Mechanical Discordance between Left Atrium and Left Atrial Appendage

During standard transesophageal echocardiographic examinations in sinus rhythm (SR) patients, the left atrial appendage (LAA) is not routinely assessed with Doppler. Despite having a SR, it is still possible to have irregular activity in the LAA. This situation is even more important for SR patients where assessment of the left atrium is often foregone. We describe a case where we encountered this situation and briefly review how to assess the left atrium and its appendage in such a case scenario

Evaluation of the quality of transesophageal echocardiography images and verification of proficiency

Various metrics have been used in curriculum-based transesophageal echocardiography (TEE) training programs to evaluate acquisition of proficiency. However, the quality of task completion, that is the final image quality, was subjectively evaluated in these studies. Ideally, the endpoint metric should be an objective comparison of the trainee-acquired image with a reference ideal image. Therefore, we developed a simulator-based methodology of preclinical verification of proficiency (VOP) in trainees by tracking objective evaluation of the final acquired images. We utilized geometric data from the simulator probes to compare image acquisition of anesthesia residents who participated in our structured longitudinal simulator-based TEE educational program vs ideal image planes determined from a panel of experts. Thirty-three participants completed the study (15 experts, 7 postgraduate year (PGY)-1 and 11 PGY-4). The results of our study demonstrated a significant difference in image capture success rates between learners and experts (χ2 = 14.716, df = 2, P < 0.001) with the difference between learners (PGY-1 and PGY-4) not being statistically significant (χ2 = 0, df = 1, P = 1.000). Therefore, our results suggest that novices (i.e. PGY-1 residents) are capable of attaining a level of proficiency comparable to those with modest training (i.e. PGY-4 residents) after completion of a simulation-based training curriculum. However, professionals with years of clinical training (i.e. attending physicians) exhibit a superior mastery of such skills. It is hence feasible to develop a simulator-based VOP program in performance of TEE for junior anesthesia residents

The Management of Antiplatelet Therapy in Patients With Coronary Stents Undergoing Noncardiac Surgery

Whereas the development of coronary stents has been a major breakthrough in the treatment of coronary artery disease, stent thrombosis, associated with myocardial infarction and death, has introduced a new challenge in the care of patients with coronary stents undergoing noncardiac surgery. This review presents the authors’ recommendations regarding the optimal management of such patients. Elective surgery should be postponed for at least 6 weeks and optimally 3 months for a bare-metal stent and at least 1 year for a drug-eluting stent. On the other hand, managing a patient undergoing non-elective surgery is more difficult and necessitates a case-by-case assessment of bleeding risk versus thrombotic risk based on patient comorbidities, type of stents present, details of the coronary intervention, and type of surgical procedure. Patients with a risk of bleeding that outweighs the risk of stent thrombosis should discontinue at least clopidogrel, whereas all other patients should continue dual antiplatelet therapy throughout the perioperative period.</jats:p

A Practical Approach to Echocardiographic Assessment of Perioperative Diastolic Dysfunction

The Doppler assessment of diastolic dysfunction (DD) is not part of a standard comprehensive intraoperative echocardiographic examination. Although the reasons may be many, the lack of a simplified algorithm for the assessment of DD specific to the perioperative arena, the implications of this diagnosis on clinical care, and the absence of therapeutic options are some of the commonly cited reasons. In this article, the authors address these possible reasons for the lack of routine application of Doppler indices to assess perioperative DD. The authors have chosen to highlight some of the most common conceptual questions, which often have been raised by anesthesiologists, and attempted to suggest answers. Drawing from their experience and data, the authors propose a simplified algorithm for the application of Doppler to assess and diagnose DD with an individualized and a mechanistic approach. The proposed algorithm is from within the premise of the published guidelines and attempts to simplify the perioperative approach. The authors hope this approach will be simple enough for routine application to affect therapy and a tangible change in outcome. The authors suggest that knowledge of left atrial size is valuable as a marker for persistently increased left ventricular end-diastolic pressure and its possible role in risk stratification. (C) 2012 Elsevier Inc. All rights reserved