Intraoperative Transesophageal Echocardiography: A Critical Appraisal of Its Current Role in the Assessment of Diastolic Dysfunction

McIlroy, David R.; Lin, Enjarn; Durkin, Chris

doi:10.1053/j.jvca.2015.01.009

Cited by 14 publications

(5 citation statements)

References 69 publications

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“…Averaged LV E/e′ = 9–12 was defined as diastolic dysfunction grade 2, and LV E/e′ ≥13 was defined at diastolic dysfunction grade 3. 16 The patients with LV systolic function preserved (LV EF ≥50%) diastolic dysfunction were enrolled in this study. For patients without preoperative echocardiographic examination, we performed a transthoracic echocardiography prior to surgery.…”

Section: Methodsmentioning

confidence: 99%

The Effects of Dexmedetomidine on Myocardial Function Assessed by Tissue Doppler Echocardiography During General Anesthesia in Patients With Diastolic Dysfunction

Lee

Kim

et al. 2016

Medicine

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Dexmedetomidine is a commonly used sedative and adjuvant agent to general anesthesia. The present was designed to evaluate the effects of dexmedetomidine on myocardial function by using tissue Doppler echocardiography during general anesthesia in patients with diastolic dysfunction.Forty patients undergoing orthostatic surgery with ejection fraction preserved diastolic dysfunction grade 2 or 3 were randomly allocated to the Control and Dex group (n = 20, each). In the Dex group, dexmedetomidine was given as an initial loading dose of 1.0 μg/kg over 10 minutes followed by a maintenance dose of 0.5 μg/kg/h. The ratio of peak early diastolic transmitral or transtricuspid inflow velocity to early diastolic mitral or tricuspid annular velocity (LV or RV E/e′) and left or right ventricular myocardial performance index (LV or RV MPI) were measured at before and after the administration dexmedetomidine or saline.The Dex group showed significant decrease of heart rate (P = 0.038), and increase of mean blood pressure (P < 0.001), LV E/e′ (P = 0.025), and LV MPI (P < 0.001) compared to those of the Control group on a linear mixed model analysis. Also, the Dex group showed significant increase of RV E/e′ (P < 0.001) and RV MPI (P = 0.028) compared to those of the Control group.Intraoperative dexmedetomidine administration during general anesthesia was appeared to deteriorate biventricular function in patients with diastolic dysfunction. We suggest careful consideration and a need for reducing dosage when administrating dexmedetomidine in patients with diastolic dysfunction.

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Section: Methodsmentioning

confidence: 99%

The Effects of Dexmedetomidine on Myocardial Function Assessed by Tissue Doppler Echocardiography During General Anesthesia in Patients With Diastolic Dysfunction

Lee

Kim

et al. 2016

Medicine

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“…Although measures of agreement typically assume the parameter of interest has not changed between measurements, the induction of anesthesia, commencement of positive pressure ventilation, and modest change in loading conditions may all have impacted diastolic function and its measurement, directly or indirectly. The net effect of these changes on grading diastolic dysfunction, however, is not well established 27 and the modest decline in MAP from TTE awake to TEE anesth pragmatically reflects conditions under which clinicians likely evaluate, interpret, compare, and act on their intraoperative assessment of diastolic dysfunction. 5 Moreover, the lack of recommendation to modify grading algorithms or their thresholds in the setting of TEE and anesthesia mean clinicians may be operating under the assumption that TTE awake and TEE anesth are interchangeable for this purpose.…”

Section: Discussionmentioning

confidence: 99%

Poor Agreement Between Preoperative Transthoracic Echocardiography and Intraoperative Transesophageal Echocardiography for Grading Diastolic Dysfunction

McIlroy,

Wettig,

Burton

et al. 2023

Anesthesia &Amp; Analgesia

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BACKGROUND: Guidelines for the evaluation and grading of diastolic dysfunction are available for transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) is used for this purpose intraoperatively but the level of agreement between these 2 imaging modalities for grading diastolic dysfunction is unknown. We assessed agreement between awake preoperative TTE and intraoperative TEE for grading diastolic dysfunction. METHODS: In 98 patients undergoing cardiac surgery, key Doppler measurements were obtained using TTE and TEE at the following time points: TTE before anesthesia induction (TTEawake), TTE following anesthesia induction (TTEanesth), and TEE following anesthesia induction (TEEanesth). The primary endpoint was grade of diastolic dysfunction categorized by a simplified algorithm, and measured by TTEawake and TEEanesth, for which the weighted κ statistic assessed observed agreement beyond chance. Secondary endpoints were peak early diastolic lateral mitral annular tissue velocity (e’lat) and the ratio of peak early diastolic mitral inflow velocity (E) to e’lat (E/e’lat), measured by TTEawake and TEEanesth, were compared using Bland-Altman limits of agreement. RESULTS: Disagreement in grading diastolic dysfunction by ≥1 grade occurred in 43 (54%) of 79 patients and by ≥2 grades in 8 (10%) patients with paired measurements for analysis, yielding a weighted κ of 0.35 (95% confidence interval [CI], 0.19–0.51) for the observed level of agreement beyond chance. Bland-Altman analysis of paired data for e’lat and E/e’lat demonstrated a mean difference (95% CI) of 0.51 (−0.06 to 1.09) and 0.70 (0.07–1.34), respectively, for measurements made by TTEawake compared to TEEanesth. The percentage (95% CI) of paired measurements for e’lat and E/e’lat that lay outside the [−2, +2] study-specified boundary of acceptable agreement was 36% (27%–48%) and 39% (29%–51%), respectively. Results were generally robust to sensitivity analyses, including comparing measurements between TTEawake and TTEanesth, between TTEanesth and TEEanesth, and after regrading diastolic dysfunction by the American Society of Echocardiography (ASE)/European Association of CardioVascular Imaging (EACVI) algorithm. CONCLUSIONS: There was poor agreement between TTEawake and TEEanesth for grading diastolic dysfunction by a simplified algorithm, with disagreement by ≥1 grade in 54% and by ≥2 grades in 10% of the evaluable cohort. Future studies, including comparing the prognostic utility of TTEawake and TEEanesth for clinically important adverse outcomes that may be a consequence of diastolic dysfunction, are needed to understand whether this disagreement reflects random variability in Doppler variables, misclassification by the changed technique and physiological conditions of intraoperative TEE, or the accurate detection of a clinically relevant change in diastolic dysfunction.

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“…Knowledge of the particular stage of DD has clinical implications with the potential to modify therapy. [ 10 16 17 ] During the impaired relaxation phase, the mainstay of treatment is increasing preload and reducing heart rate to allow for adequate LV filling. Patients in the decreased compliance stage have an increased LA pressure at baseline, i.e., preload intolerant, thus requiring a careful perioperative fluid management and the judicious use of diuretics.…”

Section: Discussionmentioning

confidence: 99%

Monitoring diastolic dysfunction using a simplified algorithm in patients undergoing off - pump coronary artery bypass grafting surgery

Borde¹,

Asegaonkar²,

Apsingekar³

et al. 2016

Ann Card Anaesth

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Context:Left ventricle diastolic dysfunction (LVDD) is gaining importance as useful marker of mortality and morbidity in cardiac surgical patients. Different algorithms have been proposed for the intraoperative grading of DD. Knowledge of the particular grade of DD has clinical implications with the potential to modify therapy, but there is a paucity of literature on the role of diastolic function evaluation during off-pump coronary artery bypass grafting (OPCABG) surgery.Aims:The aim of this study was to monitor changes in LVDD using simplified algorithm proposed by Swaminathan et al. in patients undergoing OPCABG.Settings and Design:The study was conducted in a tertiary care level hospital; this was a prospective, observational study.Subjects and Methods:Fifty consecutive patients undergoing OPCABG were enrolled. Hemodynamic and echocardiographic parameters were measured at 6 stages in every patient namely after anesthetic induction (baseline), during left internal mammary artery (LIMA) to left anterior descending (LAD) grafting (LIMA → LAD), saphenous vein graft (SVG) to obtuse marginal (OM) grafting (SVG → OM), SVG to posterior descending artery (PDA) grafting (SVG → PDA), during proximal anastomosis of SVG to aorta, and postprotamine. The patients were classified in grades of LVDD as per simplified algorithm proposed by Swaminathan et al. using only intraoperatively measured E and E’.Results:The success rate of measurement and classification of LVDD was 98.92% (277 out of 280 measurements). The grades of LVDD varied significantly as per surgical steps with maximum downgrading occurring during OM and LAD grafting. During OM grafting, none of the patients had normal diastolic function while 29% of patients exhibited restrictive pattern (Grade 3 LVDD). Patients with normal baseline LV diastolic function also exhibited downgrading during OM and LAD grafting. Postprotamine, 37% of patients with normal baseline diastolic function continued to exhibit some degree of DD.Conclusions:The LVDD changes dynamically during various stages of OPCABG, which can be successfully monitored with simplified algorithm.

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Intraoperative Transesophageal Echocardiography: A Critical Appraisal of Its Current Role in the Assessment of Diastolic Dysfunction

Cited by 14 publications

References 69 publications

The Effects of Dexmedetomidine on Myocardial Function Assessed by Tissue Doppler Echocardiography During General Anesthesia in Patients With Diastolic Dysfunction

The Effects of Dexmedetomidine on Myocardial Function Assessed by Tissue Doppler Echocardiography During General Anesthesia in Patients With Diastolic Dysfunction

Poor Agreement Between Preoperative Transthoracic Echocardiography and Intraoperative Transesophageal Echocardiography for Grading Diastolic Dysfunction

Monitoring diastolic dysfunction using a simplified algorithm in patients undergoing off - pump coronary artery bypass grafting surgery

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