Supervising PP cardiac

[Reveler]

Hey all, current CA3 here. I'll be staying at my home base to do a regional fellowship next year and will likely go PP once I'm finished. In talking to my co-residents who have already landed jobs and looking through job postings, I'm curious how supervising pump cases generally works out there in the wild. I've heard of places being 3:1 or 2:1 while supervising anesthetists doing pump cases and this just seems foreign to me coming out of residency. Several of my coresidents will be working in situations like this without cardiac fellowship and I'm curious how it's managed. Do the anesthetists do all the lines? If not fellowship trained, does cardiology or anesthesia do TEE, etc.? Any info about the setup at your shop is greatly appreciated!

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[Endee]

When I worked as an AA at a place that did hearts, we were 1:2 in the heart room. Very few AAs/CRNAs did the central lines (10%?) but most of us did the arterial line in preop. Our anesthesiologists did the TEE, and many but not all were cardiac fellowship trained. Because of the length of the cases, if there were 2 hearts going simultaneously in the two adjacent rooms, they were very rarely going on/off at the same time. But since the rooms were right next to each other, usually it wasn't an issue in the rare event that happened.

 

[anaesthetic]

Sounds like a disaster waiting to happen on your watch. I solo cardiac and supervise general, and there is absolutely no way we could ever supervise 1:1 let alone 1:2/1:3 for our cardiac cases. Granted, we do a lot of cases the other places don’t want to do, but there are so many nuances that require prompt/immediate treatment even in “routine” CABGs that I couldn’t imagine being out of the room for any amount of time without ultimately causing harm to the patient.

Our general folks are really, really good clinically, but no way could they understand the nuances of these cases enough to do them safely or even have the gall to do them in the first place; they know their limits, and I respect them for it. You’re asking NEW residents to do this fresh out of training without a cardiac fellowship? Oh boy. They better be getting paid for it and have excellent malpractice. I can think of ZERO of my coresidents who did not do a cardiac fellowship who can do our cardiac cases. ZERO, and we had a very strong class.

n=1. I work with some CT surgeons who have operated under both models. You can guess which one they prefer. Our CT surgeons are VERY particular about the anesthesiologists behind the drapes, but I guess we are also very good at what we do and have the luxury to be extremely selective.

 

[shepardsun]

Had a couple fellow residents at my program go off and do private practice hearts without fellowship- usually just CABGs with the occasional valve. They were let's just say, not the superstars of the program and not necessarily the people I'd want taking care of my family. I'm not the sharpest tool in the shed but I'm smart enough to know what I don't know and I would be intimidated to do those cases without the fellowship training. Everything is great and easy on pump until it isn't...

 

[nimbus]

I started doing hearts in 2005 without a fellowship and a long hiatus. I had good mentoring and backup from my partners and the support of the cardiac surgeons who knew me from their noncardiac thoracic cases. I self studied echo, attended a few echo meetings and passed the advanced echo exam. So I did cardiac for about 16years and enjoyed it very much. But I think the time for that has passed. At the end of 2021 I stopped doing cardiac because I could see that the standard of care had advanced. Our newer fellowship trained cardiac anesthesiologists all run rings around me in echo. From multiple perspectives, it is not a good idea to practice cardiac anesthesia without a fellowship nowadays. If I was having cardiac surgery, I would request a fellowship trained, echo boarded cardiac anesthesiologist. If you want to do cardiac anesthesia as part of your career, do an ACTA fellowship, not a regional fellowship.

 

[Drwine]

IMHO the rationale for a regional fellowship is to go to a different area and network for a job in an area you want to go to and don't have any connections. Unless you are going to a practice that is high volume and the existing attendings are willing to mentor you in TEE and cardiac cases and have trained the CRNAs well this isn't likely to succeed. To answer your question it depends on the experience and level of skill of those being supervised. Some CRNAs have very good technical skills and can be supervised to do lines. Others less so. If you are doing TEE make sure a certified person is available to be a resource. 2:1 supervision is reasonable. Ideally there is a straightforward room close by to supervise concurrently. Supervising 2 hearts is possible but less than ideal unless you have another colleague around to help if you need to be in 2 places at once. There are down times in cardiac like when the surgeon is taking down the IMA or when they are on pump.

 

[Reveler]

Sounds like a disaster waiting to happen on your watch. I solo cardiac and supervise general, and there is absolutely no way we could ever supervise 1:1 let alone 1:2/1:3 for our cardiac cases. Granted, we do a lot of cases the other places don’t want to do, but there are so many nuances that require prompt/immediate treatment even in “routine” CABGs that I couldn’t imagine being out of the room for any amount of time without ultimately causing harm to the patient.

Our general folks are really, really good clinically, but no way could they understand the nuances of these cases enough to do them safely or even have the gall to do them in the first place; they know their limits, and I respect them for it. You’re asking NEW residents to do this fresh out of training without a cardiac fellowship? Oh boy. They better be getting paid for it and have excellent malpractice. I can think of ZERO of my coresidents who did not do a cardiac fellowship who can do our cardiac cases. ZERO, and we had a very strong class.

n=1. I work with some CT surgeons who have operated under both models. You can guess which one they prefer. Our CT surgeons are VERY particular about the anesthesiologists behind the drapes, but I guess we are also very good at what we do and have the luxury to be extremely selective.

I currently train at a place that does lots of sick hearts and its tough for me to imagine supervising these rooms vs sitting solo. That's why I was curious how these go down outside of the ivory tower.

 

[Reveler]

IMHO the rationale for a regional fellowship is to go to a different area and network for a job in an area you want to go to and don't have any connections. Unless you are going to a practice that is high volume and the existing attendings are willing to mentor you in TEE and cardiac cases and have trained the CRNAs well this isn't likely to succeed. To answer your question it depends on the experience and level of skill of those being supervised. Some CRNAs have very good technical skills and can be supervised to do lines. Others less so. If you are doing TEE make sure a certified person is available to be a resource. 2:1 supervision is reasonable. Ideally there is a straightforward room close by to supervise concurrently. Supervising 2 hearts is possible but less than ideal unless you have another colleague around to help if you need to be in 2 places at once. There are down times in cardiac like when the surgeon is taking down the IMA or when they are on pump.

I've been in contact with a few groups in which you opt in to hearts, but as I've seen postings for such jobs and know people going into those practice environments, I'm more just curious how they work. While I feel comfortable doing a relatively straight-forward pump case now and have decent TEE skills, a year of fellowship won't increase my comfort level in these cases so I'll likely choose a practice that doesn't require me to do them.

 

[Reveler]

If you want to do cardiac anesthesia as part of your career, do an ACTA fellowship, not a regional fellowship.

Lol, I have no real desire to do these cases

 

[nimbus]

Lol, I have no real desire to do these cases

Your original post gave the impression that you want to.

 

[Hork Bajir]

Where I am at it is exclusively supervision outside of the cardiac rooms, doc only (or resident/fellow supervision) in the heart room. As an aside, it is very important to me that I have the opportunity to do my own cases some of the time.

But just last week, I was doing a “straightforward” normal EF CABG, and on the pre-bypass echo diagnosed previously undiscovered paradoxical low flow low gradient severe AS. I advised surgeon to replace the valve, which he did. Ask yourself if that is a call you would feel comfortable making without fairly extensive cardiac experience, not to mention at the very least PTE testamur status?

 

[nimbus]

Where I am at it is exclusively supervision outside of the cardiac rooms, doc only (or resident/fellow supervision) in the heart room. As an aside, it is very important to me that I have the opportunity to do my own cases some of the time.

But just last week, I was doing a “straightforward” normal EF CABG, and on the pre-bypass echo diagnosed previously undiscovered paradoxical low flow low gradient severe AS. I advised surgeon to replace the valve, which he did. Ask yourself if that is a call you would feel comfortable making without fairly extensive cardiac experience, not to mention at the very least PTE testamur status?

Kinda weird to have low gradient sev AS with nl ef but patients are strange.

 

[Hork Bajir]

Kinda weird to have low gradient sev AS with nl ef but patients are strange.

Defined as paradoxical LFLG; by definition has a normal EF, but stroke volume index < 35 cc/m^2. Usually patients with LVH, small LV cavity (low LVEDV), diastolic dysfunction leading to a small stroke volume despite an apparently normal EF.

“Paradoxical LF-LG AS occurs in 5-15% of patients with AS2and it is defined as a preserved LVEF (≥50%), a low LV outflow (i.e. stroke volume index <35 mL/m2), a small AVA (≤1 cm2 and ≤0.6 cm2/m2), and a low gradient (<40 mmHg) (Slide #3)2, 3. In these patients, the low flow state is generally related to a pronounced LV concentric remodeling with impaired LV filling, and reduced systolic global longitudinal strain (despite normal LVEF)1, 2, 10, 11. Other factors may also contribute to the reduced stroke volume in the context of a preserved LVEF including: atrial fibrillation, concomitant mitral regurgitation, tricuspid regurgitation, or mitral stenosis etc. In the ACC/AHA guidelines3, a new class IIa indication of AVR was included for patients with paradoxical LF-LG AS if they are symptomatic, normotensive and the clinical, anatomical, and hemodynamic factors support the presence of a severe stenosis as the most likely cause of symptoms (Slide #1). This recommendation further emphasizes the importance of confirming the stenosis severity in these patients.”

Low-Flow Low-Gradient Aortic Stenosis: When is it Severe? - American College of Cardiology

www.acc.org

 

[Status Sciaticus]

Lol, I have no real desire to do these cases

then why are you asking about solo vs supervision in cardiac cases? lol wut

 

[Hork Bajir]

Since the diagnosis of paradoxical LFLG AS relies heavily on echocardiographic measurement of stroke volume, accurate LVOT CSA measurement is critical. Usual 2D measurement assumes a circular LVOT, when in fact it is usually elliptical… and the 2D measurement that we make usually is the smaller axis of that ellipse. 3D LVOT planimetry results in an LVOT area that is on average 17% larger than those derived from 2D measurements (source: Three-dimensional imaging of the left ventricular outflow tract: impact on aortic valve area estimation by the continuity equation - PubMed )

Therefore, I usually try to use a 3D LVOT area to calculate SVI when diagnosing paradoxical LFLG AS in the OR, since it’s a kind of tricky and potentially high stakes call. It’s only a class IIa recommendation to replace at the time of CABG, so involves a lot of patient-specific decision making (is the anatomy suitable for TAVR down the road, etc).

BTW, in case the poster in the other thread who said “all cardiac cases are easy and the same” is reading this… These are the sorts of nuances that fly right over the heads of those who think cardiac cases just mean putting in lines.

 

[vector2]

Hey all, current CA3 here. I'll be staying at my home base to do a regional fellowship next year and will likely go PP once I'm finished. In talking to my co-residents who have already landed jobs and looking through job postings, I'm curious how supervising pump cases generally works out there in the wild. I've heard of places being 3:1 or 2:1 while supervising anesthetists doing pump cases and this just seems foreign to me coming out of residency. Several of my coresidents will be working in situations like this without cardiac fellowship and I'm curious how it's managed. Do the anesthetists do all the lines? If not fellowship trained, does cardiology or anesthesia do TEE, etc.? Any info about the setup at your shop is greatly appreciated!

Having seen/done cardiac cases in a few different institutions, I will tell you that practices can vary wildly. Community centers, while they do occasionally have some sick pts that are put on the schedule, by and large have "straightforward" cases. But the degree to which they are straightforward varies tremendously based on the surgeon(s) as well. The surgeons I work with cover 4 different hospitals between them, so efficiency and patient selection are king. They tend to try and not book severely decreased EFs, double valves, florid endocarditis if possible. When they do a 3v CABG for instance, incision is at 7am, they do vein harvest and LIMA takedown simultaneously with two people scrubbed in, the pump time is maybe 1h, and we're out of the room by 10:30. Pts rarely require vasopressor let alone inotropic support with pump and clamp times that short, and hemodynamics can be treated empirically or by swan since every pt gets one. They bring a pt back to the OR for post-op bleeding maybe three times a year. I TEE everyone if I am doing the case (advanced testamur), but if I'm not there cards will TEE for bentalls, MVR/r, etc. They don't even request TEE for CAB and AVR (crazy, I know). When you have surgeons like these who very rarely put anesthesiologists in difficult situations, the level of skill required - on average - for your anesthesia group changes. That being said, if you look at the echo thread, there's some clips from a redo MVR for prosthetic mitral fungal endocarditis in a 300 lb guy with right heart failure that I did with them as well.

If I have the heart room, I'm usually supervising 2:1. Occasionally 1:1 if the schedule is light. My other room is usually something like cataracts or a port placement under MAC, etc. I've also done cardiac locums where I've supervised 2-3 CRNAs (the 3rd being in outpt TEE land or cath lab). Start times are staggered so that I can induce/line/TEE to start and come off pump at different times. At another hospital across town where there's no cardiac trained people, the MD who has a pump case will put in the lines in preop, maybe show up for induction, and usually not show up for coming off pump. Likely because they have 3 other rooms (and not just MACs/easy stuff). So essentially the "cardiac" CRNA and the surgeon manage the case. Another practice a couple hours from me, there are a couple cardiac trained MDs, and one of them might have two pump cases plus one or two other rooms of varying difficulty.

Overall, I'll reiterate, the ability of an anesthesia group to handle some degree of cardiac volume without cardiac trained folks is highly variable. If you are at a hospital with surgeons who are routinely operating on pts with STS scores > 2-3% and who routinely have long pump/clamp times and high bring back rates, it is dangerous situation for patients and your group to continue this arrangement without fellowship trained folks and you are asking for trouble. I would never recommend to a friend or family member of mine who had the choice to get heart surgery at a center without cardiac fellowship trained (or bare minimum, longstanding experience + advanced TEE) anesthesiologists, but just realize that the experience one has at the mothership in training is nowhere close to the reality at the vast majority of hospitals out there.

 

[vector2]

Where I am at it is exclusively supervision outside of the cardiac rooms, doc only (or resident/fellow supervision) in the heart room. As an aside, it is very important to me that I have the opportunity to do my own cases some of the time.

But just last week, I was doing a “straightforward” normal EF CABG, and on the pre-bypass echo diagnosed previously undiscovered paradoxical low flow low gradient severe AS. I advised surgeon to replace the valve, which he did. Ask yourself if that is a call you would feel comfortable making without fairly extensive cardiac experience, not to mention at the very least PTE testamur status?

What did the preop TTE say

 

[anaesthetic]

Where I am at it is exclusively supervision outside of the cardiac rooms, doc only (or resident/fellow supervision) in the heart room. As an aside, it is very important to me that I have the opportunity to do my own cases some of the time.

But just last week, I was doing a “straightforward” normal EF CABG, and on the pre-bypass echo diagnosed previously undiscovered paradoxical low flow low gradient severe AS. I advised surgeon to replace the valve, which he did. Ask yourself if that is a call you would feel comfortable making without fairly extensive cardiac experience, not to mention at the very least PTE testamur status?

Exactly what I mean when I put “routine” in quotes. I’ve intubated and lined up several “straightforward” CABG patients only to wake them up after an unexpected TEE finding. Making that call would be difficult without the extra training/experience and trust with the surgeons.

 

[Reveler]

then why are you asking about solo vs supervision in cardiac cases? lol wut

Bc several of my co-residents are going to these practices as generalists and as someone who hasn't dug deep into the market yet, I'm curious how these setups operate. My preference is to avoid them but, again, having never held an anesthesia job outside of residency, I don't know what the norm is or what proportion of PP operates this way.

 

[nimbus]

Bc several of my co-residents are going to these practices as generalists and as someone who hasn't dug deep into the market yet, I'm curious how these setups operate. My preference is to avoid them but, again, having never held an anesthesia job outside of residency, I don't know what the norm is or what proportion of PP operates this way.

Our large west coast practice now requires ACTA fellowship for anyone who wants to take cardiac call and cover cardiac cases. A few old timers are still grandfathered in to the cardiac rotations but any new person who wants to join is required to have a fellowship. In fact we have one recently hired partner who is currently applying to ACTA fellowship because she is interested in doing hearts.

 

[vector2]

Exactly what I mean when I put “routine” in quotes. I’ve intubated and lined up several “straightforward” CABG patients only to wake them up after an unexpected TEE finding. Making that call would be difficult without the extra training/experience and trust with the surgeons.

There's a whole world out there where there's either no TEE for CAB (despite this massive retrospective JACC paper incidence of TEE for CAB is still only 60%), or there's a "don't ask don't tell" thing going on between the surgeon and echocardiographer regarding findings which don't absolutely have to be fixed that day.

 

[D P356]

Hey all, current CA3 here. I'll be staying at my home base to do a regional fellowship next year and will likely go PP once I'm finished. In talking to my co-residents who have already landed jobs and looking through job postings, I'm curious how supervising pump cases generally works out there in the wild. I've heard of places being 3:1 or 2:1 while supervising anesthetists doing pump cases and this just seems foreign to me coming out of residency. Several of my coresidents will be working in situations like this without cardiac fellowship and I'm curious how it's managed. Do the anesthetists do all the lines? If not fellowship trained, does cardiology or anesthesia do TEE, etc.? Any info about the setup at your shop is greatly appreciated!

Don’t worry, I read someone here stating cardiac anesthesiology is too easy…..

 

[Nivens]

I’m dual trained, 6 months out. Supervising 2 cardiac rooms and a general or thoracic/vascular room is challenging. Very grateful for my training.

 

[anaesthetic]

While I feel comfortable doing a relatively straight-forward pump case now and have decent TEE skills, a year of fellowship won't increase my comfort level in these cases so I'll likely choose a practice that doesn't require me to do them.

As a resident, I did the most number of cardiac and ICU rotations out of all of my classmates, partly on purpose and partly due to circumstance. I felt the same way, “comfortable” with a “straightforward” pump case, I thought. I was able to do a full TEE exam by the end of residency and was proficient with lines.

Now having been through fellowship training and working in a busy practice, I can safely say that I was completely wrong and was in no way prepared to do cardiac cases fresh out of residency. There is no way to prepare for the nuances of these cases and the variations of things that can go wrong without solely doing these cases for a year and looking at the TEE every single day. I am still seeing crazy things go wrong on the most routine cases.

I’m not saying it can’t be done. With the right attitude, motivation, and the right support/mentorship from your partners and surgeons, you can probably get to a point where you can do these cases very well over a couple of years. Some of our best guys never did a fellowship, although all of them have since stopped doing cardiac, owing to the increasing reliance on advanced TEE for our cases.

It sounds like you don’t really want to be doing these cardiac cases anyway, so being thrown into the fold for the sole purpose of landing a desirable job will get you into trouble, IMO, doubly so if you are doing a regional fellowship after training which will take you out of the OR even more. Proceed with caution.

 

[hiyaman]

Where I am at it is exclusively supervision outside of the cardiac rooms, doc only (or resident/fellow supervision) in the heart room. As an aside, it is very important to me that I have the opportunity to do my own cases some of the time.

But just last week, I was doing a “straightforward” normal EF CABG, and on the pre-bypass echo diagnosed previously undiscovered paradoxical low flow low gradient severe AS. I advised surgeon to replace the valve, which he did. Ask yourself if that is a call you would feel comfortable making without fairly extensive cardiac experience, not to mention at the very least PTE testamur status?

It's stuff like this is why I do not want to do cardiac and leave that to the cardiac trained ppl.

That's a pretty big call and you certainly improved that patients care that day

 

[JiPo]

Where I am at it is exclusively supervision outside of the cardiac rooms, doc only (or resident/fellow supervision) in the heart room. As an aside, it is very important to me that I have the opportunity to do my own cases some of the time.

But just last week, I was doing a “straightforward” normal EF CABG, and on the pre-bypass echo diagnosed previously undiscovered paradoxical low flow low gradient severe AS. I advised surgeon to replace the valve, which he did. Ask yourself if that is a call you would feel comfortable making without fairly extensive cardiac experience, not to mention at the very least PTE testamur status?

How does this work in terms of patient consent? Was there a suspicion that AVR was a possibility beforehand? Or did the surgeon get the consent from healthcare proxy over the phone intraop?

AVR for AS in the setting of CABG is the right call, but if no one mentioned AVR to the patient beforehand, I don’t know how I would feel about telling the patient in ICU that he/she either needs a tavr/re-op avr 15 years later or needs to be on AC for the rest of his/her life.

 

[anaesthetic]

How does this work in terms of patient consent? Was there a suspicion that AVR was a possibility beforehand? Or did the surgeon get the consent from healthcare proxy over the phone intraop?

AVR for AS in the setting of CABG is the right call, but if no one mentioned AVR to the patient beforehand, I don’t know how I would feel about telling the patient in ICU that he/she either needs a tavr/re-op avr 15 years later or needs to be on AC for the rest of his/her life.

I’ve had this happen. 50s M going for a CABG, pre-op TTE normal, severe AI on TEE after induction and lines. We woke him up, surgeon spoke to him about mechanical vs. bioprosthetic AVR, did his CABG AVR the following week. Surgeon and I were on the same page. The implications of putting in one valve versus the other warranted a proper discussion with the patient, IMO.

 

[sethco]

How does this work in terms of patient consent? Was there a suspicion that AVR was a possibility beforehand? Or did the surgeon get the consent from healthcare proxy over the phone intraop?

AVR for AS in the setting of CABG is the right call, but if no one mentioned AVR to the patient beforehand, I don’t know how I would feel about telling the patient in ICU that he/she either needs a tavr/re-op avr 15 years later or needs to be on AC for the rest of his/her life.

Maybe it's just me, but this seems to happen about once every 1-2 months where we have to change the operation based on TEE findings. Last week, it was a patient with a previous TIA with a highly mobile filamentous Fibroelastoma at the time of CABG that was not seen on TTE. Couple weeks before that, noted mild AI on preop TTE "suddenly" became severe in the OR. Surgeon will usually just talk to the family post-induction and get consent

As for doing Cardiac now a days without fellowship...As a group that does a heavy volume of Cardiac and multiple different levels of hospital cardiac volume, we are 100% solo and 70% of the people are Cardiac trained with the rest being Grandfathered (but still have TEE certification, which is needed for our hospitals credentials). We have had multiple people inquire over the years about doing Cardiac without fellowship, but the credentialing process would preclude it and the group mostly feels that it would be doing our surgeons a disservice, since we can't be there helping out most of the time

 

[vector2]

I’ve had this happen. 50s M going for a CABG, pre-op TTE normal, severe AI on TEE after induction and lines. We woke him up, surgeon spoke to him about mechanical vs. bioprosthetic AVR, did his CABG AVR the following week. Surgeon and I were on the same page. The implications of putting in one valve versus the other warranted a proper discussion with the patient, IMO.

I don't even understand how this happens anymore (assuming hemodynamic conditions are the same). Modern echo machines and surface probes are so good wrt penetrance, resolution, harmonic imaging etc that I can't even imagine missing severe AI on a routine pre-op TTE, esp when so many get definity or optison if the study is challenging at all.

Last week when a CABG I dropped off started to not do so well 15 min after arrival to ICU, I didn't go grab a TEE probe- I called an echo tech. With the GE vivid e9 and whatever latest probe he was using, the image quality might as well have been a TEE, even in a supine mechanically ventilated person with chest tubes.

 

[Robotic Wis-Hipple]

I don't even understand how this happens anymore (assuming hemodynamic conditions are the same). Modern echo machines and surface probes are so good wrt penetrance, resolution, harmonic imaging etc that I can't even imagine missing severe AI on a routine pre-op TTE, esp when so many get definity or optison if the study is challenging at all.

Last week when a CABG I dropped off started to not do so well 15 min after arrival to ICU, I didn't go grab a TEE probe- I called an echo tech. With the GE vivid e9 and whatever latest probe he was using, the image quality might as well have been a TEE, even in a supine mechanically ventilated person with chest tubes.

I don’t know man, I see a lot of poor quality TTEs. And then if the patient is booked for a CABG or there’s no mention of any suspicion of valvulopathy I think it’s conceivable the echo techs aren’t spending 5min trying to optimize their AV view for CFD/CWD/PWD analysis.

But iirc there’s a study that showed something like 9% of cardiac cases are “altered” by the intraop TEE. Now I don’t think I’ve seen anywhere near 10% of mine get altered, but there’s a lot of valvular pathology that grading is wildly different between preop and intraop studies.

 

[Robotic Wis-Hipple]

I currently train at a place that does lots of sick hearts and its tough for me to imagine supervising these rooms vs sitting solo. That's why I was curious how these go down outside of the ivory tower.

The day my career is limited to supervising multiple hearts in private practice (aka without ACTA Fellows in the rooms) is the day I never do another heart.

Imo supervising general cases is suboptimal and adds a level of liability. Doing that with 2-3 heart rooms? No thanks. I’d just supervise general rooms or if FIRE…. Peace out.

 

[anaesthetic]

I don't even understand how this happens anymore (assuming hemodynamic conditions are the same). Modern echo machines and surface probes are so good wrt penetrance, resolution, harmonic imaging etc that I can't even imagine missing severe AI on a routine pre-op TTE, esp when so many get definity or optison if the study is challenging at all.

Last week when a CABG I dropped off started to not do so well 15 min after arrival to ICU, I didn't go grab a TEE probe- I called an echo tech. With the GE vivid e9 and whatever latest probe he was using, the image quality might as well have been a TEE, even in a supine mechanically ventilated person with chest tubes.

I think it was a lazy cardiologist who made a fast read. It’s been a couple of years but IIRC, I went back to the TTE images, and it was present but the official read said “no valvular issues.” Probably a pre-populated template he used for normal exam findings. I don’t routinely overread the cardiologist’s TTE images, so unfortunately, the patient got two anesthetics.

A frequent issue I run into is a discrepancy in cardiac function but rarely significant valvular issues necessitating unexpected repair/replacement. It does happen though, and it’s usually in sicker patients who had borderline reads pre-op and wouldn’t tolerate a CABG+valve anyway.

 

[Hork Bajir]

How does this work in terms of patient consent? Was there a suspicion that AVR was a possibility beforehand? Or did the surgeon get the consent from healthcare proxy over the phone intraop?

AVR for AS in the setting of CABG is the right call, but if no one mentioned AVR to the patient beforehand, I don’t know how I would feel about telling the patient in ICU that he/she either needs a tavr/re-op avr 15 years later or needs to be on AC for the rest of his/her life.

Patient was mid-late 80s, surgeon called the wife as more of an FYI but put in an inspiris valve (so no AC, and I n the off chance he’s still running marathons in his 90s he can get a ViV TAVR)

 

[vector2]

I don’t know man, I see a lot of poor quality TTEs. And then if the patient is booked for a CABG or there’s no mention of any suspicion of valvulopathy I think it’s conceivable the echo techs aren’t spending 5min trying to optimize their AV view for CFD/CWD/PWD analysis.

But iirc there’s a study that showed something like 9% of cardiac cases are “altered” by the intraop TEE. Now I don’t think I’ve seen anywhere near 10% of mine get altered, but there’s a lot of valvular pathology that grading is wildly different between preop and intraop studies.

Indeed, there's definitely going to be a certain number of studies where no matter what machine they have, the study is just going to be dogsht. No way around it. But I think the cardiologist and the sonographer need to be aware of the patients who are booked for imminent so they can make sure to use alternative techniques/probes/contrast/go the extra mile etc to make sure there are no valvular lesions which are severe, or barring that, no remodeling changes which are consistent with a severe lesions, plus try to eliminate the discovery of future surprises.

In regard to the 9% figure, it comes from this paper here:

Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery - PubMed

Intraoperative TEE influences cardiac surgical decisions in more than 9% of all patients in the presented study population, with the greatest observed impact in patients undergoing combined CABG and valve procedures.

pubmed.ncbi.nlm.nih.gov

Just keep in mind it was published in 2008, and the advances in both surface and transesophageal hardware has been *insane* over the last 15 years. For instance, this is a TTE shot from my post-op CAB who started having increasing PADs, decreased CI, and hypotension in the ICU. Hx of previous inferior MI. Was worried his LIMA had gone down and/or worsening ischemic MR.

Again, I think a surface shot of this quality in a supine, intubated, mechanically ventilated pt with chest tubes would've been unthinkable 15-20 yrs ago.

I think it was a lazy cardiologist who made a fast read. It’s been a couple of years but IIRC, I went back to the TTE images, and it was present but the official read said “no valvular issues.” Probably a pre-populated template he used for normal exam findings. I don’t routinely overread the cardiologist’s TTE images, so unfortunately, the patient got two anesthetics.

A frequent issue I run into is a discrepancy in cardiac function but rarely significant valvular issues necessitating unexpected repair/replacement. It does happen though, and it’s usually in sicker patients who had borderline reads pre-op and wouldn’t tolerate a CABG+valve anyway.

I think the discrepancy in cardiac function happens all the time, and dunno if that's preventable just because of the interobserver variability, observers not looking at WMA in all views, and the difference in loading conditions under anesthesia. But that's just unacceptable imo for the pre-op read to have said "no valvular issues" when there was in fact significant AI on the pre-op TTE. That's why most good echo departments have regular QI meetings where they go over studies as a group to evaluate discrepancies and tighten interobserver variability.

When you went back to the TTE images, how bad was the AI (and was the study adequate)? If you had seen the TTE beforehand would you have told the surgeon he needs to amend his consent before you roll the OR?

 

[anaesthetic]

I think the discrepancy in cardiac function happens all the time, and dunno if that's preventable just because of the interobserver variability, observers not looking at WMA in all views, and the difference in loading conditions under anesthesia. But that's just unacceptable imo for the pre-op read to have said "no valvular issues" when there was in fact significant AI on the pre-op TTE. That's why most good echo departments have regular QI meetings where they go over studies as a group to evaluate discrepancies and tighten interobserver variability.

When you went back to the TTE images, how bad was the AI (and was the study adequate)? If you had seen the TTE beforehand would you have told the surgeon he needs to amend his consent before you roll the OR?

Agreed. I see a discrepancy in LV function probably 2-3 times a month, sometimes more if I’m doing a lot of cardiac cases. None that really alter the surgery all that much except having inotropes dialed in for CPB weaning. Probably a combination of interobserver variability and hemodynamics intra-op. I’ve seen it change from initial TEE exam, mostly improving prior to going on pump once hemodynamics/fluids were optimized.

I remember the AI was significant (at least moderate) but don’t remember the exact numbers. I would have definitely visited with the surgeon prior to rolling had I caught it in pre-op. We pulled up the TTE images intra-op and confirmed it was present pre-op. I’m not TTE certified, but the AI was obvious enough to warrant addressing. I’m wondering if the cardiologist just assumed a 50 y/o would not have significant valvular issues without a bicuspid valve. Oh well. The patient was reasonable and did well, thankfully.

 

[coffeebythelake]

Two words: liability sponge

 

[Robotic Wis-Hipple]

Indeed, there's definitely going to be a certain number of studies where no matter what machine they have, the study is just going to be dogsht. No way around it. But I think the cardiologist and the sonographer need to be aware of the patients who are booked for imminent so they can make sure to use alternative techniques/probes/contrast/go the extra mile etc to make sure there are no valvular lesions which are severe, or barring that, no remodeling changes which are consistent with a severe lesions, plus try to eliminate the discovery of future surprises.

In regard to the 9% figure, it comes from this paper here:

Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery - PubMed

Intraoperative TEE influences cardiac surgical decisions in more than 9% of all patients in the presented study population, with the greatest observed impact in patients undergoing combined CABG and valve procedures.

pubmed.ncbi.nlm.nih.gov

Just keep in mind it was published in 2008, and the advances in both surface and transesophageal hardware has been *insane* over the last 15 years. For instance, this is a TTE shot from my post-op CAB who started having increasing PADs, decreased CI, and hypotension in the ICU. Hx of previous inferior MI. Was worried his LIMA had gone down and/or worsening ischemic MR.

View attachment 351072

Again, I think a surface shot of this quality in a supine, intubated, mechanically ventilated pt with chest tubes would've been unthinkable 15-20 yrs ago.

I think the discrepancy in cardiac function happens all the time, and dunno if that's preventable just because of the interobserver variability, observers not looking at WMA in all views, and the difference in loading conditions under anesthesia. But that's just unacceptable imo for the pre-op read to have said "no valvular issues" when there was in fact significant AI on the pre-op TTE. That's why most good echo departments have regular QI meetings where they go over studies as a group to evaluate discrepancies and tighten interobserver variability.

When you went back to the TTE images, how bad was the AI (and was the study adequate)? If you had seen the TTE beforehand would you have told the surgeon he needs to amend his consent before you roll the OR?

Somehow I knew either you or @coffeebythelake would provide the study I was too lazy to google myself.

But agree that there’s been huge gains in TTE.

But either way, I see discrepancy between TTE/TEE monthly.

 

[pgg]

I don't even understand how this happens anymore (assuming hemodynamic conditions are the same). Modern echo machines and surface probes are so good wrt penetrance, resolution, harmonic imaging etc that I can't even imagine missing severe AI on a routine pre-op TTE, esp when so many get definity or optison if the study is challenging at all.

A couple months ago we had a CABG patient that made it to the OR without a big ol' honkin' mxyoma in the left atrium being picked up by preop imaging. Literally the first thing seen after putting the TEE in.

I hear the arguments for not doing TEE on routine CABGs but then outliers like that come up...

 

[vector2]

Somehow I knew either you or @coffeebythelake would provide the study I was too lazy to google myself.

But agree that there’s been huge gains in TTE.

But either way, I see discrepancy between TTE/TEE monthly.

Indeed, the rate of discrepancy between imaging modalities is never going to be zero, but I do think it's going to go lower and lower and lower as tech gets better.

A couple months ago we had a CABG patient that made it to the OR without a big ol' honkin' mxyoma in the left atrium being picked up by preop imaging. Literally the first thing seen after putting the TEE in.

I hear the arguments for not doing TEE on routine CABGs but then outliers like that come up...

Was the myxoma absent on the TTE or did the reader just miss it? Big ones aren't subtle, even on surface imaging

Regardless, TEE should be routine on CAB beyond reasons of just picking up missed pre-op findings. As everyone knows it's the most valuable monitor, esp since most folks don't routinely swan anymore