Looking inside the third generation left ventricular assist device using color doppler transesophageal echocardiography

HeartWare is a third-generation continuous flow left ventricular assist device (LVAD) and generates centrifugal pattern of blood flow. In the perioperative setting, interrogating the HeartWare devices is very difficult due to the interference of the Doppler by the impeller frequency and generation of the waterfall artifact. We present a case where using color Doppler a view “inside“ the impeller can be seen which corresponds to the centrifugal flow of blood. With time, these images can be looked into in pathological states such as pump thrombosis, to come to a more meaningful conclusion regarding the flow of blood within the centrifugal chamber. Newer technologies are constantly evolving to give us more meaningful insights into the flow of blood within the heart chambers. We believe similar technologies can be applied to see the flow of blood inside the LVAD devices

Paravertebral analgesia in transapical transcatheter aortic valve replacement.

INTRODUCTION: Transapical transcatheter aortic valve replacement is an option for patients who are not candidates for traditional aortic valve surgery but have severe aortic stenosis and unfavorable ileo-femoral anatomy. Epidural analgesia in these cases has been associated with improved morbidity and mortality. The following manuscript presents the findings of an initial clinical experience employing paravertebral analgesia for patients undergoing transapical transcatheter aortic valve replacement. METHODS: A retrospective review was performed of 61 transapical transcatheter aortic valve replacement cases over a two-year period from November 2012 through July 2014. Paravertebral analgesia was provided as left sided single injections covering 1-3 dermatome levels using 0.2% ropivicaine with supplemental clonidine to 48 patients. The following outcome metrics were collected: 1) peri-operative opiate administration, 2) rate of extubation in the operating room, 3) new atrial fibrillation, 4) duration of intensive care stay, 5) 30-day mortality. RESULTS: The mean opiate administration was less in patients with paravertebral analgesia (128.65mcg vs. 163.46mcg fentanyl, p value 0.05) and these patients were more frequently extubated in the operating room (83.3% vs. 46.2%, p-value 0.0107). Incidence of atrial fibrillation was less in patients who received paravertebral analgesia (18.8% vs. 75.0%, p-value 0.0048). There was a non-significant trend towards decreased intensive care stay in patients who received paravertebral analgesia (58.3 hrs vs 75.8 hrs, p value 0.35). There was no difference in 30-day mortality. No complications resulted from paravertebral analgesia. CONCLUSIONS: This is the first reported case series of paravertebral blockade in transapical transcatheter aortic valve replacement patients. The findings suggest that paravertebral single shot blocks are both safe and practical for use in this patient population. A formal prospective investigation of paravertebral analgesia in these patients is warranted

Paravertebral analgesia in transapical transcatheter aortic valve replacement.

INTRODUCTION: Transapical transcatheter aortic valve replacement is an option for patients who are not candidates for traditional aortic valve surgery but have severe aortic stenosis and unfavorable ileo-femoral anatomy. Epidural analgesia in these cases has been associated with improved morbidity and mortality. The following manuscript presents the findings of an initial clinical experience employing paravertebral analgesia for patients undergoing transapical transcatheter aortic valve replacement. METHODS: A retrospective review was performed of 61 transapical transcatheter aortic valve replacement cases over a two-year period from November 2012 through July 2014. Paravertebral analgesia was provided as left sided single injections covering 1-3 dermatome levels using 0.2% ropivicaine with supplemental clonidine to 48 patients. The following outcome metrics were collected: 1) peri-operative opiate administration, 2) rate of extubation in the operating room, 3) new atrial fibrillation, 4) duration of intensive care stay, 5) 30-day mortality. RESULTS: The mean opiate administration was less in patients with paravertebral analgesia (128.65mcg vs. 163.46mcg fentanyl, p value 0.05) and these patients were more frequently extubated in the operating room (83.3% vs. 46.2%, p-value 0.0107). Incidence of atrial fibrillation was less in patients who received paravertebral analgesia (18.8% vs. 75.0%, p-value 0.0048). There was a non-significant trend towards decreased intensive care stay in patients who received paravertebral analgesia (58.3 hrs vs 75.8 hrs, p value 0.35). There was no difference in 30-day mortality. No complications resulted from paravertebral analgesia. CONCLUSIONS: This is the first reported case series of paravertebral blockade in transapical transcatheter aortic valve replacement patients. The findings suggest that paravertebral single shot blocks are both safe and practical for use in this patient population. A formal prospective investigation of paravertebral analgesia in these patients is warranted

Late Clinical Presentation of Prosthesis-Patient Mismatch Following Transcatheter Aortic Valve Replacement.

Prosthesis-patient mismatch (PPM) is relatively common after aortic valve replacement (AVR) and generally is associated with reduced regression of left ventricular (LV) mass. PPM after valve-in-valve transcatheter aortic valve replacement (TAVR) was reported to be 38%. PPM generally is manifested clinically by dyspnea and echocardiographically by high transvalvular gradients. In this E-Challenge, the authors will review a case of a late clinical presentation of PPM 1-year following a valve-in-valve TAVR

Echocardiography in Pandemic: Front-Line Perspective, Expanding Role of Ultrasound, and Ethics of Resource Allocation

The grave clinical context of the coronavirus disease 2019 (COVID-19) pandemic must be understood. Italy is immersed in the COVID-19 pandemic. Most of the world will soon follow. The United States currently has the most documented cases of COVID-19 of any nation. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated acute cardiomyopathy is common in critical care patients and is associated with a high mortality rate. Patients with COVID-19 frequently require mechanical support for adequate oxygenation. A severe shortfall of ventilators is predicted. Of equal concern is the projected shortage of trained professionals required to care for patients on mechanical ventilation. Ultrasonography is proving to be a valuable tool for identifying the pulmonary manifestations and progression of COVID-19. Lung ultrasound also facilitates successful weaning from mechanical ventilation. Ultrasonography of the lung, pleura, and diaphragm are easily mastered by experienced echocardiographers. Echocardiography has an established role for optimal fluid management and recognition of cardiac disease, including SARS-CoV-2-associated acute cardiomyopathy. Cardiologists, anesthesiologists, sonographers, and all providers should be prepared to commit their full spectrum of skills to mitigate the consequences of the pandemic. We should also be prepared to collaborate and cross-train to expand professional services as necessary. During a declared health care crisis, providers must be familiar with the ethical principles, organizational structure, practical application, and gravity of limited resource allocation

Tissue doppler imaging (E/e\u27) and pulmonary capillary wedge pressure in patients with severe aortic stenosis

Objective: Although American and European consensus statements advocate using the ratio of the transmitral E velocity and tissue Doppler early diastolic mitral annular velocity (E/e\u27) in the assessment of left-sided heart filling pressures, recent reports have questioned the reliability of this ratio to predict left atrial pressures in a variety of disease states. The authors hypothesized that there is a clinically significant correlation between E/e\u27 and pulmonary capillary wedge pressure (PCWP) in patients with severe aortic stenosis. Design: Retrospective cohort study. Participants: The study comprised 733 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve replacement for severe aortic stenosis. Interventions: None. Measurements and main results: PCWP and E/e\u27ave (average of the lateral and medial annulus tissue Doppler velocities) were measured with a pulmonary artery catheter and transthoracic echocardiography during preprocedural evaluation. Patients were grouped by left ventricular ejection fraction (LVEF) ≥50% and LVEF \u3c50%. Spearman rank correlation, analysis of variance, and t and chi-square tests were used to analyze the data. Seventy-nine patients met the inclusion criteria. There was no significant correlation between E/e\u27ave and PCWP (n = 79, Spearman r = 0.096; p = 0.3994). This correlation did not improve when ventricular function was considered (LVEF \u3c50%: n = 11, Spearman r = -0.097; p = 0.776 and LVEF ≥50%: n = 68, Spearman r = 0.116; p = 0.345). There was no statistically significant difference in mean PCWP between each range of E/e\u27ave. Conclusion: A clinically relevant relationship between E/e\u27 and PCWP was not observed in patients with severe aortic stenosis

Tissue Doppler Imaging (E/e\u27) and Pulmonary Capillary Wedge Pressure in Patients With Severe Aortic Stenosis.

OBJECTIVE: Although American and European consensus statements advocate using the ratio of the transmitral E velocity and tissue Doppler early diastolic mitral annular velocity (E/e\u27) in the assessment of left-sided heart filling pressures, recent reports have questioned the reliability of this ratio to predict left atrial pressures in a variety of disease states. The authors hypothesized that there is a clinically significant correlation between E/e\u27 and pulmonary capillary wedge pressure (PCWP) in patients with severe aortic stenosis. DESIGN: Retrospective cohort study. PARTICIPANTS: The study comprised 733 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve replacement for severe aortic stenosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PCWP and E/e\u27 CONCLUSION: A clinically relevant relationship between E/e\u27 and PCWP was not observed in patients with severe aortic stenosis