Most accurate assessment of cardiac function

[coffeebythelake]

patient for urgent-emergent surgery under GA with newly diagnosed biventricular heart failure, severe TR, severe MR, severe CAD with potential areas of reversible ischemia, STEMI, newly diagnosed AF RVR. Seen by cards who initiated BB and ACEI and who basically said, there is high cardiac risk going forward. Anticoagulation was initiated but reversed with PCC for surgery.

a few recent studies including cardiac MRI (LVEF ~15-20%, RVEF 15‐20%), stress test (severely reduced LV function with estimated LVEF 25%), TEE (mod reduced LV function with estimated LVEF 30%, mild to mod reduced RV function, sev TR and MR). All studies performed within a short time frame and presumably the same patient condition (volume status, etc).

How do you put this together and which study would you consider most likely to be accurate for your anesthetic planning?

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[Ronin786]

Honestly? None of them matter. Keep it simple.

Heart is **** anyway you slice it. Look at the LV, look at the RV, look at the valves. If it's an RV issue have pulmonary vasodilators available, if there are stenotic valves make sure you're incredibly vigilant about volume status and normal sinus rhythm if possible.

Slow cardiac induction. Have pads on and available. Make sure lytes are buffed to help prevent arrhythmia.

Cardiac MRI is theoretically the most accurate. But are you really doing anything different if the EF is 15% rather than 25 (other than relaxing your butthole a little more)?

 

[coffeebythelake]

Honestly? None of them matter. Keep it simple.

Heart is **** anyway you slice it. Look at the LV, look at the RV, look at the valves. If it's an RV issue have pulmonary vasodilators available, if there are stenotic valves make sure you're incredibly vigilant about volume status and normal sinus rhythm if possible.

Slow cardiac induction. Have pads on and available. Make sure lytes are buffed to help prevent arrhythmia.

Cardiac MRI is theoretically the most accurate. But are you really doing anything different if the EF is 15% rather than 25 (other than relaxing your butthole a little more)?

Patient did fine, not really talking about intraop management, just want to clarify the best "study" given 3 pretty disparate reads on cardiac function. Seems like you would have used MRI data

 

[Velefunt]

Just curious what the urgent/emergent case was...

 

[anaesthetic]

I think they’re all valid to an extent. Agreed that it doesn’t really change management much other than a pre-induction art line and basic hemodynamic goals, maybe a central line if the surgery is moderate/high risk.

I’ve seen the EF go from 60% to 25% by the time I drop the TEE in, so I do think a lot of it is dynamic as well, based on volume status, coronary perfusion pressure at the time of the study, etc. I’ve also seen it change intra-op just based on hemodynamics (relative hypotension and hypokinesis while doing lines, improves with normotension).

 

[nimbus]

I think they’re all valid to an extent. Agreed that it doesn’t really change management much other than a pre-induction art line and basic hemodynamic goals, maybe a central line if the surgery is moderate/high risk.

I’ve seen the EF go from 60% to 25% by the time I drop the TEE in, so I do think a lot of it is dynamic as well, based on volume status, coronary perfusion pressure at the time of the study, etc. I’ve also seen it change intra-op just based on hemodynamics (relative hypotension and hypokinesis while doing lines, improves with normotension).

Common to see similar changes with inotropes and vasopressors and nonischemic vs ischemic hearts too.

 

[thinkorswim]

Patient did fine, not really talking about intraop management, just want to clarify the best "study" given 3 pretty disparate reads on cardiac function. Seems like you would have used MRI data

Cardiac MRI is the best imaging study for quantification of LV ejection fraction. It’s also the least prone to human error.

 

[coffeebythelake]

Cardiac MRI is the best imaging study for quantification of LV ejection fraction. It’s also the least prone to human error.

Same w RV function? (Which was the bigger concern in this particular case)

 

[vector2]

Same w RV function? (Which was the bigger concern in this particular case)

Yes, as far as the textbook answer, cardiac MR is the gold standard for both chambers for volumetric analysis, ejection fraction, and quantitative regurgitant lesion calculations.

 

[thinkorswim]

Same w RV function? (Which was the bigger concern in this particular case)

Yes, I would say even more so than LV function. The echocardiographic quantification of RV function is rather rudimentary compared to LV function methods and usually relies on qualitative analysis.

 

[vector2]

They literally measure the area change in a bunch of tomographic slices and then put them together to get a volume change. There's no geometric assumptions at all.

 

[RemyMcswain]

I think MRI is best for quantifying EF. However, you can also look at things like strain analysis to determine depressed ventricular fx despite a normal EF. Segments may be moving abnormally despite the global ventricle being able to eject blood

 

[sethco]

Cardiac MRI is the best imaging study for quantification of LV ejection fraction. It’s also the least prone to human error.

Not to sound arrogant or anything, but I only trust a TEE/TTE that I have done myself or personally reviewed the images (assuming good quality images)

 

[thinkorswim]

Not to sound arrogant or anything, but I only trust a TEE/TTE that I have done myself or personally reviewed the images (assuming good quality images)

That’s fine and all, but OP is presumably a non-cardiac trained anesthesiologist and asking which preoperative imaging study can be most trusted at face value. Sorry to say, but even if it were you who performed and interpreted the echo, the answer would still be cardiac MRI.

 

[Volatile]

How do you put this together and which study would you consider most likely to be accurate for your anesthetic planning?

Can he climb two flights of stairs? 😂

 

[coffeebythelake]

Can he climb two flights of stairs? 😂

Hahahahahaaaaa maybe he can crawl up, slowly

 

[sethco]

That’s fine and all, but OP is presumably a non-cardiac trained anesthesiologist and asking which preoperative imaging study can be most trusted at face value. Sorry to say, but even if it were you who performed and interpreted the echo, the answer would still be cardiac MRI.

Not disagreeing with you at all in regards to MRI vs Echo. Just a general statement on my distrust of preop TTE/TEE reports

 

[Hork Bajir]

While MRI is considered the “gold standard”, there’s still plenty of room for error. Different radiologists will give you different opinions on handling the papillary muscles, but more importantly the thin MV leaflets are hard to see well on MRI… as a result defining the left atrial vs the left ventricular blood pool is challenging, and this does matter quite a bit since the base of the LV will descend towards the apex with contraction.

That being said, a lot of this is academic masturbation, made even more silly by the fact that ejection fraction is a profoundly flawed way to conceptualize LV contractile function. Consider the patient with severe MR, who has an EF of 50 that drops to 30 after the mitral valve is repaired… Presumably nothing has changed about the contractile function of the ventricle, it is now just facing a normalized affective afterload. EF is much more about ventriculo-arterial coupling than intrinsic contractile state.