Severe bioprosthetic MS - How to proceed?

[anes121508]

As a side note, was it mentioned that this patient was already put to sleep for mviv and case was aborted? What type of workup occurred beforehand? Avoidable? Any workup beforehand in terms of predicting lvot obstruction?

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[Dexmetaketapropofol]

Has she posted a video or a paper specifically on her method of 3D vca measurement?

I ask because I think some of the hesitancy for people to do this is that it’s relatively new and people aren’t comfortable with it. Even those that had recent fellowships, I find that there can be more variability in obtaining the 3D vca measurement than other simple metrics.

It's not specifically "her" method. She refers to:

https://www.asecho.org/wp-content/uploads/2014/05/2012_Three-Dimensional-Echo.pdf

And Lang refers to:

Velayudhan DE, Brown TM, Nanda NC, Patel V, Miller AP, Mehmood F,
et al. Quantification of tricuspid regurgitation by live three-dimensional
transthoracic echocardiographic measurements of vena contracta area.
Echocardiography 2006;23:793-800.

These are by no means "new" methods to the world of ASE. Also, one of the advantages is that it is less variable for quantification. You shouldn't be hesitant about doing it. In the future when your cardiologist asks you, "how much reduction did we get in TR?" Your ability as a newly minted fellow would be to use this to help in making judgements to add a second clip, reposition a first clip, determine where the Triclip should be placed to get the most bang for your buck, etc.

If you don't believe me, then you don't believe them either:

Comprehensive Evaluation of Tricuspid Regurgitation Location and Severity Using Vena Contracta Analysis: A Color Doppler Three-Dimensional Transesophageal Echocardiographic Study

The clinical significance of three-dimensional (3D) vena contracta area (VCA) in tricuspid regurgitation (TR) is not fully elucidated. The aim of this…

www.sciencedirect.com

You should expect more from your academic attendings to help you lead the way to the future of structural imaging because it's fast approaching. It's not uncommon for cardiac anesthesiologists to be better than Cardiologists at imaging more now than ever before.

This is all of course, my opinion only. Hope this helps.

 

[vector2]

As a side note, was it mentioned that this patient was already put to sleep for mviv and case was aborted? What type of workup occurred beforehand? Avoidable? Any workup beforehand in terms of predicting lvot obstruction?

It was aborted cause of the persistent LAA clot he had despite being on eliquis.


He had a cardiac CTA done beforehand but the guy reading it pretty much just mentioned to bioprosthetic mitral annular size.... didn't mention some of the more novel CT stuff related to neo-LVOTO s/p TMVR

Predicting LVOT Obstruction in Transcatheter Mitral Valve Implantation: Concept of the Neo-LVOT​

https://www.jacc.org/doi/full/10.1016/j.jcmg.2016.01.005

 

[T-burglar]

People sometimes forget that in the CT OR you have a CVP and most times an entire RHC trace to look at. Don’t bother wracking your brain with spectral Doppler analysis if you can just look at the cvp trace. If there’s no big V wave, then it’s RV diastolic dysfunction that’s causing the caval pressurization. A TV ring won’t improve the caval pressure unless there are significant V waves on the CVP. Sinus rhythm is the other thing that may help of course as well, but That’s not always possible. Even if it is possible in a given case, remember that the atrium is probably stunned enough from chronic arrhythmia that it won’t recover function and make a good contribution to diastolic throughput of the right heart for days (until it recovers contractile function - if it ever does).

This patient could have died on induction so at the very least I think a CT scan for emergency CPB planning should have been done and cannula sizes and sites picked , if not wired prior to induction.

 

[anes121508]

It's not specifically "her" method. She refers to:

https://www.asecho.org/wp-content/uploads/2014/05/2012_Three-Dimensional-Echo.pdf

And Lang refers to:

Velayudhan DE, Brown TM, Nanda NC, Patel V, Miller AP, Mehmood F,
et al. Quantification of tricuspid regurgitation by live three-dimensional
transthoracic echocardiographic measurements of vena contracta area.
Echocardiography 2006;23:793-800.

These are by no means "new" methods to the world of ASE. Also, one of the advantages is that it is less variable for quantification. You shouldn't be hesitant about doing it. In the future when your cardiologist asks you, "how much reduction did we get in TR?" Your ability as a newly minted fellow would be to use this to help in making judgements to add a second clip, reposition a first clip, determine where the Triclip should be placed to get the most bang for your buck, etc.

If you don't believe me, then you don't believe them either:

Comprehensive Evaluation of Tricuspid Regurgitation Location and Severity Using Vena Contracta Analysis: A Color Doppler Three-Dimensional Transesophageal Echocardiographic Study

The clinical significance of three-dimensional (3D) vena contracta area (VCA) in tricuspid regurgitation (TR) is not fully elucidated. The aim of this…

www.sciencedirect.com

You should expect more from your academic attendings to help you lead the way to the future of structural imaging because it's fast approaching. It's not uncommon for cardiac anesthesiologists to be better than Cardiologists at imaging more now than ever before.

This is all of course, my opinion only. Hope this helps.

Sorry, I didn’t make that post clear enough....

I was lucky enough to do a fellowship with really good exposure and training on 3D. I use it daily and am constantly trying to get people to use it. So many false assumptions on 2D....

But either way I’ve noticed short of going to a hands on workshop or recent fellowship there isn’t a great detailed how to manual on this stuff. The papers published have the methods sections, but it’s pretty limited and not in depth.

I’ll do 3D vca on nearly every significant lesion I see, and still I find myself asking certain questions.

I’d love to see a video or something with detailed instructions and the “i gotchas” of 3D vca measurement. Mainly setting up your planes accurately and how to tell when you have actually done it right and what signs to tell when you might be missing something. Some of the more complex jets can be challenging to get it right. Would be nice to see a review or video post that details this and discusses it.

 

[anes121508]

Sorry, I didn’t make that post clear enough....

I was lucky enough to do a fellowship with really good exposure and training on 3D. I use it daily and am constantly trying to get people to use it. So many false assumptions on 2D....

But either way I’ve noticed short of going to a hands on workshop or recent fellowship there isn’t a great detailed how to manual on this stuff. The papers published have the methods sections, but it’s pretty limited and not in depth.

I’ll do 3D vca on nearly every significant lesion I see, and still I find myself asking certain questions.

I’d love to see a video or something with detailed instructions and the “i gotchas” of 3D vca measurement. Mainly setting up your planes accurately and how to tell when you have actually done it right and what signs to tell when you might be missing something. Some of the more complex jets can be challenging to get it right. Would be nice to see a review or video post that details this and discusses it.

not even sure I really agree with where the blue plane is set in the first mpr image of the 2019 jase paper

 

[anes121508]

It was aborted cause of the persistent LAA clot he had despite being on eliquis.


He had a cardiac CTA done beforehand but the guy reading it pretty much just mentioned to bioprosthetic mitral annular size.... didn't mention some of the more novel CT stuff related to neo-LVOTO s/p TMVR

Predicting LVOT Obstruction in Transcatheter Mitral Valve Implantation: Concept of the Neo-LVOT​

https://www.jacc.org/doi/full/10.1016/j.jcmg.2016.01.005

That’s really a shame.

 

[Dexmetaketapropofol]

Sorry, I didn’t make that post clear enough....

I was lucky enough to do a fellowship with really good exposure and training on 3D. I use it daily and am constantly trying to get people to use it. So many false assumptions on 2D....

But either way I’ve noticed short of going to a hands on workshop or recent fellowship there isn’t a great detailed how to manual on this stuff. The papers published have the methods sections, but it’s pretty limited and not in depth.

I’ll do 3D vca on nearly every significant lesion I see, and still I find myself asking certain questions.

I’d love to see a video or something with detailed instructions and the “i gotchas” of 3D vca measurement. Mainly setting up your planes accurately and how to tell when you have actually done it right and what signs to tell when you might be missing something. Some of the more complex jets can be challenging to get it right. Would be nice to see a review or video post that details this and discusses it.

 

[Dexmetaketapropofol]

I understand now, yes to my knowledge there isn't a quick and easy video that I've ever seen on the internet.

I just applied the same concept of mitral 3d VC in the modified 4 chamber view (deeper esophageal view), inflow outflow view with 3d zoom and color for faster planimetry and combined that with a 4 beat full volume acquisition (if feasible)

It also helps me to use ventilation strategies such as apnea, low TV, high peep to stabilizie stitching temporarily so see if it helps if its not straightforward.

If the distance of the TV is too far for resolution I also use the transgastric view looking at the LV in long axis and turn the probe to look at the TV closer to the ultrasound.

Hope this helps.

 

[anes121508]

I understand now, yes to my knowledge there isn't a quick and easy video that I've ever seen on the internet.

I just applied the same concept of mitral 3d VC in the modified 4 chamber view (deeper esophageal view), inflow outflow view with 3d zoom and color for faster planimetry and combined that with a 4 beat full volume acquisition (if feasible)

It also helps me to use ventilation strategies such as apnea, low TV, high peep to stabilizie stitching temporarily so see if it helps if its not straightforward.

If the distance of the TV is too far for resolution I also use the transgastric view looking at the LV in long axis and turn the probe to look at the TV closer to the ultrasound.

Hope this helps.

That’s all image acquisition. I’m talking about a standardized method of offline processing in qlab and adjustment of the planes to ensure your vca is an accurate measurement.

 

[anes121508]

Have you guys seen anything out there on this?