiac anesthesia caseload was reported as>50 for 82% of respondents and>100 for 49% of

Discussion

In a survey of the SCA membership, 86% of respondents reported modifying their intraoperative management strategy in adult patients undergoing cardiac surgery if they believed the patient was experiencing diastolic dysfunction, with the majority varying the nature of that modification according to identified grade of diastolic dysfunction. Although the majority of respondents typically used intraoperative TEE to evaluate diastolic dysfunction, there was wide variation in the specific algorithm

Conclusions

In a survey of current practice, the authors identified marked variation in the use and interpretation of TEE for the intraoperative evaluation of diastolic function. Despite limited evidence to support its validity and guide its use for this purpose, a significant proportion of respondents currently modified their perioperative management strategy based on an intraoperative evaluation of diastolic function using TEE. There is an urgent need for high-quality, generalizable evidence to determine

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Cited by (14)

International Survey on Perioperative Management of Patients With Infective Endocarditis
2023, Journal of Cardiothoracic and Vascular Anesthesia
To estimate the current practice in the perioperative management of patients undergoing cardiac surgery due to infective endocarditis.
A prospective, open, 24-item, web-based cross-sectional survey.
Online survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC).
Members of the EACTAIC.
None.
A total of 156 responses from 44 countries were received, with a completion rate of 99%. The response rate was 16.6%. Most respondents (76%) practiced cardiac anesthesia in European hospitals, and most respondents stated that a multidisciplinary endocarditis team was not established at their center, that cardiac anesthesiologists appeared to be involved infrequently in those teams (36%), and that they were not involved in decision-making on indication and timing of surgery (88%). In contrast, the cardiac anesthesiologist performed intraoperative antibiotic therapy (62%) and intraoperative transesophageal echocardiography (90%). Furthermore, there was a relative heterogeneity concerning perioperative monitoring, as well as for coagulation and transfusion management.
This international survey evaluated current practice among cardiac anesthesiologists in the perioperative management of patients with infective endocarditis and the anesthesiologist's role in multidisciplinary decision-making. Heterogeneity in treatment approaches was identified, indicating relevant knowledge gaps that should encourage further clinical research to optimize treatment and postoperative outcomes in this specific population.
Potential Renoprotective Strategies in Adult Cardiac Surgery: A Survey of Society of Cardiovascular Anesthesiologists Members to Explore the Rationale and Beliefs Driving Current Clinical Decision-Making
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Pragmatic suggestions to explore for evidence of such bias include comparing the demographics of respondents with the known demographics of the target population.31 Demographics of respondents to the current survey (academic v private practice, case volume, level of training and geographic location) appear broadly comparable to that reported by a selection of previously published surveys of the SCA membership, supporting the absence of identifiable nonresponder bias within these domains.27-29 Anesthesiologists have been affected variably by the coronavirus disease 2019 pandemic, including increased workload with high-risk exposure for some, and a decreased workload for others.32
The authors sought to (1) characterize the rationale underpinning anesthesiologists’ use of various perioperative strategies hypothesized to affect renal function in adult patients undergoing cardiac surgery, (2) characterize existing belief about the quality of evidence addressing the renal impact of these strategies, and (3) identify potentially renoprotective strategies for which anesthesiologists would most value a detailed, evidence-based review.
Survey of perioperative practice in adult patients undergoing cardiac surgery.
Online survey.
Members of the Society of Cardiovascular Anesthesiologists (SCA).
None.
The survey was distributed to more than 2,000 SCA members and completed in whole or in part by 202 respondents. Selection of target intraoperative blood pressure (and relative hypotension avoidance) was the strategy most frequently reported to reflect belief about its potential renal effect (79%; 95% CI: 72-85). Most respondents believed the evidence supporting an effect on renal injury of intraoperative target blood pressure during cardiac surgery was of high or moderate quality. Other factors, including a specific nonrenal rationale, surgeon preference, department- or institution-level decisions, tradition, or habit, also frequently were reported to affect decision making across queried strategies. Potential renoprotective strategies most frequently requested for inclusion in a subsequent detailed, evidence-based review were intraoperative target blood pressure and choice of vasopressor agent to achieve target pressure.
A large number of perioperative strategies are believed to variably affect renal injury in adult patients undergoing cardiac surgery, with wide variation in perceived quality of evidence for a renal effect of these strategies.
Left Atrial Strain as a Single Parameter to Predict Left Ventricular Diastolic Dysfunction and Elevated Left Ventricular Filling Pressure in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Still, the need to measure multiple parameters is a major challenge in accurately following the ASE/EACVI 2016 LVDD guidelines. Among cardiac anesthesiologists, marked variations currently exist to evaluate, grade, and monitor LVDD during cardiac surgery in a busy perioperative setting, as observed by Mcllory et al. in a recent survey.8 All these multiple parameters are difficult to obtain in busy perioperative settings; therefore, there is an unmet need for a single parameter that can guide quick assessment of LVDD and LVFP to assist with dynamic decision-making in the perioperative period.
Left ventricular diastolic dysfunction (LVDD) is very common among patients undergoing cardiac surgery and is associated with increased mortality and morbidity. The present study tested the hypothesis of whether left atrial strain (LAS) can be used as a single parameter to predict LVDD (per 2016 LVDD evaluation guidelines) and elevated left ventricular filling pressure (LVFP) (ie, LVDD grades II and III) in patients scheduled for off-pump coronary artery bypass grafting (OPCABG) surgery.
A prospective observational study.
Tertiary-care level hospital.
The study comprised 60 patients undergoing elective OPCABG.
None.
Transthoracic echocardiography was performed within 24 hours of surgery by an anesthesiologist. LVDD was graded per American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations for 2016 LVDD guidelines. Left atrial (LA) function was evaluated using two-dimensional strain measurements obtained with the speckle-tracking echocardiography technique. Receiver operating characteristic curves were constructed, and the area under the curve was derived for the prediction of elevated LVFP by LAS.
Fourteen (23.3%) patients had elevated LVFP. Global LA reservoir strain (LAS_r) reduced significantly as the LVDD grade worsened (28.9% ± 8.3%, 21.8% ± 7.2%, 15.6% ± 4.5% and 11.9% ± 1.3%, respectively, for normal LV diastolic function and grades I, II, and III LVDD; p < 0.0001). Similar trends were noted for other components of LAS; namely, global LA conduction, global LA contraction strain, and LAS rate. The ability to predict high LVFP with LAS_r was statistically significant, with an area under the receiver operating characteristic curve of 0.92 (confidence interval 0.82-0.97; p < 0.001), and a Youden's index for LAS_r of 19% was obtained with 85.71% sensitivity and 84.78% specificity. The ability of LAS and its components to predict increased LVFP in various subpopulations (normal v reduced ejection fraction) yielded statistically significant results.
In patients scheduled for OPCABG, cardiac anesthesiologists successfully could measure LAS with speckle-tracking echocardiography in the preoperative period. LAS as a single parameter was significantly associated with the grade of LVDD. LAS_r decreased significantly with worsening grade of LVDD. Furthermore, an LAS_r value <19% significantly predicted a high LVFP, and LAS_r predicted high LVFP in both preserved and reduced ejection fraction equally well.
Management of Challenging Cardiopulmonary Bypass Separation
2020, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Separation from CPB may be challenged by diastolic dysfunction. The hallmark of diastolic dysfunction is the inability of the ventricle to accept an adequate volume of blood, despite a normal preload.101 As a result, myocardial contractility is reduced but maintains a normal or almost normal systolic function.
SEPARATION from cardiopulmonary bypass (CPB) after cardiac surgery is a progressive transition from full mechanical circulatory and respiratory support to spontaneous mechanical activity of the lungs and heart. During the separation phase, measurements of cardiac performance with transesophageal echocardiography (TEE) provide the rationale behind the diagnostic and therapeutic decision-making process. In many cases, it is possible to predict a complex separation from CPB, such as when there is known preoperative left or right ventricular dysfunction, bleeding, hypovolemia, vasoplegia, pulmonary hypertension, or owing to technical complications related to the surgery. Prompt diagnosis and therapeutic decisions regarding mechanical or pharmacologic support have to be made within a few minutes. In fact, a complex separation from CPB if not adequately treated leads to a poor outcome in the vast majority of cases. Unfortunately, no specific criteria defining complex separation from CPB and no management guidelines for these patients currently exist. Taking into account the above considerations, the aim of the present review is to describe the most common scenarios associated with a complex CPB separation and to suggest strategies, pharmacologic agents, and para-corporeal mechanical devices that can be adopted to manage patients with complex separation from CPB. The routine management strategies of complex CPB separation of 17 large cardiac centers from 14 countries in 5 continents will also be described.
Is Intraoperative Strain Analysis for Left Ventricular Diastolic Function Practical?
2019, Journal of Cardiothoracic and Vascular Anesthesia
Multicenter International Survey on the Clinical Practice of Ultra-Fast-Track Anesthesia with On-Table Extubation in Pediatric Congenital Cardiac Surgery
2019, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
The majority of these centers were located in both European countries (United Kingdom and Turkey) and non-European countries (India and Bahrain); therefore, geographic influences seem to be of lesser importance for this reluctance. The present survey had a relatively high response rate of 63%, which is significantly greater than in other online surveys in the field of cardiac anesthesia, including 28%, 14%, and 13% for surveys on perioperative fluid management,24 current use of the pulmonary artery catheter,25 and management of diastolic dysfunction,26 respectively. Assessing practice is difficult because it usually varies, not only from institution to institution but also among physicians, even those in the same division.
To describe global practices for on-table extubation (OTE) in pediatric cardiac anesthesia in European and non-European countries.
Multiple-choice, web-based survey with 34 questions addressing organizational data, existence of OTE programs, inclusion and exclusion criteria for OTE, and intraoperative and immediate postoperative management.
Online survey endorsed by the European Association of Cardiothoracic Anesthesiologists.
Anesthesiologists departments in European and non-European pediatric cardiac surgical centers.
None.
The survey was sent to 144 pediatric cardiac surgical centers in 29 countries as a web-based questionnaire. Addressees were pediatric cardiac anesthesiologists who were members of European Association of Cardiothoracic Anesthesiologists or were known to the authors. The response rate was 63%. Fifty percent of the respondents were practicing in university hospitals. The survey demonstrated that 76% of the respondents practiced OTE, with 50% of the pediatric cardiac anesthesiologists regularly performing OTE in different proportions, ranging from 1 to 51% of on-pump pediatric cardiac surgeries. Seventy-seven percent of respondents made their decision to perform OTE on an individual case-by-case basis. Seventy-eight percent of the congenital cardiac lesions deemed eligible for OTE fell into Risk Adjustment for Congenital Heart Surgery-1 categories 1 and 2. In patients for whom OTE was planned, anesthesia primarily was maintained using a combined inhalational and intravenous technique. The main reasons not to perform OTE were that it was deemed to provide no major advantage (45%), to be dangerous (9%), or to decrease operating room efficiency by increasing operating room turnover time (36%).
The survey demonstrated that the majority of the approached pediatric cardiac anesthesiologists practice OTE regularly in pediatric cardiac surgery. Frequency of OTE and inclusion criteria vary widely. The observations made in this survey should prompt appropriately powered, randomized controlled clinical trials to examine the effect of OTE on various effectiveness and safety outcomes.

View all citing articles on Scopus

: This work was supported by intramural funding from the Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia.

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Original ArticleIntraoperative Transesophageal Echocardiography for the Evaluation and Management of Diastolic Dysfunction in Patients Undergoing Cardiac Surgery: A Survey of Current Practice

Objectives

Design

Setting

Participants

Interventions

Measurements and Main Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Conclusions

Br J Anaesth

J Am Coll Cardiol

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Am Soc Echocardiogr

Br J Anaesth

J Am Soc Echocardiogr

Original Article
Intraoperative Transesophageal Echocardiography for the Evaluation and Management of Diastolic Dysfunction in Patients Undergoing Cardiac Surgery: A Survey of Current Practice