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Transcript of TRANSTHORACIC ECHOCARDIOGRAPHY (TTE) - …ECHOCARDIOGRA… · TRANSTHORACIC ECHOCARDIOGRAPHY (TTE)...
TRANSTHORACICECHOCARDIOGRAPHY(TTE)AnoverviewforPerioperativeCare
DrAndrewCluer,Sydney,Australia2015Thispieceofworkisnotmeanttoteachstudentsechointerpretation,butinsteadoffersaninsightintointerpretationandgivesthereaderabroadunderstandingoftheusesandlimitationsofthispowerfultechnology.Itisimportanttorecognisefromtheoutsetthatechodatashouldbeconsideredinclinicalcontextandassuchisusefulwhenitcorroboratesclinicalsuspicionsandoftenmisleadingwhenusedinisolation.Thisisparticularlysowhenadoctorsays“Iknow,letsgetanecho”!Bothimagesandclipsareincludedforstudentinterest.Bywayofintroductionandforthosestudentswhohaveneverbeenintroducedtothetechnicalaspectsofultrasound,Wikipediaisonhandtohelp!Thislinkactsasagoodintroduction,butitisnotconsideredessentialreadingforthisechoreview.Ratherthepieceaddsvaluewherestudentswouldliketoreadmorewidely.https://en.wikipedia.org/wiki/Medical_ultrasoundIndicationsforrestingpreoperativetransthoracicechocardiogram(TTE)havebeenpublishedbytheEuropeanSocietyofCardiology(ESC)/EuropeanSocietyofAnaesthesiology(ESA),BritishSocietyofEchocardiography(BSE)andAmericanHeartAssociation(AHA)/AmericanCollegeofCardiology(ACC)(seelinksattheendofthedocument).ForeaseofreadingthedocumentshavebeensummarisedinTable1.Theseguidelinesareextremelyusefulbutitisworthnotingtheydonotadequatelyaddresssomeimportantissuessuchassuspectedorknownpulmonaryhypertension(PHT).Wheredeficientsupplementallinksareprovided.IngeneraltermstheadvantagesofrestingpreoperativeTransThoracicEchocardiography(TTE)innon-cardiacsurgicalpatientsarenotentirelyclear.Wijeysunderaetal.(2011)retrospectivelylookedatover260,000patientswhohadundergonemediumorhighrisknon-cardiacsurgeryandfoundthatpreoperativerestingTTEwasnotassociatedwitheitheradecreasedhospitalstayoranimprovedsurvival.Althoughretrospectivethisverylargestudysuggeststhatmuchmoreresearchneedstobedonetodefinewhichpatientsbenefitfromanincreasinglycommonpreoperativeinvestigation.ArelativelyrecenteditorialinAnaesthesia(Heyburn&McBrien2012)hasactuallyadvocatedrestingpreoperativeTTEforallpatientswithhipfracturesthoughtheserecommendationsarenotreflectedinanycurrentinternationalguidelines.DespitetheaboveitisgenerallyacceptedthatforspecificindividualsTTEcanhaveamajorimpactontheirperioperativeclinicalmanagement.TTEenablesrapidassessmentofcardiacstructureandfunction.IthascertainadvantagesoverTransoesophagealEchocardiography(TOE)includingsuperiorassessmentofaorticvalveareasandgradients,betterimagingoftheleftventricularapexandmoreaccurateassessmentofejectionfraction(EF%).Itisalsonon-invasive,quickerandinvolvesminimalrisktothepatient.IndicationsforTOEincludeimagingofthemitralvalvepriortocardiacsurgery,detailedassessmentofatrialstructures,
suspectedaorticdissectionandinvestigationofendocarditisandisrarelyindicatedintheperioperativeperiod.ItisimportanttounderstandthatTTEisa‘snapshot’atoneparticularpointintime.Thisisnotanissueineuvolaemic,hemodynamicallystablepatientsbutcanbeofrelevanceatothertimesintheperioperativeperiod.IntheunstablepatientmeasurementsmadeusingTTEcanchangerapidlyandaredependentonmanyfactorsincludingvolumeloading,inotropeuseandlungventilatorysettings.Itmaythereforebeappropriatetocarryoutserialexaminationsintheperioperativeperiod,echobeingusedasamonitorratherthanadiagnostictool.ItisalsoimportanttounderstandthatTTEisa‘snapshot’atrestandthereforehasaverylimitedroleinthepreoperativeassessmentofischaemicheartdisease.RecommendationsonpreoperativeimagingstresstestingareincludedintheESC/ESAandAHA/ACCdocumentsmentionedabove.Askilledechocardiographerwillalwaysacquireasetofstandardviewsandmeasurementshowever,theywillseektoobtainextrainformationdependentonthepatientinformationprovided.ItisthereforeessentialthatTTEreferralsstatetheclinicalquestiontobeanswered.Acomprehensiveechocardiographicassessmentofpulmonaryhypertensionisverydifferenttoanassessmentofaorticstenosis.AcasestudyinheartfailureMrsPisa60yearsoldladyreviewedinthesurgicalpre-assessmentclinicpriortoplannedOesophagectomyforcancer.Thepatientspastmedicalhistoryincludes:-
ParoxysmalAtrialFibrillation(anticoagulated)Non-InsulinDependentDiabetesMellitusNewonsetparoxysmalnocturnaldyspnoeaandorthopnoeaExercisetoleranceiscurrently50metresontheflatAsystolicmurmurisheardonauscultation
TheTTErequeststates–‘Pleaseassessbiventricularfunction,pulmonarypressuresandcheckforanyvalvularpathology’.MrsP’sTTEreportprovidesanoverallpictureofhercardiacstructureandfunction.Likeallreportsitshouldmakesenseclinicallyandtheindividualcomponentsmustfittogether.Forexample,severelyimpairedleftventricular(LV)systolicfunctionwillgenerallybeassociatedwithsomediastolicdysfunction,severemitralregurgitation(MR)willgenerallybeassociatedwithsignificantlyraisedpulmonarypressuresandsignificantdiastolicdysfunctionwillgenerallybeaccompaniedbyalargeleftatrium.AspectsofaTTEreportthatdonotmakeclinicalsenseimplysomeerrorsinmeasurementmayhavebeenmadeandshouldbeviewedwithsuspicion.UnderstandingtheoverallmessageanechocardiographerorcardiologististryingtoconveywithaTTEreportismoreimportantthansimplyfocusingonisolatednumberssuchasejectionfraction(EF%).ThereferencerangesofmostTTE
measurementsareaffectedbyageandsex.ManymeasurementsshouldalsobeindexedtoBodySurfaceArea(BSA)soapatient’sheightandweightshouldideallyberecorded(whenwasthelasttimeyouincludedthisdatainyourrequestforinvestigation?).ForexampleaLeftVentricularEndDiastolicDiameter(LVEDD)of6.0cmcanbenormalforalargemanbutveryabnormalforasmallwoman.TheBritishSocietyofEchocardiographysmartphoneapp.isfreetodownloadandisausefulreferencefornormalandabnormalvalues.
MedicalpractitionersoftenviewaTTEreportasabewilderingarrayofdataandfocusonlyontheshortwrittenconclusionwhichcanoccasionallybefalselyreassuring.ItisimportanttounderstandthatanechocardiographerandclinicianmayregarddifferentaspectsofaTTEreportasbeingsignificant.Togetthemostoutofareportitisbettertotryandseparatethemeaningfuldatafromthelesshelpfulmeasurementsandgainadeeperunderstandingofalltheinformationprovided.ForexampleEF%(measuredbySimpsonsBiplanetechnique)isavalidatedandreproduciblemeasurement,whereasEF%(measuredbyTeichholztechnique)isnot.AsummaryofthemostusefulmeasurementsonaTTEreportisprovidedinTable2andthefollowingdiscussionaimstoprovidesomeguidanceonhowtointerpretthedata.
Understandingthedetail:Aguidetoechointerpretation
Thedetailbelowisnotmeanttobememorised,ratherthestudentshouldbegintounderstandwhatelementsoftheinvestigationaregloballyassessed(oftenwiththeexperiencedeyeball)andwhicharemeasured.Forbothelementsofassessmentitisimportanttoappreciatethescopeforerror.
1. LEFTVENTRICLE:Assessmentoftheleftventricleshouldbedividedintostructureandfunction(systolicanddiastolic).
Structure-ThemostimportantaspectsofLVstructurearesizeandwallthickness.BotharemeasuredatenddiastoleonaParasternalLong-AxisView(PLAX)(Video1-PLAX)Thethicknessoftheinterventricularseptum(IVS)andposteriorwall(PW)isroutinelyreportedalongwithanyotherabnormalitiessuchasasymmetrichypertrophyorscarredmyocardium.StructureoftheLValsoincludesotherpathologysuchasthrombusorseptaldefects.Simple2-Dmeasurements(seewikilinktounderstandthesemodesofimaging)aregenerallymoreaccuratethanM-Mode,whichcanoverestimatetheLVdiameterifnotcareful.Itisimportanttonotethatisolatedbasalseptalhypertrophycanbeanormalfindingintheelderlyandshouldnotbeconfusedwithhypertrophiccardiomyopathy.
MrsP:LVDiastolicDiameter=5.6cm,IVS=0.9cm,PW=1.0cm.Conclusion=mildlydilatedLVwithnormalwallthickness.(Image1–LVSize&WallThickness)
Image1
SystolicFunction-LVsystolicfunctioncanbegloballyorregionallyimpaired.QuantificationofsystolicfunctionisbestachievedbycalculatinganEF%usingSimpson’sBiplanemethod.ViewsrequiredaretheApical4Chamber(Video2–A4C)andApical2Chamber(Video3-A2C).OnoccasionsanexperiencedechocardiographerwillvisuallyestimatetheEF%orsimplyquantifysystolicfunctionasgoodoverallfunctionormild,moderateorsevereimpairment.ItisaninterestingandimportantfactthatvisualestimatesbyexperiencedpractitionersareasusefulasacalculatedEF%.Regionalwallmotionabnormalities(RWMA)usuallyimplyischaemicheartdiseaseandtheirdistributionoftenassistsindeterminingthespecificcoronaryarteryaffected.Forexample,anakineticLVapexandanteriorseptumislikelysecondarytodiseaseoftheleftanteriordescendingcoronaryartery.RWMAcanbesubtleanddifficulttoidentifyandthereareoftenvariationsinreportingbetweenechocardiographers.Segmentalbasalinferiorandinferoseptalhypokinesisiscommonlyreportedandoflittlesignificance.Apicalakinesisshouldalwaysraisethesuspicionofathrombusandsomedepartmentswillroutinelyinvestigatewithacontraststudy.MrsP:LVEjectionFraction=20.2%.Conclusion=Global,severeimpairmentofsystolicfunction.(Image2,3,4&5)
Image5
DiastolicFunction(dysfunction-alternativelyknownasheartfailurewithpreservedejectionfraction).LVDiastolicfunctionassessmentiscomplexandinterestedreadersaredirectedtoESCguidelinesonthistopic(Linkprovidedattheendofthedocument).AnimportantdistinctiontomakeiswhetherthereisisolatedLVdiastolicdysfunctionordoesitaccompanyLVsystolicdysfunction.Traditionallydiastolicdysfunctionisgraded(1-4)usingDopplerpatternsfrommitralinflow(MitralEandAwaves)andtissueDopplerfromLVSeptal(E’SeptalVelocity)andLVLateralWalls(E’LateralVelocity).Grade1dysfunctionisdefinedasimpairedrelaxationwhereasGrade4dysfunctionisdefinedasirreversiblerestrictivedisease.Inthepresenceofnormalsystolicfunctionitisappropriatetogradediastolicdysfunctioninthismanner.Importantlytype1diastolicdysfunctionintheelderlyisanormalfinding.E/E’ratioisthemostusefulmeasurementandanE/E’Septal>15orE/E’Lateral>12isabnormal.DiastolicdysfunctionisgenerallyalwayspresentinpatientswithsignificantlyimpairedLVsystolicfunctionandinthissituationitmakesmoresensetotryandquantifyelevationsinleftatrialpressure.E/E’isusefulandwillincreaseasleftatrialpressure(LAP)increases.E/E’isthereforeadynamicmeasurementandchangeswithfluidloading.MrsP:MitralEtoLVE’SeptalRatio=39.4.Conclusion=SeverelyelevatedLAP(Image6–MitralE&AWaves,Image7-E’SeptalVelocity)
2.RIGHTVENTRICLE:Therightventricle(RV)isbestassessedqualitativelyforsize,structureandfunction.Fewquantitativemeasurementsareuseful.IftheRVisenlargedandhasnormalsystolicfunctionthenitislikelytobevolumeoverloaded(TricuspidRegurgitation(TR),PulmonaryRegurgitationorAtrialSeptalDefect).IftheRVisenlargedandhassignificantlyimpairedsystolicfunctionthenpossiblepathologyincludesRVpressureoverload,cardiomyopathyorinfarction.TricuspidAnnularPlaneSystolicExcursion(TAPSE)isoftenquotedasaquantitativemeasureofRVsystolicfunctionbutinrealityonlyreflectsbasalRVfunctionandprovidesnoinformationabouttheRVfreewall.MrsP:Qualitativecomment‘NormalRVsizeandmildlyimpairedsystolicfunction’(Video4-RV).TAPSE=1.5cm(Image8)CalculationofRightVentricularSystolicPressure(RVSP)orPulmonaryArterySystolicPressure(PASP)isrelativelyeasyandanextremelyusefulmeasurementintheassessmentofPHT.RVSP=4x(PeakTRVelocity)2+RightAtrialPressure(RAP).RAPisestimatedfromthesizeoftheInferiorVenaCava(IVC)anditscollapsibilityondeepinspiration(Video5–IVC).Itisimportanttonotethatpulmonaryhypertensionisdefinedbymeanpulmonaryarterypressure(linkprovided)andnotPASP(orRVSP)whichisquotedonaTTEreport.ComprehensiveechocardiographicassessmentofPHThasbeenoutlinedinanexcellentdocumentwrittenbyHammersmithHospitalCardiologyDepartment(linkprovided).MrsP:TRPeakVelocity=3.95m/sec,RAP=10mmHg.PASP=72.4mmHg.Conclusion=moderate/severeelevationinpulmonarypressures.(Video6–TRColourDoppler,Image9–PeakTRVelocity)
3.ATRIA:Atriaareconsideredasthe‘window’totheventricles.ForexamplethefirstsignofsignificantLVdiastolicdysfunctionisanenlargedleftatrium.Qualitativecommentsabouttheshapeoftheinteratrialseptumcanalsohelpwiththeassessmentofleftandrightatrialpressure.Volumetricmeasurementsaremostaccurate.MrsP:LAVolume=66.5mls.Conclusion=EnlargedLeftAtrium.(Image10–LAVolume)Image10
4.VALVES:Assessmentofeachvalveshouldbebystructureandfunction.Structureisusuallyassessedbyzoomed2DimageswhereasassessmentofvalvularfunctionrequiresDopplerinterrogationofbloodflowthroughthevalve.Dopplerinterrogationrequiresexcellenttechnicalskillsandoffaxismeasurements(misalignedDopplercursor)cansignificantlyunderestimatetrans-valvulargradients.ReferencerangesforallmeasurementscanbefoundontheBSEsmartphoneapp.Tricuspid&PulmonaryValves-TRandPRareusuallyassessedby‘eyeballing’thecolourDopplerregurgitantjet.MildTRandPRisofnoclinicalsignificance.SevereTRcausesflowreversalinthehepaticveins.Bothtricuspidandpulmonarystenosisisrarebuttrans-valvulargradientscanbemeasured.Ingeneralqualitativecommentsaboutthetricuspidandpulmonaryvalvesaresufficient.MrsP:Structurallynormaltricuspidvalvewithmoderateregurgitation.Structurallynormalpulmonaryvalvewithnoregurgitation.
AorticValve(AV)-SignificantaorticstenosisisusuallydiagnosedbytheappearanceofcalcifiedandrestrictedleafletsonPara-sternallongaxis(PLAX)andParasternalShortAxis(PSAX)views(Video7–PLAXAorticStenosis&Video8–PSAXAorticStenosis.BothvideosareprovidedasexamplesbutarenotrelevanttothecaseofMrsP).Thecontinuityequationisthemostaccuratemethodofestimatingaorticvalveareaandisgivenbytheequationbelow.ExtremelyaccuratemeasurementsfromtheLeftVentricularOutflowTract(LVOT)arerequired.ItisassumedthattheLVOTisacircleandthereforeLVOTareaissimplycalculatedusingtheformulaπr2.ImportantlysmallerrorsmeasuringtheLVOTdiameterorradiusaremagnifiedbecausethevalueisthensubsequentlysquaredinthecalculation.VelocityTimeIntegrals(VTI)areusuallycalculatedautomaticallybystandardsoftwareinstalledonmostultrasoundmachines.AorticValveArea=(LVOTVTIxLVOTArea)/AorticValveVTI(Images11–LVOTDiameter,Image12–LVOTVTI,Image13–AVVTI.TheseimagesareprovidedasexamplesbutarenotrelevanttothecaseofMrsP).PressuregradientsacrossastenoticvalvearealsousedtogradeseveritybuttheyaremorepronetoerrorandcanbeaffectedbyotherfactorssuchasLVsystolicfunction.InterestedstudentsaredirectedtotheESCguidelines(linkprovided).AorticregurgitationisassessedbyacombinationofmethodsincludingcolourandspectralDoppler.MrsP:Nomeasurementsneededasvalvenormal.Onlyaqualitativecomment‘Structurallynormaltrileafletvalvewithnosignificantregurgitation’Image11
Image12
MitralValve-Mitralstenosisis99%rheumaticinaetiologyandthevalvehasacharacteristic‘hockeystick’appearanceonPLAXview.MitralvalveareaisbestcalculatedbytracingaroundtheopenvalveleafletsinaPSAXview(planimetry)butinformationderivedfromDopplerinterrogationisalsouseful.Mitralregurgitation(Video9-MR)isthemostdifficultofvalvularlesionstoaccuratelyassessandinterrogationfromallparasternalandapicalviewsinrequired.ThemostaccuratewaytoquantifyMRisbycalculatingregurgitantvolumefrommeasurementofProximalIsovelocitySurfaceArea(PISA)oncolourDoppler(Image13-PISA).TheaetiologyofMRshouldalwaysbestatedandcanbedividedintoorganicorfunctionalcauses.MildMRisofnoclinicalsignificance.InterestedstudentsareagaindirectedtotheESCguidelines(linkprovided)MrsP:MRRegurgitantVolumePISA=43.9mls.Conclusion=ModeratefunctionalMRAORTA,PERICARDIUM&OTHERFINDINGS:Theaortacanbeassessedatmanypoints(ascending,arch,descending)usingTTE.Standardmeasurementsincludethewidthatthelevelofaorticsinuses.Pericardialeffusionsaremeasuredatenddiastoleandquantifiedassmall,moderateorlargehowever,sizeislessimportantthanwhetherthereareanyechocardiographicsignsofhemodynamiccompromiseasaresultofthepericardialeffusion.https://www.youtube.com/watch?v=eCZQig--5oQ
Image13
ManyadditionalfindingscanbeidentifiedonTTEincludingnon-cardiacpathologysuchaspleuraleffusionsandabdominalaorticaneurysms.SIGNIFICANTFINDINGSONPERIOPERATIVETTEInpatientsscheduledfornon-cardiacsurgeryitisalsohelpfultoconsiderthequestionofwhatconstitutesasignificantfindingonpreoperativerestingTTE.Significantfindingscanbeconsideredasthosewhichaffectperioperativeriskstratification,alterclinical(medical,anaestheticorsurgical)managementandattheextremeendofthescalethosefindingswhichleadtocardiacsurgicalinterventionpriortoundergoingnon-cardiacsurgery.Leftventricular(LV)systolicheartfailureisconsideredariskfactorforadverseperioperativecardiaceventsandisacomponentofseveralclinicalriskindices.Kazmersetal.(1988)foundanLVejectionfraction(EF)oflessthan35%tobethemostaccuratepredictorofadverseperioperativeeventsandthiswasconfirmedbyHammilletal.(2008).Matyaletal.(2009)showedthatdiastolicdysfunctionwasanindependentriskfactorforperioperativecongestiveheartfailureinastudyof313highriskpatientsundergoingvascularsurgery.However,moreresearchiscertainlyneededinthisparticulararea.Diastolicdysfunctionisoftennotassessedpreoperativelyanddoesnotfeatureonanycommonlyutilizedclinicalriskindicesandmaybeanevolvingpathologythatwewillbegintounderstandbetterinthefuture.
Withregardstovalvularfunctionitishelpfultoconsiderstenoticandregurgitantpathologyseparatelywithstenoticpathologybeingmorepoorlytoleratedbypatientsundergoingnon-cardiacsurgery.TheACC/AHAconsidersseverestenoticvalvulardisease(ASwithavalveareaof<1sqcmandsymptomaticmitralstenosis(MS))asoneoffouractivecardiacconditionsthatrequireevaluationandtreatmentpriortonon-cardiacsurgery.Theissuewithregardstovalvularregurgitationinpatientsundergoingnon-cardiacsurgeryismorecomplex.TheESC/ESAguidelines(DalbyKristensenetal.2014)advisethatasymptomaticpatientswithpreservedLVsystolicfunctionandseveremitralregurgitation(MR)oraorticregurgitation(AR)arenotatincreasedperioperativerisk.The2014ACC/AHAValvularHeartDiseaseGuidelines(Nishimuraetal.2014)statethatitisreasonabletoperformmoderaterisknon-cardiacsurgery,withappropriatehaemodymanicmonitoring,onpatientswithasymptomaticsevereMRandasymptomaticsevereARifEF%ispreserved.Althoughitmaybereasonabletoproceedwithsurgeryinthesecasespriordiagnosisandaccuratequantificationofvalvularregurgitationisclearlyessentialforperioperativeplanning.Inadditiontherewillbemanyotherfactorsthatdeterminehowanindividualpatientismanaged.Pulmonaryhypertension(PHT)isanotherareaofuncertaintywithmostevidencecomingfromobservationaldataofpatientswithpulmonaryarterialhypertension(Type1PHT).However,complicationratesareextremelyhighinthisgroupwithsignificantperioperativemorbidityandmortality.BoththeESC/ESAandACC/AHAmakeanumberofrecommendationsregardingtheperioperativemanagementofpatientswithPHTincludingthoroughevaluationandoptimisationbyaPHTspecialistpriortosurgery.Itisknownthatelevationsinrightatrialpressure(RAP)andreducedcardiacoutputaremoreimportantthanisolatedelevationsinrightventricularsystolicpressure(RVSP)astheformerarerepresentativeofrightventricular(RV)failure.AnRVSP>70mmHghas,neverthelessbeenidentifiedasariskfactorforadverseperioperativeevents(Minaietal.2014).Itisextremelyunlikelytherewilleverbeanystudieslookingatmajorincidentalfindingssuchasintra-cardiacmassorpericardialeffusiononpreoperativerestingTTEhowever,itwouldseemlogicaltoconsiderthesefindingssignificant.ThechallengeofinterpretingapreoperativerestingTTEisseparatingthe‘woodfromthetrees’.TheclinicianneedstoextractalltherelevantfindingswhilstnotattachingsignificancetominorandirrelevantabnormalitiessuchasPASPof40mmHginanobesepatientorType1diastolicdysfunctioninanelderlyman.CorrectinterpretationcomeswithexperienceandbystudyingalargenumberofTTEreports,seekingadvicewhennecessaryfromexpertsinthefield.AnoteregardingthelinksbelowLinks1and2areincludedtogivethereaderanideaofthecomplexnatureofadiagnosticTTE.Link3givesreferencerangesforallTTEdata(itisnotexpectedthisinformationiscommittedtomemory).SomeofthearticlesreferencedinthediscussionarealsooutsidethescopeofMScPerioperativeMedicineandprovidedforinterestonly.
Keylinks:1-https://www.youtube.com/watch?v=NUVF-RxEZbE,2-http://www.bsecho.org/tte-minimum-dataset/3-http://www.bsecho.org/bse-app/
Appendices:
Table1:IndicationsforPreoperativeRestingTTEasperAHA/ACC,ESC/ESA&BSE
Indication ClassofRecommendation
LevelofEvidence
Organisationrecommending
Patientswithshortnessofbreath(SOB)ofunknownorigin
ClassIIa LevelC AHA/ACC
HeartfailurewithworseningSOBorotherchangeinclinicalstate
ClassIIa LevelC AHA/ACC
Patientswithclinicallysuspectedmoderateorgreaterdegreesofvalvularstenosisorregurgitationifa/nopriorTTEin1yearorb/significantclinicalchangesincelaststudy.
ClassI LevelC AHA/ACC
‘SystolicmurmursuggestiveofAS’
‘Appropriate’ AHA/ACC
‘Clinicalhistoryorphysicalexaminationsuggestsvalvulardisease’
‘Helpful’ AHA/ACC
‘Estimatepulmonaryarterysystolicpressure(PASP)’
‘Usefulinperioperativeplanning’
AHA/ACC
Patientsundergoinghighrisksurgery
ClassIIb LevelC ESC/ESA
AllpatientswithknownorsuspectedValvularHeartDisease,whoarescheduledforelectiveintermediateorhighrisk,non-cardiacsurgery.
ClassI LevelC ESC/ESA
Ischaemicheartdisease&Exercisetolerance<4metabolicequivalents(METS)
BSE
SOBinabsenceofclinicalsignsofheartfailure.Electrocardiogram(ECG)+/-ChestX-Ray(CXR)abnormal)
BSE
Heartmurmur&cardiacorrespiratorysymptoms
BSE
Presenceofheartmurmurinasymptomaticpatientwhohasclinicallysuspectedseverestructuralheartdisease.
BSE
Table2:MostUsefulMeasurementsonaTTEReportStructure MeasurementLeftVentricleSize LeftVentricularEndDiastolicDiameter(PLAX)LeftVentricleWallThickness LVInterventricularSeptum(PLAX)
LVPosteriorWall(PLAX)LeftVentricleSystolicFunction LVEjectionFractionMODBPLeftVentricleDiastolicFunction E/E’,LAVolumeRightVentricleSystolicFunction TAPSE
RVS’LeftAtrium LAVolumeRightAtrium RAVolumeAorta AortaatSinuses(+otherlocations) Pericardium SizeofPericardialEffusionIVC SizeandCollapsibility(toestimateRAP) Valves AorticStenosis AVPeakVelocity&Gradient
AVMeanGradientAVAreaContEqn(VTI)
AorticRegurgitation AIPressureHalfTimeAIVenaContracta
MitralStenosis MitralValveArea(Planimetry)PressureHalfTimeMVMeanGradient
MitralRegurgitation RegurgitantVolume(PISA)TricuspidRegurgitation TRPeakVelocity(toestimateRVSP/PASP)PulmonaryStenosis PVPeakvelocity
References:
Hammill, B.G. et al., 2008. Impact of heart failure on patients undergoingmajornoncardiacsurgery.Anesthesiology,108(4),pp.559–567.Heyburn, G. &McBrien,M.E., 2012. Pre-operative echocardiography for hipfractures: time tomake it a standardof care.Anaesthesia, 67(11), pp.1189–1193.Kazmers,A.etal.,1988.Perioperativeandlateoutcomeinpatientswithleftventricularejectionfractionof35%orlesswhorequiremajorvascularsurgery.JVascSurg.1988Sep;8(3):307-15Matyal, R. et al., 2009. Perioperative diastolic dysfunction during vascularsurgery and its association with postoperative outcome. Journal of vascularsurgery,50(1),pp.70–76. Minai,O.A.etal., 2013.Perioperative riskandmanagement inpatientswithpulmonaryhypertension.Chest,144(1),pp.329–340.
Nishimura et al., 2014. 2014 AHA/ACC Guideline for the Management ofPatientsWithValvularHeartDisease.JAC,63(22),pp.e57–e185.Wijeysundera,D.N.etal.,2011.Associationofechocardiographybeforemajorelectivenon-cardiacsurgerywithpostoperativesurvivalandlengthofhospitalstay:populationbasedcohortstudy.BMJ,342(jun301),pp.d3695–d3695.