TEE

[jeesapeesa]

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hey guys, just a quick case just wondering what you guys think..

pt is scheduled for TEE/RHC by the cardiologist and you are asked to provide anesthesia.

37 yo F with coronary artery vasospasm: s/p LHC on 5/13 with 90% narrowing of the LAD. staged PCI revealed normal coronaries. acute systolic CHF: Patient in respiratory distress with bilateral crackles on exam. chest x-ray on 05/18 revealed new interstitial pulmonary edema. chest x-ray on 5/20 shows worsening infiltrates and/or edema. TTE on 5/14 revealed mildly increased LV wall thickness with normal systolic function and estimated LVEF 55-60%. TTE on 5/18 revealed LVEF 35-45% with akinesis of basal-mid inferior lateral myocardium with severe MR (possible ruptured chordae),
RVSP=31mmHg

she is currently tachycardic in the 120s and hypotensive with blood pressure ranging in 80s-90/50s-60s with s/s of acute respiratory failure on oximyzer 11 LPM most likely cardiogenic pulm edema from acute CHF.

obviously i'm concerned about cardiopulmonary/hemodynamic decompensation so..

would you consider telling the cardiologist to spray some topical lido and give a touch of midaz/fentanyl and give it a go?
touch of prop/versed/fent/ketamine?
cancel?
CT surgery?

 

[Ronin786]

What are the cardiologists looking to find?

Elevated PA pressures? She has them.

Elevated CVP? She has it.

Better classify the MR jet? She's 37 years old, she doesn't need a Mitra-clip.

This lady needs BiPAP, a furosemide infusion and maybe a CT surgery consult once euvolemic. Classic cardiologists ****ing around looking for more numbers.

 

[Planktonmd]

From your description it sounds to me that the priority now is to treat the patient not do a couple of useless diagnostic tests.
I would also make sure that she does not have Covid 19.

 

[Hork Bajir]

Agree with above. But I’ll bite, for the sake of argument: topicalize well, small amount of versed and fent, give your drugs plenty of time to circulate and work, maaaaaybe 10mg of prop with a phenylephrine chaser for the probe passing UES (if you’re feeling generous. No anesthesia needed other than a lido skin wheal for the RHC... Unless you’re that thirsty for units in the era of COVID, in which case you can do a superficial cervical plexus block. Be sure to make a big production out of it so that everyone thinks you’re doing something important

 

[deleted171991]

hey guys, just a quick case just wondering what you guys think..

pt is scheduled for TEE/RHC by the cardiologist and you are asked to provide anesthesia.

37 yo F with coronary artery vasospasm: s/p LHC on 5/13 with 90% narrowing of the LAD. staged PCI revealed normal coronaries. acute systolic CHF: Patient in respiratory distress with bilateral crackles on exam. chest x-ray on 05/18 revealed new interstitial pulmonary edema. chest x-ray on 5/20 shows worsening infiltrates and/or edema. TTE on 5/14 revealed mildly increased LV wall thickness with normal systolic function and estimated LVEF 55-60%. TTE on 5/18 revealed LVEF 35-45% with akinesis of basal-mid inferior lateral myocardium with severe MR (possible ruptured chordae),
RVSP=31mmHg

she is currently tachycardic in the 120s and hypotensive with blood pressure ranging in 80s-90/50s-60s with s/s of acute respiratory failure on oximyzer 11 LPM most likely cardiogenic pulm edema from acute CHF.

obviously i'm concerned about cardiopulmonary/hemodynamic decompensation so..

would you consider telling the cardiologist to spray some topical lido and give a touch of midaz/fentanyl and give it a go?
touch of prop/versed/fent/ketamine?
cancel?
CT surgery?

I would cancel. This is an almost elective procedure on a patient in pulmonary edema. They can go F themselves. *****s. They need to optimize the patient first. That should take 1-2 days only. This patient needs NIPPV and diuresis; a medical student would know that. Serious lasix drip, touch of phenylephrine gtt to support the BP and coronary perfusion, CPAP. There is nothing that the TEE will tell them that will change management at this point. By the time she's euvolemic, she probably won't need anything.

If the patient gets better, they can do the study then, if they really must. If the patient gets worse, she will be intubated and on pressors, and they can do the study then. Both options are better than playing ICU in the cath lab with an unstable patient (and I am an intensivist).

All those numbers you quoted and all the echos are volatile like ether, depending on vasospasm. Even if they did a TEE/RHC, whatever they see/measure may be gone by tomorrow. Btw, how does her ECG look now?

 

[dannyboy1]

Agree with above. But I’ll bite, for the sake of argument: topicalize well, small amount of versed and fent, give your drugs plenty of time to circulate and work, maaaaaybe 10mg of prop with a phenylephrine chaser for the probe passing UES (if you’re feeling generous. No anesthesia needed other than a lido skin wheal for the RHC... Unless you’re that thirsty for units in the era of COVID, in which case you can do a superficial cervical plexus block. Be sure to make a big production out of it so that everyone thinks you’re doing something important

10 mg of prop? This patient is 37 years old, gonna take a lot more then that to pass the probe. I would feel better if this patient was 87, you don’t have to give much, their throats are half dead anyways. The younger the patient the more nervous I become when doing TEE or EGD.

 

[cchoukal]

Assuming you're not able to talk the cardiologists out of doing it, and assuming FFP won't come and do it for you, yes, these can be done 100% with local. If they don't want to topicalize, then you do it. Since SOME sedation is warranted, whether it's midaz/fent or prop is probably not that relevant, but go slow either way.

 

[vector2]

I was about to reply but then I went back to the OP and saw I missed he wrote severe MR (possible ruptured chordae). If the suspicion of chordal or papillary rupture is high enough then a TEE is warranted. If the pt has clean coronaries and we think LV function is down due to vasospasm and MR is due to spastic ischemia, then make sure the damned vasospasm and acute CHF is actually being treated and worry about the RHC/TEE later.

 

[AdmiralChz]

Prop sux tube TEE cardiac OR

 

[MoMoGesiologist]

One thing that becomes clearer as I continue in my medical career: medicine specialties keep ordering more labs/tests while delaying care for a crumping pt vs surgical specialties treat the patient without necessarily knowing wth is going on or trying too hard to figure it out. Anesthesia: do the minimum and appropriate workup and optimize the patient, all while trying to make it home by 3pm!

 

[coffeebythelake]

Prop sux tube TEE cardiac OR

I mean this is one way to do it.

Getting this patient alive through the procedure isn't the problem.

Being able to extubate them expeditiously or not requiring massive doses of pressors/inotropes, art line, etc is.

 

[vector2]

One thing that becomes clearer as I continue in my medical career: medicine specialties keep ordering more labs/tests while delaying care for a crumping pt vs surgical specialties treat the patient without necessarily knowing wth is going on or trying too hard to figure it out. Anesthesia: do the minimum and appropriate workup and optimize the patient, all while trying to make it home by 3pm!

One of my colleagues not too long ago had a pt who was booked by gen surg for some LLE wound washout/flap nonsense. She was a polytrauma (including a small head bleed) who had been in the hospital for a couple weeks and was now stable enough on the floor to get the lower acuity stuff done in the OR.

We look at her labs. Sodium is 118. Scroll back to her admission labs. Na 141. Click over to trauma surg intern progress note:

Plan:
...
Hyponatremia
Continue salt tabs
...



As you can imagine, no further chemistries, no urine labs, no nephro consult or other mgmt by surgery. Obviously we cancel....nephro later diagnosed SIADH.

 

[MoMoGesiologist]

One of my colleagues not too long ago had a pt who was booked by gen surg for some LLE wound washout/flap nonsense. She was a polytrauma (including a small head bleed) who had been in the hospital for a couple weeks and was now stable enough on the floor to get the lower acuity stuff done in the OR.

We look at her labs. Sodium is 118. Scroll back to her admission labs. Na 141. Click over to trauma surg intern progress note:

Plan:
...
Hyponatremia
Continue salt tabs
...



As you can imagine, no further chemistries, no urine labs, no nephro consult or other mgmt by surgery. Obviously we cancel....nephro later diagnosed SIADH.

Is this a generally a good hospital you work at? Or are you at a very rural community place? Hope this kind of stuff isn't common, but from what I hear from my friends at community places, care can be real bad. Of course patients are none the wiser

 

[vector2]

Is this a generally a good hospital you work at? Or are you at a very rural community place? Hope this kind of stuff isn't common, but from what I hear from my friends at community places, care can be real bad. Of course patients are none the wiser

Nope, tertiary level I center. Major (medical) ball dropping sometimes happens on floor surgical pts depending on whether the floor trauma census is huge and depending on which trauma staff is rounding that day.

 

[dchz]

37 yo F with coronary artery vasospasm: s/p LHC on 5/13 with 90% narrowing of the LAD. staged PCI revealed normal coronaries.

The way you state this is a bit confusing, my reply is based on the assumption she's got normal coronaries at the time of the TEE. (i'm not sure if the 90% narrowing is due to vasospasm or it got stented or both?).

she is currently tachycardic in the 120s and hypotensive with blood pressure ranging in 80s-90/50s-60s with s/s of acute respiratory failure on oximyzer 11 LPM most likely cardiogenic pulm edema from severe MR.

FTFY

What are the cardiologists looking to find?

Elevated PA pressures? She has them.

Elevated CVP? She has it.

Better classify the MR jet? She's 37 years old, she doesn't need a Mitra-clip.

This lady needs BiPAP, a furosemide infusion and maybe a CT surgery consult once euvolemic. Classic cardiologists ****ing around looking for more numbers.

I can understand sentiment above, it's frustrating because it feels like the TEE is unnecessary - they are going to do a TEE when they repair the mitral valve anyways. Obviously, until you state that lactate is a better test than base excess for ischemia, i'm gonna disagree with you on everything.

In all seriousness, I actually believe the TEE might affect the decision making for the patient. The RHC is pointless. I have been doing a lot of TTEs for the past few weeks and I've actually had a case very similar to this recently - I discovered severe MR on TTE and wasn't sure if it was primary or secondary, it didn't make any difference because the patient needed an open heart operation anyways, so we could figure out what to do about the mitral valve intra op. Not the case for this patient.

First, TTE isn't the best modality for grading MR. The LA is the near field for TEE views, but it's the farfield for all TTE views. The grading between severe and moderate between cardiologists reading TTEs is closer than you think. So if we are going commit her to an operation, let's make sure she needs it first?

Let's examine the decision making for this patient after a TEE:

If this is severe primary MR and amendable to a mitraclip, i would actually argue she should get a mitra-clip. It spares her the open heart surgery with almost equivalent survival: Source.

If this is severe primary MR and not amenable to mitraclip: repair of mitral valve would give her best long term mortality benefit. No source because i'm lazy and because it's pretty much accepted if it's primary severe MR you fix it.

If this is severe secondary MR: you wait until the myocardium recovers and see if it gets better. Source Page 262 after you open the PDF

If this MR is moderate: you medically stabilize to see if it gets better.

All of what I typed up can be summed up with this figure:

In my book, level IIa and IIb evidence means nothing. But notice what we do changes a lot with what kind of MR it is.



Now with regards about the anesthesia provided, several things have to be considered:

- EF of 35-45% with severe MR is VERY LOW, the number is lying to you, a lot of the EF is pushed retrograde rather than antegrade.
- Lowering SVR HELPS all regurgitant lesions.
- Pt is 37 years old and clean coronaries.
- This TEE will take at least 10 mins for an experienced operator if they want to do a full study, probably longer for cardiologists that don't do a lot of TEE. At the same time, if they catch the cords and know it's severe, they might get all the info they need in 2 mins. So your anesthetic needs to be flexible and titratable.

What i'm about to say sounds extremely cavalier, but i assure you that i'm not crazy: I would propfol infusion with some epi (10mcg/cc) on standby.


Tl; DR: Do the TEE with propofol (but it can be done with local only). No RHC. Would definitely not cancel, but the best alternative is to argue this TEE should be done with MitraClip and Surgical repair on standby so you can just tube the pt and get it over with, AKA:

Prop sux tube TEE cardiac OR

 

[vector2]

The way you state this is a bit confusing, my reply is based on the assumption she's got normal coronaries at the time of the TEE. (i'm not sure if the 90% narrowing is due to vasospasm or it got stented or both?).



FTFY



I can understand sentiment above, it's frustrating because it feels like the TEE is unnecessary - they are going to do a TEE when they repair the mitral valve anyways. Obviously, until you state that lactate is a better test than base excess for ischemia, i'm gonna disagree with you on everything.

In all seriousness, I actually believe the TEE might affect the decision making for the patient. The RHC is pointless. I have been doing a lot of TTEs for the past few weeks and I've actually had a case very similar to this recently - I discovered severe MR on TTE and wasn't sure if it was primary or secondary, it didn't make any difference because the patient needed an open heart operation anyways, so we could figure out what to do about the mitral valve intra op. Not the case for this patient.

First, TTE isn't the best modality for grading MR. The LA is the near field for TEE views, but it's the farfield for all TTE views. The grading between severe and moderate between cardiologists reading TTEs is closer than you think. So if we are going commit her to an operation, let's make sure she needs it first?

Let's examine the decision making for this patient after a TEE:

If this is severe primary MR and amendable to a mitraclip, i would actually argue she should get a mitra-clip. It spares her the open heart surgery with almost equivalent survival: Source.

If this is severe primary MR and not amenable to mitraclip: repair of mitral valve would give her best long term mortality benefit. No source because i'm lazy and because it's pretty much accepted if it's primary severe MR you fix it.

If this is severe secondary MR: you wait until the myocardium recovers and see if it gets better. Source Page 262 after you open the PDF

If this MR is moderate: you medically stabilize to see if it gets better.

All of what I typed up can be summed up with this figure:

In my book, level IIa and IIb evidence means nothing. But notice what we do changes a lot with what kind of MR it is.



Now with regards about the anesthesia provided, several things have to be considered:

- EF of 35-45% with severe MR is VERY LOW, the number is lying to you, a lot of the EF is pushed retrograde rather than antegrade.
- Lowering SVR HELPS all regurgitant lesions.
- Pt is 37 years old and clean coronaries.
- This TEE will take at least 10 mins for an experienced operator if they want to do a full study, probably longer for cardiologists that don't do a lot of TEE. At the same time, if they catch the cords and know it's severe, they might get all the info they need in 2 mins. So your anesthetic needs to be flexible and titratable.

What i'm about to say sounds extremely cavalier, but i assure you that i'm not crazy: I would propfol infusion with some epi (10mcg/cc) on standby.


Tl; DR: Do the TEE with propofol (but it can be done with local only). No RHC. Would definitely not cancel, but the best alternative is to argue this TEE should be done with MitraClip and Surgical repair on standby so you can just tube the pt and get it over with, AKA:

I know if you spot checked a euroscore or STS on this lady in her current condition it would he high but there is no chance I'm taking a 37yo with primary MR, clean coronaries, no other valve issues, no other severe systemic disease for some POS clip that might not not even fix the problem let alone be durable in 10 years.

In the throws of decompensated primary MR with pulm edema, intubate, impella vs. Iabp, tell perfusionist to remove a bunch of volume on pump, repair the valve, leave MCS in until her function recovers in the ICU. I honestly don't think her clinical picture is prohibitive for surgery, especially if she is not in multi system organ failure from hypoperfusion. I'm sure you've also taken younger, much sicker left and right sided native valve endocarditis pts to the OR....they typically do better than you would think from looking at them on paper.

 

[deleted697535]

What are the cardiologists looking to find?

Elevated PA pressures? She has them.

Elevated CVP? She has it.

Better classify the MR jet? She's 37 years old, she doesn't need a Mitra-clip.

This lady needs BiPAP, a furosemide infusion and maybe a CT surgery consult once euvolemic. Classic cardiologists ****ing around looking for more numbers.

I would imagine they're not looking for numbers, they're looking for what the f is causing her MR and how to fix her.
CT are probably on board asking for this, i would also hope.

And i would also imagine shes on bipap/lasix which she obviously needs.

Carpentier 1vs 3a or 3b is very different MR with different treatments.
MV replace vs MV repair vs Medical mgt ie Dob+-LVAD.

Id honestly stick the probe on her chest and see what the MR looks like. Id bring the cardiologist to the bedside, andCT, or else review their shots.

Perrino's chapter on MR really spells all this out.
If they insist on TEE, id give her 48 hours of dob, bipap and lasix then ketofol low dose with epi running. Be grand

As already alluded to her 35% LVfn is severely reduced with 4+MR. Be careful

Functional MR has a central jet, no and unless she has **** windows or is very obese id hope tte could tell next step.

 

[dchz]

I know if you spot checked a euroscore or STS on this lady in her current condition it would he high but there is no chance I'm taking a 37yo with primary MR, clean coronaries, no other valve issues, no other severe systemic disease for some POS clip that might not not even fix the problem let alone be durable in 10 years.

In the throws of decompensated primary MR with pulm edema, intubate, impella vs. Iabp, tell perfusionist to remove a bunch of volume on pump, repair the valve, leave MCS in until her function recovers in the ICU. I honestly don't think her clinical picture is prohibitive for surgery, especially if she is not in multi system organ failure from hypoperfusion. I'm sure you've also taken younger, much sicker left and right sided native valve endocarditis pts to the OR....they typically do better than you would think from looking at them on paper.

Which one of the following patients would you take to the OR:

47F w/ previous MI and MitraClip with previous NYHA class 1 normal exercise capacity and new acute decrease in exercise capacity.

37F w/ STEMI 1 week ago s/p stent on antiplatelate therapy NYHA class 4 with primary MR.

You can call it POS clip if you want, but it's a viable option for this lady. We aren't giving her either primary repair or mitraclip and then throwing her on an island. We are going to continue follow ups and yearly TTEs. Mitral repair after mitraclip is well documented and a completely viable option.

 

[Hoya11]

hey guys, just a quick case just wondering what you guys think..

pt is scheduled for TEE/RHC by the cardiologist and you are asked to provide anesthesia.

37 yo F with coronary artery vasospasm: s/p LHC on 5/13 with 90% narrowing of the LAD. staged PCI revealed normal coronaries. acute systolic CHF: Patient in respiratory distress with bilateral crackles on exam. chest x-ray on 05/18 revealed new interstitial pulmonary edema. chest x-ray on 5/20 shows worsening infiltrates and/or edema. TTE on 5/14 revealed mildly increased LV wall thickness with normal systolic function and estimated LVEF 55-60%. TTE on 5/18 revealed LVEF 35-45% with akinesis of basal-mid inferior lateral myocardium with severe MR (possible ruptured chordae),
RVSP=31mmHg

she is currently tachycardic in the 120s and hypotensive with blood pressure ranging in 80s-90/50s-60s with s/s of acute respiratory failure on oximyzer 11 LPM most likely cardiogenic pulm edema from acute CHF.

obviously i'm concerned about cardiopulmonary/hemodynamic decompensation so..

would you consider telling the cardiologist to spray some topical lido and give a touch of midaz/fentanyl and give it a go?
touch of prop/versed/fent/ketamine?
cancel?
CT surgery?

You've got to pick your battles..

In the end this boils down to a 10 minute anesthetic with versed, fentanyl, etomidate - shell be fine. She has an EF >35. She has clean coronaries. Shes 37. People who are 90 with EF of 10% and ESRD can tolerate a TEE/Endoscopy. Just do it..

You are inserting yourself into the cardiac decision making process inappropriately.. they thought it was a useful test so they ordered it..

Are they clueless about anesthetic risks? Yes. But they are not asking you to do a VATS on her or a TKR, its a quick and useful diagnostic test..

 

[deleted697535]

You've got to pick your battles..

In the end this boils down to a 10 minute anesthetic with versed, fentanyl, etomidate - shell be fine. She has an EF >35. She has clean coronaries. Shes 37. People who are 90 with EF of 10% and ESRD can tolerate a TEE/Endoscopy. Just do it..

You are inserting yourself into the cardiac decision making process inappropriately.. they thought it was a useful test so they ordered it..

Are they clueless about anesthetic risks? Yes. But they are not asking you to do a VATS on her or a TKR, its a quick and useful diagnostic test..

Mostly agree except for italics. She has severe MR

 

[dchz]

You've got to pick your battles..

In the end this boils down to a 10 minute anesthetic with versed, fentanyl, etomidate - shell be fine. She has an EF >35. She has clean coronaries. Shes 37. People who are 90 with EF of 10% and ESRD can tolerate a TEE/Endoscopy. Just do it..

You are inserting yourself into the cardiac decision making process inappropriately.. they thought it was a useful test so they ordered it..

Are they clueless about anesthetic risks? Yes. But they are not asking you to do a VATS on her or a TKR, its a quick and useful diagnostic test..

Counterpoint: Anesthesiologists are physicians too and should be involved in the process. You should not involve yourself in the process if you don't know the risks long term.

Also EF > 35% with severe MR is EF 15% w/o severe MR.

 

[kidthor]

Counterpoint: Anesthesiologists are physicians too and should be involved in the process. You should not involve yourself in the process if you don't know the risks long term.

Also EF > 35% with severe MR is EF 15% w/o severe MR.

Yeah, surgeons and others try to do stuff with patients that could incur unbalanced risk to benefit. A physician to physician discussion can work this out. And you must refuse to do anything and everything you think is unwarranted or unsafe.

Don’t do something stupid because someone (an Intern, an office manager, a misguided hyper-billing poor TEE-performing cardiologist, or a misinformed patient) clicked a box saying “with anesthesia”.

 

[vector2]

Which one of the following patients would you take to the OR:

47F w/ previous MI and MitraClip with previous NYHA class 1 normal exercise capacity and new acute decrease in exercise capacity.

37F w/ STEMI 1 week ago s/p stent on antiplatelate therapy NYHA class 4 with primary MR.

You can call it POS clip if you want, but it's a viable option for this lady. We aren't giving her either primary repair or mitraclip and then throwing her on an island. We are going to continue follow ups and yearly TTEs. Mitral repair after mitraclip is well documented and a completely viable option.

Just because one is in favor of surgical repair doesn't mean she has to go to the OR in the next 15 minutes either. It wasn't particularly clear in the OP if she actually got the stent or not, but if she did then she can still be treated with bipap/intubation, lasix, and MCS for a few days while the plavix washes out and have some plts and ddavp ready when she goes.

Even though the clip is "viable" does not mean it's anywhere close to being the best choice. It is "a" choice. There is a reason that it's barely a grade 2c recommendation for its classic indication for old sick gomers with chronic primary severe MR who meet all the criteria, let alone some young lady with ?vasospasm and a possibly acutely ruptured ischemic PM pap/chords.

Honestly I think we need more information about all the other comorbidities that would contribute to an accurate assessment of her morbidity and mortality. Additionally, what is the current status of her vasospasm and how is that affecting her function? Clip is viable if she is death door sick with MSOF and/or we find she has absolutely perfect, pristine clippable anatomy with isolated P2 prolapse- not so much if her only negative predictors are urgent status, reduced EF, and NYHA IV, in which case she buys herself a surgical repair.

 

[deleted59964]

swab Prop sux tube TEE cardiac OR

ftfy

 

[deleted171991]

One of my colleagues not too long ago had a pt who was booked by gen surg for some LLE wound washout/flap nonsense. She was a polytrauma (including a small head bleed) who had been in the hospital for a couple weeks and was now stable enough on the floor to get the lower acuity stuff done in the OR.

We look at her labs. Sodium is 118. Scroll back to her admission labs. Na 141. Click over to trauma surg intern progress note:

Plan:
...
Hyponatremia
Continue salt tabs
...



As you can imagine, no further chemistries, no urine labs, no nephro consult or other mgmt by surgery. Obviously we cancel....nephro later diagnosed SIADH.

There is a reason the Brits don't call a surgeon Doctor.

 

[deleted171991]

The way you state this is a bit confusing, my reply is based on the assumption she's got normal coronaries at the time of the TEE. (i'm not sure if the 90% narrowing is due to vasospasm or it got stented or both?).



FTFY



I can understand sentiment above, it's frustrating because it feels like the TEE is unnecessary - they are going to do a TEE when they repair the mitral valve anyways. Obviously, until you state that lactate is a better test than base excess for ischemia, i'm gonna disagree with you on everything.

In all seriousness, I actually believe the TEE might affect the decision making for the patient. The RHC is pointless. I have been doing a lot of TTEs for the past few weeks and I've actually had a case very similar to this recently - I discovered severe MR on TTE and wasn't sure if it was primary or secondary, it didn't make any difference because the patient needed an open heart operation anyways, so we could figure out what to do about the mitral valve intra op. Not the case for this patient.

First, TTE isn't the best modality for grading MR. The LA is the near field for TEE views, but it's the farfield for all TTE views. The grading between severe and moderate between cardiologists reading TTEs is closer than you think. So if we are going commit her to an operation, let's make sure she needs it first?

Let's examine the decision making for this patient after a TEE:

If this is severe primary MR and amendable to a mitraclip, i would actually argue she should get a mitra-clip. It spares her the open heart surgery with almost equivalent survival: Source.

If this is severe primary MR and not amenable to mitraclip: repair of mitral valve would give her best long term mortality benefit. No source because i'm lazy and because it's pretty much accepted if it's primary severe MR you fix it.

If this is severe secondary MR: you wait until the myocardium recovers and see if it gets better. Source Page 262 after you open the PDF

If this MR is moderate: you medically stabilize to see if it gets better.

All of what I typed up can be summed up with this figure:

In my book, level IIa and IIb evidence means nothing. But notice what we do changes a lot with what kind of MR it is.



Now with regards about the anesthesia provided, several things have to be considered:

- EF of 35-45% with severe MR is VERY LOW, the number is lying to you, a lot of the EF is pushed retrograde rather than antegrade.
- Lowering SVR HELPS all regurgitant lesions.
- Pt is 37 years old and clean coronaries.
- This TEE will take at least 10 mins for an experienced operator if they want to do a full study, probably longer for cardiologists that don't do a lot of TEE. At the same time, if they catch the cords and know it's severe, they might get all the info they need in 2 mins. So your anesthetic needs to be flexible and titratable.

What i'm about to say sounds extremely cavalier, but i assure you that i'm not crazy: I would propfol infusion with some epi (10mcg/cc) on standby.


Tl; DR: Do the TEE with propofol (but it can be done with local only). No RHC. Would definitely not cancel, but the best alternative is to argue this TEE should be done with MitraClip and Surgical repair on standby so you can just tube the pt and get it over with, AKA:

You wanna bet it's not chord rupture?

Btw, my protest was for the TEE/RHC. I may talk her through a 15 minute-TEE, while sitting, with some lidocaine, fentanyl and versed, especially in the hands of an expert. TEE is an awake procedure in many countries. Not that I think she needs one. What she may need is a better cardiologist, but let's see the rest of the story.

And anybody who thinks this lady needs a RHC now, before being diuresed to euvolemia, is a *****, hence my previous post. The number one cause of increased pulmonary pressures is left heart disease (type 2 PHTN), many times due to fluid overload (which I bet she got a ton of, to "treat" her hypotension). The likelihood of a primary MR is very-very low.

 

[deleted171991]

You've got to pick your battles..

In the end this boils down to a 10 minute anesthetic with versed, fentanyl, etomidate - shell be fine. She has an EF >35. She has clean coronaries. Shes 37. People who are 90 with EF of 10% and ESRD can tolerate a TEE/Endoscopy. Just do it..

You are inserting yourself into the cardiac decision making process inappropriately.. they thought it was a useful test so they ordered it..

Are they clueless about anesthetic risks? Yes. But they are not asking you to do a VATS on her or a TKR, its a quick and useful diagnostic test..

This is how one ends up being considered a tech/tube monkey, not a consultant. Yes, we need to be part of that decision-making process in a patient like this. The anesthesiologist is not just the monkey, at the head of the bed, who keeps the patient comfortable.

If I order a heart cath on a patient, as an intensivist, would a cardiologist just jump and execute, especially if he thinks it's inappropriate?

Anesthesiologists in this country have been in need of a pair for a very long time. That's why this specialty is becoming a nursing specialty. One doesn't need medical school to become a yesman monkey.

 

[deleted171991]

Counterpoint: Anesthesiologists are physicians too and should be involved in the process. You should not involve yourself in the process if you don't know the risks long term.

Also EF > 35% with severe MR is EF 15% w/o severe MR.

YOU WON'T TRULY KNOW HOW BAD IT IS UNTIL SHE'S EUVOLEMIC AGAIN! You put 5 liters of fluid in a borderline heart and it becomes a bad heart (for the time being). There is that obscure physiologic mechanism nobody has heard about, called Frank-Starling. A volume overload will make a mild-moderate MR look severe.

Any study at this time is worthless. An echo reflects the MOMENTARY status of a patient. It's like a photograph of a runner. Basing one's surgical decision on a decompensated echo leads to those Oops! moments when the intraop TEE on the optimized (in the meanwhile) heart looks way better, and one wonders whether the patient even needs valve surgery.

@jeesapeesa, tell us kids how the story ends.

 

[Hoya11]

This is how one ends up being considered a tech/tube monkey, not a consultant. Yes, we need to be part of that decision-making process in a patient like this. The anesthesiologist is not just the monkey, at the head of the bed, who keeps the patient comfortable.

If I order a heart cath on a patient, as an intensivist, would a cardiologist just jump and execute, especially if he thinks it's inappropriate?

Anesthesiologists in this country have been in need of a pair for a very long time. That's why this specialty is becoming a nursing specialty. One doesn't need medical school to become a yesman monkey.

I guess what Im saying is that I disagree that its inappropriate.

I am not going to argue against a cardiologist about the utility of a cardiac study unless i think its wildly out of line

This is a person with an urgent issue and a very high chance of a successful basic anesthetic, people not doing this case are obstructing her care for mental masturbation - not a matter of "growing a pair" if you want to grow a pair take on this difficult case for the benefit of your patient and the cardiology team

you know what would happen if i refused this case? they would do it with versed and a sedation nurse and everything would be fine

 

[Hoya11]

Counterpoint: Anesthesiologists are physicians too and should be involved in the process. You should not involve yourself in the process if you don't know the risks long term.

Also EF > 35% with severe MR is EF 15% w/o severe MR.

You should be involved in the process about anesthetic risks, not the cardiac decision making..

so what exactly are your concerns for sedation in this 37 year old patient that you are going to delay her care?

the etomidate and versed and fentanyl will be the final straw for her? too much hypotension? hypercarbia? hypoxia? she is going to breath spontaneously, keep her pressure right where it is, maintain her sat, this is a nothing anesthetic... sorry to downplay this but you guys have to get real

 

[dchz]

YOU WON'T TRULY KNOW HOW BAD IT IS UNTIL SHE'S EUVOLEMIC AGAIN! You put 5 liters of fluid in a borderline heart and it becomes a bad heart (for the time being). There is that obscure physiologic mechanism nobody has heard about, called Frank-Starling. A volume overload will make a mild-moderate MR look severe.

Any study at this time is worthless. An echo reflects the MOMENTARY status of a patient. It's like a photograph of a runner. Basing one's surgical decision on a decompensated echo leads to those Oops! moments when the intraop TEE on the optimized (in the meanwhile) heart looks way better, and one wonders whether the patient even needs valve surgery.

@jeesapeesa, tell us kids how the story ends.

Let's examine the decision making for this patient after a TEE:

If this is severe primary MR and amendable to a mitraclip, i would actually argue she should get a mitra-clip. It spares her the open heart surgery with almost equivalent survival: Source.

If this is severe primary MR and not amenable to mitraclip: repair of mitral valve would give her best long term mortality benefit. No source because i'm lazy and because it's pretty much accepted if it's primary severe MR you fix it.

If this is severe secondary MR: you wait until the myocardium recovers and see if it gets better. Source Page 262 after you open the PDF

If this MR is moderate: you medically stabilize to see if it gets better.

I disagree any study at this time is worthless. I feel like you're intentionally misquoting me so you can have an argument. Yes you should medically optimize if it's not primary MR, i have stated this.

You wanna bet it's not chord rupture?

No i don't want to bet, i want to get a TEE so we don't gamble.

 

[dchz]

You should be involved in the process about anesthetic risks, not the cardiac decision making..

so what exactly are your concerns for sedation in this 37 year old patient that you are going to delay her care?

the etomidate and versed and fentanyl will be the final straw for her? too much hypotension? hypercarbia? hypoxia? she is going to breath spontaneously, keep her pressure right where it is, maintain her sat, this is a nothing anesthetic... sorry to downplay this but you guys have to get real

Tl; DR: Do the TEE

In the end this boils down to a 10 minute anesthetic with versed, fentanyl, etomidate - shell be fine. She has an EF >35. She has clean coronaries. Shes 37. People who are 90 with EF of 10% and ESRD can tolerate a TEE/Endoscopy. Just do it..

Now with regards about the anesthesia provided, several things have to be considered:

- EF of 35-45% with severe MR is VERY LOW

Feels like you're not reading my posts before you reply to me.

 

[vector2]

You should be involved in the process about anesthetic risks, not the cardiac decision making..

I disagree. Pretty much anyone doing consultant level cardiac anesthesia nowadays should be involved in the decision making. For cardiac fellows training nowadays, they can't simply be trained to be tube/line/echo monkeys- one should know the diagnostic criteria and all the indications for surgical repair, because inevitably these situations are going to come up preop or intraop when a surgeon or IC is asking if X, Y, or Z needs to be fixed.

Additionally, even if you don't know the specific decision points stemming from the TEE/RHC results, it's good just to make sure the cardiologist's answer isn't "nothing in particular, it's not going to change management, I'm just curious"

 

[bigdan]

I re-read the initial post twice, and still can’t believe a cardiologist presented this case to you without placing a balloon pump.

I don’t mind facilitating the TEE, but I mind doing it RIGHT NOW without any optimization.

1. IABP
2. Inotropy of local flavor; prefer small dose of Milrinone
3. CPAP
4. Wait a bit and see how things go. If she NEEDS the PPV, she gets nasal PAP or an ETT.
5. I’m not opposed to low dose furosemide if she’s in a world of hypoxic hurt.

 

[deleted697535]

YOU WON'T TRULY KNOW HOW BAD IT IS UNTIL SHE'S EUVOLEMIC AGAIN! You put 5 liters of fluid in a borderline heart and it becomes a bad heart (for the time being). There is that obscure physiologic mechanism nobody has heard about, called Frank-Starling. A volume overload will make a mild-moderate MR look severe.

Any study at this time is worthless. An echo reflects the MOMENTARY status of a patient. It's like a photograph of a runner. Basing one's surgical decision on a decompensated echo leads to those Oops! moments when the intraop TEE on the optimized (in the meanwhile) heart looks way better, and one wonders whether the patient even needs valve surgery.

@jeesapeesa, tell us kids how the story ends.

Loading conditions under GA change MR drastically. That is a trap.

We dont know her fluid status. That is a big sweeping statement considering you're basing it on an assumption

There are so many unknowns in this case to be making these definitive 'must-do', and 'cant do' statements really amazes me. Hey this is SDN of course and everyone knows everything.

Ive outline what i think is the rationale for the TEE and that would make sense for it.

In this scenario CT and card's, have no good TTE views to see whether this is Carpentier 1, 2 or 3a which means surgery or a clip or 3b which means absolutely no surgery and dob/diuresis/LVAD maybe transplant if she doesnt improve.
3d TEE really is a magnificent tool for MR

If this is the case this lady needs 2 types of anesthesioogists. 1 - a slick one but non cardiac anesthesia to give a touch of sedation so they can get the diagnosis. Then 2 a cardiac anesthesiologist aka consultant to put her on pump for her inevitable MVrepair or what im betting this is chordae rupture or acute P2 flail

A lot of people on here have had opinions, but i wonder how many do cardiac anesthesia regularly. And that doesnt mean CABG without TEE 2 days a week. Anyone can do that. If you dont understand the reason for the test or the types of MR and their treatments i probably wouldnt deny another service or indeed this lady her best shot without exploring why they need the test first

 

[jeesapeesa]

the patient was seen in the morning ... sitting up, 100% O2 sats on 11 LPM oxymizer, BPs 80/50s with consistent pink frothy secretions/diaphoresis and HRs 120s. I's/O's were 900/2825 in the last 24 hours. she is on low dose lasix, no CPAP. after discussing with cards and in fact addressing the fact that he thought the EF was actually lower than 35% today hence with MR making it significantly lower like you guys alluded to.
although chordae rupture was a possibility he though ischemic with teathering of the MV likely to be main mechanism. on previous TTE, likely evidence of chordal tear but no leaflet flail was noted.

he was also not too keen in proceeding with the TEE after discussion but i did offer to support with some anxiolysis and narcs and plenty of topical. also made sure backup CT was close. after all of that he backed out on the TEE so a RHC/LHC was done......versed and a touch of fentanyl was enough for her to breeze through it and was uneventful.

left main/distal vessel lesion with 85% stenosis along with severe spasm of the LM and entire circumflex. right pressures were elevated as predicted with severe MR. IABP will be trialed tomorrow. so did this procedure make a difference in management? like you guys said all of this supported what she had before.

 

[vector2]

IABP will be trialed tomorrow.

Your cards department is ridiculous. It sounds like this lady has been in shock or borderline shock for days and yet they're mostly just sitting on their hands ..if low-dose lasix is the only thing they're doing to manage her frank pulmonary edema, functional MR, worsening CHF and vasospastic ischemia. She doesn't need a IABP tomorrow- she needs a IABP 5 days ago

 

[bigdan]

Vector -

AGREE.

The literature on IABP improving CS is weak at best. But clawing the dead with acute MR due to MI or pap mm rupture is a great use of IABP.

I dunno if it’s because of the RVU bonus, but there’s no way this lady leaves the Cath Lab in our hospital without a balloon, and in the hospital I do ICU at, they’d come in at my request to place one if this type of patient was transferred in.

I can’t make sense of this case, and it may just be that I’m not following it well. If the original post follows in true chronological sequence, she should have either gotten a balloon in the CL on 5/13 during the diagnostic LHC or at the time of symptom onset, whenever that was. They had diagnosed 90% LAD occlusion AND coronary vasospasm during the initial cath? You could make a compelling argument for Impella supported PCI at that time, or during the staged PCI due to high risk. With hindsight being 20/20, perhaps she should have been urgent CT surgical consult on 5/13...she still had myocardium intact on the 5/14 echo...

 

[vector2]

Vector -

AGREE.

The literature on IABP improving CS is weak at best. But clawing the dead with acute MR due to MI or pap mm rupture is a great use of IABP.

I dunno if it’s because of the RVU bonus, but there’s no way this lady leaves the Cath Lab in our hospital without a balloon, and in the hospital I do ICU at, they’d come in at my request to place one if this type of patient was transferred in.

I can’t make sense of this case, and it may just be that I’m not following it well. If the original post follows in true chronological sequence, she should have either gotten a balloon in the CL on 5/13 during the diagnostic LHC or at the time of symptom onset, whenever that was. They had diagnosed 90% LAD occlusion AND coronary vasospasm during the initial cath? You could make a compelling argument for Impella supported PCI at that time, or during the staged PCI due to high risk. With hindsight being 20/20, perhaps she should have been urgent CT surgical consult on 5/13...she still had myocardium intact on the 5/14 echo...

I would go with impella as well since that would immediately bring her LVEDP down to physiologic levels and reduce the MR while supporting perfusion.....but it doesn't sound like OP is at that kind of institution. It really is absurd that her cardiac. respiratory and hemodynamic status is so tenuous that cards was too scared to do a TEE, but yet they still take her to the cathlab where in addition to seeing severe spasm they must've seen a shtty LV gram and bad angiographic MR (not to mention whatever abysmal SvO2 / CI her RHC revealed)......and they still didn't put any kind of mechanical circulatory support in. I mean...wtf??????????

 

[deleted171991]

the patient was seen in the morning ... sitting up, 100% O2 sats on 11 LPM oxymizer, BPs 80/50s with consistent pink frothy secretions/diaphoresis and HRs 120s. I's/O's were 900/2825 in the last 24 hours. she is on low dose lasix, no CPAP. after discussing with cards and in fact addressing the fact that he thought the EF was actually lower than 35% today hence with MR making it significantly lower like you guys alluded to.
although chordae rupture was a possibility he though ischemic with teathering of the MV likely to be main mechanism. on previous TTE, likely evidence of chordal tear but no leaflet flail was noted.

he was also not too keen in proceeding with the TEE after discussion but i did offer to support with some anxiolysis and narcs and plenty of topical. also made sure backup CT was close. after all of that he backed out on the TEE so a RHC/LHC was done......versed and a touch of fentanyl was enough for her to breeze through it and was uneventful.

left main/distal vessel lesion with 85% stenosis along with severe spasm of the LM and entire circumflex. right pressures were elevated as predicted with severe MR. IABP will be trialed tomorrow. so did this procedure make a difference in management? like you guys said all of this supported what she had before.

Now LHC made way more sense here. And of course it's ischemic. Those chordae would be ruptured only if she had an MI from all this crazy futzing around.

No CPAP? Wow! Just wow. I'm glad she tolerated lying flat through a catheterization. And they still haven't treated that spasm properly? Glad I'm not a patient wherever this is happening. They are probably dealing with way more than they are qualified to.

Btw, this is textbook how you kill/harm a CAD patient: you let her sit with untreated tachycardia and hypotension for days and days.

 

[CopaceticOne]

Just wanted to say thanks to everyone contributing in this thread. I keep learning every day from these types of discussion / debates.

That said, I just don't understand the "trial" of the IABP tomorrow. Why not do it today? @jeesapeesa, Is it a physical resource issue (e.g. no free device available)?

 

[dchz]

That said, I just don't understand the "trial" of the IABP tomorrow. Why not do it today? @jeesapeesa, Is it a physical resource issue (e.g. no free device available)?

As @bigdan and @vector2 stated, the IABP should have been done days ago. The reason why it isn't done has more to do with the cardiologists than what's good for the patient imo.

 

[deleted171991]

As @bigdan and @vector2 stated, the IABP should have been done days ago. The reason why it isn't done has more to do with the cardiologists than what's good for the patient imo.

Bad care all around, dude. These people sound seriously overwhelmed. How do I know? They keep doing the same things (LHC after LHC, echo after echo). They knew she had vasospastic angina for a week, and yet they thought her pathology was coming from ruptured cords. All the while she's in the same miserable shape.

If I were her intensivist, I couldn't sleep well at night. My bet is that she does not have a fellowship-trained intensivist, just cardiologists playing critical care. That should stop happening in this country (same for surgeons etc.).

To be honest, I kind of assumed they don't even have IABP in this place.

 

[dchz]

@vector2 You are making good points. I think we would probably treat this patient very similarly in practice if we were the anesthesiologist/intensivist. But I don't get why you are making extreme absolute statements and then changing your mind.

I know if you spot checked a euroscore or STS on this lady in her current condition it would he high but there is no chance I'm taking a 37yo with primary MR, clean coronaries, no other valve issues, no other severe systemic disease for some POS clip that might not not even fix the problem let alone be durable in 10 years.

Clip is viable if she is death door sick with MSOF and/or we find she has absolutely perfect, pristine clippable anatomy with isolated P2 prolapse- not so much if her only negative predictors are urgent status, reduced EF, and NYHA IV, in which case she buys herself a surgical repair.

You could also clip a A2 prolapse as well btw and have really good results. And whether or not she goes for a clip certainly involves a conversation with the surgeon and cardiologist and it's not completely up to us, because we will never follow up with the patient and manage her long term. Let's just agree that it's an option some percentage of the time and move on.

 

[vector2]

@vector2 You are making good points. I think we would probably treat this patient very similarly in practice if we were the anesthesiologist/intensivist. But I don't get what you are making extreme absolute statements and then changing your mind.





You could also clip a A2 prolapse as well btw and have really good results. And whether or not she goes for a clip certainly involves a conversation with the surgeon and cardiologist and it's not completely up to us, because we will never follow up with the patient and manage her long term. Let's just agree that it's an option some percentage of the time and move on.

I was being hyperbolic cause obviously one should never say never in medicine. So let me take a mulligan and say instead of "no chance" there is a 99.9% chance based on what we know so far comorbidity-wise and the likelihood of perfect anatomy that I'm recommending surgery over clip if primary MR was discovered with TEE.

 

[jeesapeesa]

Bad care all around, dude. These people sound seriously overwhelmed. How do I know? They keep doing the same things (LHC after LHC, echo after echo). They knew she had vasospastic angina for a week, and yet they thought her pathology was coming from ruptured cords. All the while she's in the same miserable shape.

If I were her intensivist, I couldn't sleep well at night. My bet is that she does not have a fellowship-trained intensivist, just cardiologists playing critical care. That should stop happening in this country (same for surgeons etc.).

To be honest, I kind of assumed they don't even have IABP in this place.

very astute and partly correct. lots of frustrations with this place and one of the 3 facilities i work at with my group. i do think they are overwhelmed and they do the same things over and over since i just found out they repeated a TTE today with basically the same results. you are wrong with the intensivist part - they used to hold a contract that affiliated them with a large academic institution with which chiefs of anesthesia critical care department would moonlight here. that is gone and now there are still fellowship trained intensivists that give absolutely no pushback to the cardiologists.

 

[jeesapeesa]

As @bigdan and @vector2 stated, the IABP should have been done days ago. The reason why it isn't done has more to do with the cardiologists than what's good for the patient imo.

this. trust me this place has these things.

 

[Southpaw]

excellent thread. completely brilliant. i feel awful for the patient suffering from lackluster care. i appreciate the posts from @dchz, @bigdan, @vector2, and @FFP. thanks @jeesapeesa for posting. this is why i love this forum and keep coming back after all these years.

 

[deleted697535]

Now LHC made way more sense here. And of course it's ischemic. Those chordae would be ruptured only if she had an MI from all this crazy futzing around.

No CPAP? Wow! Just wow. I'm glad she tolerated lying flat through a catheterization. And they still haven't treated that spasm properly? Glad I'm not a patient wherever this is happening. They are probably dealing with way more than they are qualified to.

Btw, this is textbook how you kill/harm a CAD patient: you let her sit with untreated tachycardia and hypotension for days and days.

"staged PCI revealed normal coronaries"

We were told She had coronary vasospam and now has MR with clean coronaries. How do know she has coronary artery disease and why would you treat her for that when she doesn't have it?

We know for sure She has Mr with low ef. What are the hemodynamic goals for that?

 

[itwasalladream]

In my mind decompensated heart failure and CS means no anesthesia unless for a lifesaving procedure.
If she has functional MR she needs optimization and likely MCS. I like Impella here, given the pulmonary edema (feel like it gives better offloading than an IABP).
If it's pap rupture she needs surgery. This seems pretty unlikely with 3 TTEs and no clear rupture. Did she get a trop?
Cardiac CT might give a quick answer to primary vs secondary MR.