Advanced TEE..no cardiac fellowship

[vector2]

PVL is a whole lecture in and of itself, but a quick a dirty way to look at it is:

*Do not accept anything over mild PVL*

1. If you are replacing, then know what the normal washing jets look like for the particular valve you are placing.
2. During the MV repair/replacement was there any surgical issues that may have complicated the procedure?
3. Evaluate leaks under awake conditions (don’t measure leaks with your typical low BPs you see after bypass). Drive up the pressures to normal conditions to get a good exam of your PVL. Everything looks better with a BP of 80 systolic and under GA.
4. 2D: Are all the leaflets opening and closing, is the valve well seated or is there any rocking motion? 2D CFD: Eval the full specturm of 0-180 degrees. Is it low velocity or high velocity? Symmetrical jet or asymmetrical? How far does the jet extend into the LA- is it a deeply penetrating jet? Eccentric jet? with coanda? What’s the VC, is there a pisa shell present on the other side of the valve, if so how big? Inside or outside of the sewing ring? How dense is the jet when looking at CWD? Save a clip… play back and forth frame by frame. You can look at pulmonary venous flow for extra credit, but I rarely do.
5. 3D: Either with live 3d or 3D zoom (higher frame rate), you can REALLY examine the suture ring and the PVL. Start with a good en face view. Look for dehiscence, rocking, etc. Then rotate your 3D image so you are looking into the anterior commissure and then the posterior commissure then 6 and 12 o’clock. You can slowly rotate 360 degrees to examine every segment of the sewing ring from every angle with extreme detail adding magnification if you need to (do the same for a BPV). When you locate a problem look at it from both the atrial and ventricular views. Next do 3D color exam and crop down to where your leak is emerging so you can get great definition of the pathology. At this point you can rotate the PVL in all dimensions to get a good feel for it and measure cross sectional lengths, areas as well as getting a good view of the surrounding stuctures that may be involved.

This all sounds like it takes time. It doesn’t. If it’s Moderate-Severe or Severe, the decision making takes no time at all.

Mild to Moderate deserve close attention to detail, but in general… anything over mild isn’t an acceptable repair or replacement (exception is Mitral clips where =/<2+ is considered adequate when you are dealing with severe MR in a 90 y/o as they will get resolution of alot of their symptoms).

Also, keep in mind a lot of the mild PVL go away after protamine.

thanks dude. very helpful

---

Members don't see this ad.

 

[T-burglar]

PVL is a whole lecture in and of itself, but a quick a dirty way to look at it is:

*Do not accept anything over mild PVL*

1. If you are replacing, then know what the normal washing jets look like for the particular valve you are placing.
2. During the MV repair/replacement was there any surgical issues that may have complicated the procedure?
3. Evaluate leaks under awake conditions (don’t measure leaks with your typical low BPs you see after bypass). Drive up the pressures to normal conditions to get a good exam of your PVL. Everything looks better with a BP of 80 systolic and under GA.
4. 2D: Are all the leaflets opening and closing, is the valve well seated or is there any rocking motion? 2D CFD: Eval the full specturm of 0-180 degrees. Is it low velocity or high velocity? Symmetrical jet or asymmetrical? How far does the jet extend into the LA- is it a deeply penetrating jet? Eccentric jet? with coanda? What’s the VC, is there a pisa shell present on the other side of the valve, if so how big? Inside or outside of the sewing ring? How dense is the jet when looking at CWD? Save a clip… play back and forth frame by frame. You can look at pulmonary venous flow for extra credit, but I rarely do.
5. 3D: Either with live 3d or 3D zoom (higher frame rate), you can REALLY examine the suture ring and the PVL. Start with a good en face view. Look for dehiscence, rocking, etc. Then rotate your 3D image so you are looking into the anterior commissure and then the posterior commissure then 6 and 12 o’clock. You can slowly rotate 360 degrees to examine every segment of the sewing ring from every angle with extreme detail adding magnification if you need to (do the same for a BPV). When you locate a problem look at it from both the atrial and ventricular views. Next do 3D color exam and crop down to where your leak is emerging so you can get great definition of the pathology. At this point you can rotate the PVL in all dimensions to get a good feel for it and measure cross sectional lengths, areas as well as getting a good view of the surrounding stuctures that may be involved.

This all sounds like it takes time. It doesn’t. If it’s Moderate-Severe or Severe, the decision making takes no time at all.

Mild to Moderate deserve close attention to detail, but in general… anything over mild isn’t an acceptable repair or replacement (exception is Mitral clips where =/<2+ is considered adequate when you are dealing with severe MR in a 90 y/o as they will get resolution of alot of their symptoms).

Also, keep in mind a lot of the mild PVL go away after protamine.

Nice post. Additionally I would say it should be easy to do spectral volumetrics after bypass if the patient is in sinus rhythm or AOO / AV sequential

I wrote a workflow tool for our practice that does all our clinical calculations and puts them in the report (we use epic). So since its usually easy to get a nice clean PW signal from Main PA, LVOT, and Mitral (annulus level), you can just plug them into a calculator and get stroke volume differences for R. Vol. , R. Frac. , EROA. This assumes no signficant regurg at the non-operated site of course. This method quantifies the entirety of prosthetic regurgitation in the case of multiple jets.

 

[deleted171991]

I have no doubt that what you're saying is true of CCM fellowships. Critical care is by its nature the care of many patients in parallel, and there's surely far more value for a fellow in the thinking and decision making ,rather than direct care of the patients in the rooms. The residents, interns, students, NPs, etc should be doing the information gathering, consult chasing, scut work, and most of the procedures.

I feel that cardiac is different and I deliberately chose a program where I would not be supervising. (I'd also spent the previous years supervising residents as an attending, and wanted some alone time, so to speak.) A cardiac fellowship where the fellow actively supervises two residents at a time, increasing the number of cases the fellow is exposed to over the year, might have some advantages. But that doesn't actually appear to be the reality of the "supervisory" cardiac fellowships. The ones I talked to and visited had the fellows supervising one case at a time ... and you know what the fellows did when they weren't in the room? Had pretty relaxed days.

The advertised "value" of the supervisory programs was more time out of the OR during "boring" periods. But you know what? Much of anesthesia training is preparing for rare events, and avoiding them, and recognizing them quickly when they do occur, and handling them on your feet. And you've got to be present to experience these events during training. I think we go a little overboard dismissing the stool-sitters, and I think every new grad would benefit from some time when they're doing their own cases solo and just have time in the OR.

I'm a little weird in that I refuse almost every break I get offered. But I can't tell you how many times this year I've declined a break only to have a decision point, small or large, come up minutes later. Even during "boring" periods when nothing is supposed to happen. There's just no substitute for time in the OR, and everywhere I went that had fellows supervising residents, the fellows spent an awful lot of time not in an OR.

But they had plenty of time to look at pictures of echoes, and float through rooms to put their hands on probes.

I've supervised a resident about a dozen times this entire year, yet I've had superb TEE training and am approaching a certain comfort level with the sickest patients and most complex procedures (all the while being mindful of Dunning-Kruger pitfalls ... few people can be as dangerous as a doctor who's almost done with a period of training).

There have been times when I've felt overly micromanaged, and occasionally some days were filled with more work than learning, but if I had it to do over again, I still wouldn't choose an ACTA program that had more than occasional supervision.

While I was giving CCM as an example, I don't think what I said should apply only to CCM. I think every fellowship should have a healthy mixture of developing the appropriate thinker and doer skills. The former require a bit more perspective; that's why the code runner in a CPR team shouldn't do chest compressions. I don't believe in see one, do one, teach one. I believe in see one, go read, do one, go read some more, do more, go read some more, and maybe then teach one. It's not the monkey skills that separate me from a CRNA (theirs are probably better, because that's most of what they do); it's the decisional skills. And those require not only experience, but especially knowledge. I completely agree that one has to stay in the room and run the show to gain experience; I disagree that one has to be the one setting up pumps, intubating, putting in lines, pushing drugs etc. That's superresidency not fellowship. While my residents were doing the scutwork, I was the one calling the shots and taking decisions.

When someone works (physically) in a room from 6 am to 6 pm, I doubt that there is much energy left for extensive studying. That's how one gets into the "that's how we did it at the ..." mindset, people who learned everything mostly by doing, and who lack the global scientific perspective required to become a truly valuable consultant. While I agree that an "echo fellowship" is not a good thing either, I believe that there should be a nice balance between "monkey days" and "fellow days", so that people have enough energy left to go home and look up pertinent stuff every day. This is a fellowship, not an apprenticeship, or internship. We shouldn't just imitate the master; we should be trying out things that the master hasn't even heard of.

@pgg's program is famous for the great training, so this is not about them. This is about the many no-name cardiac programs that use their fellows as residents. Yes, their monkeys graduates are good at keeping cardiac patients alive. But do they get the best training they could, for example in truly advanced echo skills (e.g. 3D)? Respectfully, one doesn't need a fellowship for the former in many cases; a lot of generalists still practice cardiac with no fellowship or board certification, but I would not consider them true cardiac anesthesiology consultants. Btw, the latter is not synonymous with advanced PTE certification either.

 

[Robotic Wis-Hipple]

I know there is still a lot of skepticism surrounding 3D.
I still believe in it's power and ability to add significant relevant information to our exams (2d, pwd, cwd, cfd).
At the very least... they are some of the prettiest pictures in medicine.

Are you using percentage of circumference for PVL severity grading? There's not a ton of data or guidelines for this and I agree that moderate-severe basically fall in the "I know it when I see it" category, and the surgeon typically sees the image(s) and agrees. However, in the mild to moderate range, deciding to go back on when you do not plainly see a suture disruption or instability of the prosthesis etc can be a difficult decision and I'm not entirely convinced using VC or other native valve regurgitation metrics are as applicable as we'd like.

 

[sevoflurane]

Are you using percentage of circumference for PVL severity grading? There's not a ton of data or guidelines for this and I agree that moderate-severe basically fall in the "I know it when I see it" category, and the surgeon typically sees the image(s) and agrees. However, in the mild to moderate range, deciding to go back on when you do not plainly see a suture disruption or instability of the prosthesis etc can be a difficult decision and I'm not entirely convinced using VC or other native valve regurgitation metrics are as applicable as we'd like.

Check this paper out. I think you'll like it. Specifically table 4. Like with any grading, if you fall on the line, you need to go hunting a little further and find support for or against what you might be doing within the context of the patient, the case and the capabilites of the surgeon you are working with.

I find that measurements with 3D TEE and specifically qlab are of immense help here as you are taking very accurate measurements.

http://www.cardioaragon.com/web/pdf/Paravalvular_Leaks_in_Surgical_Prosthesis.JACC.2017.pdf#page9

 

[Robotic Wis-Hipple]

+1

Thanks for that paper, I think the existence of that paper exemplifies the issue we are discussing. There just isn't any good data here, which further complicates the decision to add CPB time and all associated concerns to fix moderate PVL. This isn't even considering individual comorbid condition, surgeon skill, etc.

I agree with whoever said it earlier, I think TEE 3D metrics for the mitral valve at least are coming. TEE validated (as opposed to TTE validated but assumed to be valid in TEE) measuring and grading standards as well as outcome data is likely to explode in the next decade I think.

 

[anes121508]

I enjoyed this thread a while back and am again enjoying the discussion. Admittedly, I was somewhat defensive of the career path I chose to take back when the thread was first going.

In response to you anes, I would say I think/hope no patients suffered and no inaccurate assessments were made. My fellowship allowed me to staff cases with a resident and I had back up as well, much like an accredited fellowship. I had a lot of experience as a resident performing TEE and making calls in the OR during a variety of procedures including mitralclip, TAVR, as well as the usual cardiac stuff. I passed the advanced TEE exam during residency.

I apologize again for the mopping comment. Nice to see it getting requoted though.

I perform 3D in all my exams. Sometimes out of necessity, sometimes just to practice. I hope we use 3D color more in the future as the technology gets better. Anyone see how nice it looks on a Philips Epiq and the new X8-2T probe?

You seem like you are way ahead of the curve. Advanced exam during residency is impressive. Interested to know why you ended up doing a non acgme acredited fellowship...whats the story behind that?

The new Philips software and the new probe is awesome. The live 3D color is ridiculous. Hardly need to do full beat acquisitions the frame rates are so good.

 

[anes121508]

Me too.

Mark my words... at some point there will be a grading system for MR that is based on 3D color Vena Contracta Area.

The automation that is coming out with some of the machines is actually quite impressive.

Sevo, I agree 100%. The guidelines in the futures are going to rely on 3d color assessments. We make major assumptions using 2D in terms of VC and PISA. Truthfully, 3D still isn't perfect because the VCA is no holosytolic and the same throughout all of systole. 3D still does not get around this temporal nature of the jet. The latest guidelines for regurge finally point this out and have included 3D VCA values. They also recognize the different cutoffs for primary vs functional MR (EROA depending on the etiology of MR).

 

[anes121508]

Me too.

Show your surgeon the en face 3d Color regurgitant jet and the communication between anesthesiologitst and CT surgeon is done via a clip. .

I believe that if you are in fellowship and not learning 3D, then your fellowship training is leaving you a day late and a dollar short.

What you say above is very true. Our surgeons walk right over and want to see the "surgeon's view" with and without color. Then they want me to tell them the etiology and exactly where the jets are coming from. The surgeons love it. I think 3D echo fits as part of the whole "showing your value" thing.

 

[anes121508]

I fully agree with this and this is how I chose my fellowship program as well. I totally understand the utility of a supervisory fellowship, but as pgg says it takes a very motivated, adult learner to stay actively involved throughout the case and not just roll in for TEE insertion and coming off CPB. We have a supervisory fellowship at my shop and while some fellows are around and actively participate, some would disappear. That's not what I wanted for myself.

Also, my group does solo cases for hearts so I wanted to gain comfort doing everything myself including the TEE exam and incorporating it into management. I don't feel like I'm doing another residency or being scut like a (very grumpy) FFP describes at all - I'll be honing my overall skill set and adding new facets as well. I don't want "hours" to read - to me that time isn't priceless in fact I feel the opposite, I want to be engaged in a case. That's a large difference that CCM has.

I also love the description of fellowship programs as cardiac anesthesia or echo-based. Some of my colleagues are more drawn to the echo-centric programs, which may be great for them and their career goals especially if you'll be at a supervisory academic center. It's largely a personal decision about which path to take.

Yeah I 100% agree, there is some real value in being in the room and the moment sh** starts heading south and makign the decisions on your own. Lots of scut involved, but it may be worth it. Some mix of supervising and sitting the stool (for the most complex cases) is probably best.

 

[anes121508]

PVL is a whole lecture in and of itself, but a quick a dirty way to look at it is:

*Do not accept anything over mild PVL*

1. If you are replacing, then know what the normal washing jets look like for the particular valve you are placing.
2. During the MV repair/replacement was there any surgical issues that may have complicated the procedure?
3. Evaluate leaks under awake conditions (don’t measure leaks with your typical low BPs you see after bypass). Drive up the pressures to normal conditions to get a good exam of your PVL. Everything looks better with a BP of 80 systolic and under GA.
4. 2D: Are all the leaflets opening and closing, is the valve well seated or is there any rocking motion? 2D CFD: Eval the full specturm of 0-180 degrees. Is it low velocity or high velocity? Symmetrical jet or asymmetrical? How far does the jet extend into the LA- is it a deeply penetrating jet? Eccentric jet? with coanda? What’s the VC, is there a pisa shell present on the other side of the valve, if so how big? Inside or outside of the sewing ring? How dense is the jet when looking at CWD? Save a clip… play back and forth frame by frame. You can look at pulmonary venous flow for extra credit, but I rarely do.
5. 3D: Either with live 3d or 3D zoom (higher frame rate), you can REALLY examine the suture ring and the PVL. Start with a good en face view. Look for dehiscence, rocking, etc. Then rotate your 3D image so you are looking into the anterior commissure and then the posterior commissure then 6 and 12 o’clock. You can slowly rotate 360 degrees to examine every segment of the sewing ring from every angle with extreme detail adding magnification if you need to (do the same for a BPV). When you locate a problem look at it from both the atrial and ventricular views. Next do 3D color exam and crop down to where your leak is emerging so you can get great definition of the pathology. At this point you can rotate the PVL in all dimensions to get a good feel for it and measure cross sectional lengths, areas as well as getting a good view of the surrounding stuctures that may be involved.

This all sounds like it takes time. It doesn’t. If it’s Moderate-Severe or Severe, the decision making takes no time at all.

Mild to Moderate deserve close attention to detail, but in general… anything over mild isn’t an acceptable repair or replacement (exception is Mitral clips where =/<2+ is considered adequate when you are dealing with severe MR in a 90 y/o as they will get resolution of alot of their symptoms).

Also, keep in mind a lot of the mild PVL go away after protamine.

JUST WANTED TO ADD SOME THINGS TO SEVO'S POST....
*Do not accept anything over mild PVL*

1. During the MV repair/replacement was there any surgical issues that may have complicated the procedure? I find this to be very important. Communication with the surgeon is key. For example knowing where he/she may have struggled with a really calcified annulus is a major give away. If you see heavy MAC or a bad aortic valve, just ask the surgeon if it made their life difficult.
2. Evaluate leaks under awake conditions (don’t measure leaks with your typical low BPs you see after bypass). Drive up the pressures to normal conditions to get a good exam of your PVL. Everything looks better with a BP of 80 systolic and under GA. This goes for evaluation of MR as well. It's incredible how dynamic regurgitant jets can be. Secondary/Ischemic MR especially. Don't jump to making a judgement call and tell your surgeon something before knowing what the pressure is what you looked at the jet. This is a really trickey topic...interested to know what you all do in practice...
3. 2D: Are all the leaflets opening and closing, is the valve well seated or is there any rocking motion? 2D CFD: Eval the full specturm of 0-180 degrees. Agree 100%. Omniplane around. If I see a PVL on the mitral, I will center the jet on the screen, then omniplane around to see how many degrees it extends. For example: jet shows up at 30 and extends to 90. That tells you the jet is X% of the circumference of the valve. (90-30)/180. This is helpful because one metric of grading a PVL is the % of the circumference that the jet extends. Is it low velocity or high velocity? Symmetrical jet or asymmetrical? How far does the jet extend into the LA- is it a deeply penetrating jet? This was historically included in the guidelines, but the latest guidelines point out that this can be misleading and not to put too much emphasis on this. Eccentric jet? with coanda? What’s the VC, VC is really useful for multiple jets as well (VC is additive). In 3D color: Cropping down on each jet and adding them up is an approach I find not all that time consuming.is there a pisa shell present on the other side of the valve, if so how big? Inside or outside of the sewing ring? How dense is the jet when looking at CWD? Save a clip… play back and forth frame by frame. You can look at pulmonary venous flow for extra credit, but I rarely do. Remember that the pulmonary vein flow in the LEFT UPPER can be different than the RIGHT UPPER if the jet is eccentric (it'd be pointing towards one vein and not the other).
4. 3D: Either with live 3d or 3D zoom (higher frame rate), you can REALLY examine the suture ring and the PVL. Start with a good en face view. Look for dehiscence, rocking, etc. Then rotate your 3D image so you are looking into the anterior commissure and then the posterior commissure then 6 and 12 o’clock. You can slowly rotate 360 degrees to examine every segment of the sewing ring from every angle with extreme detail adding magnification if you need to (do the same for a BPV). When you locate a problem look at it from both the atrial and ventricular views. Next do 3D color exam and crop down to where your leak is emerging so you can get great definition of the pathology. CROPPING DOWN TO THE LEVEL OF THE RING AND LOOKING AT THE PVL ENFACE IS A GREAT WAY TO LOOK AT HOW FAR AROUND THE RING IT EXTENDS. At this point you can rotate the PVL in all dimensions to get a good feel for it and measure cross sectional lengths, areas as well as getting a good view of the surrounding stuctures that may be involved.

This all sounds like it takes time. It doesn’t. AGREE (but you gotta do it every day and practice) If it’s Moderate-Severe or Severe, the decision making takes no time at all.

Mild to Moderate deserve close attention to detail, but in general… anything over mild isn’t an acceptable repair or replacement (exception is Mitral clips where =/<2+ is considered adequate when you are dealing with severe MR in a 90 y/o as they will get resolution of alot of their symptoms). I REALLY THINK THAT MITRACLIPS ARE DIFFICULT IN GRADING THE RESIDUAL MR. THE JETS ARE VERY COMPLEX AND WE DON'T HAVE GREAT METRICS. what do you all us? This is one area we cath pressures and our pulmonary vein flows really help. What do you think?

Also, keep in mind a lot of the mild PVL go away after protamine. I really like this caveat. Often times I will just look for major leaks before we start up the protamine and if there is a small one I'll interrogate after the protamine is done.

 

[anes121508]

Check this paper out. I think you'll like it. Specifically table 4. Like with any grading, if you fall on the line, you need to go hunting a little further and find support for or against what you might be doing within the context of the patient, the case and the capabilites of the surgeon you are working with.

I find that measurements with 3D TEE and specifically qlab are of immense help here as you are taking very accurate measurements.

http://www.cardioaragon.com/web/pdf/Paravalvular_Leaks_in_Surgical_Prosthesis.JACC.2017.pdf#page9

This is saved in my GDRIVE

 

[anes121508]

At the very least... they are some of the prettiest pictures in medicine.

I've joked that I want to have a pop up art gallery in NYC of just 3D echo pics. As soon as I learn to upload to SDN from my phone I'll share some of my prelim gallery .

 

[anes121508]

I do agree with the other post below that indeed further technology can make many aspects of TEE automated, and thus more accessible, and not less. But, I can also see a point when that information becomes almost moot as the ultimate determinant of outcome is surgical technique/technology, and the surgeon his/herself. That's just my opinion.

The automated stuff has a long way to go. The Siemens machine can recognize the doppler signals and will trace it out for you. However, knowing how to interpret the doppler signals and knowing the pitfalls and limitations embedded within each of the metrics used to grade a valve is truly where the expertise is.

It will also do a "complete" exam for you with the touch of one button after you give it a few reference points....the pictures can turn out horrible though.

Agree that the technology will advance and make it easier....however it has a long way to go. Also, I think that as the technology with imaging and interventional procedures advance we will be asked tougher questions. For example...predicting LVOT obstruction for transcatheter MVIV or making the measurements for watchmann device in qlab. That takes a bit more than is there mild moderate or severe AS.

 

[sevoflurane]

It just so happens that our group is interviewing for a couple of CT guys that are comfortable with structural heart echocardiography.
Must be TEE certified and have structural heart experience. PM me if interested.