Recent cardiac case (with echo!)

[vector2]

All right, I'm sure there's some other folks out there who are big fans of e-echocardiography.com's case of the week. Let's see if we can emulate their format a little bit. Apologies in advance for the non-CFD clips...for some reason our PACS system stores them at half-speed.


77 yo M PMH HTN, DM and some other stuff who has had a previous cardiac procedure in the past that required a sternotomy. Now he's coming back for another one.

Pre bypass images:

Post-bypass images:

And....some questions for residents and fellows first:

1. What cardiac procedure did he have historically?

2. What are the pertinent pre-bypass exam findings?

3. After coming off you are on significant inotropic and vasopressor support. The surgeon asks you what you think? What do you say? What do you think has happened?

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[vector2]

One more post-bypass image:

 

[sevoflurane]

Classic P2. Back on to repair PVL.

 

[anaesthetic]

.

 

[sevoflurane]

Classic P2. Back on to repair PVL.

Is that 3D image pre-bypass?
If so, my bad. Redo-sternotomy for failed MVR.

 

[sevoflurane]

Agree with above poster. P3 looks like the culprit on 3D.

 

[sevoflurane]

Also agree with LCC being tethered.

 

[sevoflurane]

Def. more interesting than a P2 flail.

 

[urge]

The surgeon asks you what you think? What do you say? What do you think has happened?

I would tell him he needs another profession.

 

[psychbender]

Tell him to go back on and un-**** himself.

Sent from my SM-G930V using SDN mobile

 

[dchz]

And....some questions for residents and fellows first:

1. What cardiac procedure did he have historically?

2. What are the pertinent pre-bypass exam findings?

3. After coming off you are on significant inotropic and vasopressor support. The surgeon asks you what you think? What do you say? What do you think has happened?

Thank you for an interesting case:

1. I see sutures around mitral annulus. could be mitral repair or something related. shot in the dark says Barlow's?

2. Pre bypass findings: A1-A2 (edit: P2-P3, 3d orientation confused me) flail (type 2 carpentier motion), severe mitral regurg w/ eccentric jet. Not enough info about aortic valve but it looks fine.

3. probably would turn down the vaso pressor and pacing, you're gonna go back on. You have severe MR (PVL on ant lat side of the valve), severe AI (prob a stitch too aggressive on the ant medial side by the aorto-mitral curtain). Prob say something encouraging and positive like "man you did great putting in the valve, switch two of the stitches and it'd be perfect" just to keep the morale up in the room.

 

[bigdan]

1. Prior MVr w/annuloplasty ring.

2. Anteriorly directed jet suggests PMVL pathology; it looks like flail at P3 or P2/P3 location, but moreover some additional altered defect there...? old endocarditis? Normal (or even elevated) LVEF in the setting of severe MR.

3. s/p prosthetic valve replacement in mitral position, poorly seated with severe PVL, and unintended aortic valvuloplasty with AR. Sometimes, even with great images, I get better “feedback” by having the probe in my hands; I would look at the aortic root a bit - the L or N sinus is effaced and a bit hyperechoic - it almost looks like foreign material.

Back on bypass and fix.

I would just report the facts; our guys aren’t belligerent, but they have little care for “room morale”; I want things to go smoothly, but I’m not their fluffer. The surgical outcome at this point is completely ineffective at best, and any cardiac surgeon with eyeballs knows this patient has been harmed and not helped up to this point.

 

[vector2]

Nice responses so far. I'm going to wait a day or two before saying what happened next.

In the meantime, a couple comments caught my eye.

Taking a shot at this.
P3 prolapse/flail,........S/p On-X in the mitral position

2. Pre bypass findings: A1-A2 (edit: P2-P3, 3d orientation confused me) flail

We all know that 3d is a de facto gold standard for anatomic pinpointing, but as far as I know the APTE is still going to test your mind's eye mitral omniplaning ability. With the limited images provided would you guys be comfortable stating only P3 using only 2d images? Why or why not? Same question goes for describing the location of the PVL. Keep in mind the amount of the LAA that you can see in this pt at 50 degrees....


Additionally, what is the supporting evidence for stating the valve is an On-X?


Here is a bonus post-bypass clip

 

[dchz]

With the limited images provided would you guys be comfortable stating only P3 using only 2d images? Why or why not?

Nope. I would not be comfortable stating that. I would be comfortable stating that if i had the probe in my hand and i'm scanning through, but there is too much variability to go off the omniplane from images only.

 

[anaesthetic]

.

 

[vector2]

Nope. I would not be comfortable stating that. I would be comfortable stating that if i had the probe in my hand and i'm scanning through, but there is too much variability to go off the omniplane from images only.

As dchz says, without the probe in your hand and the ability to identify landmarks, any questions based around 2d omniplane angle are very difficult to answer precisely. We are tempted to think that we know the the location of a scallop lesion or know the location of a paravalvular leak based upon diagrams like the following:

Notice you have 4 different diagrams with 4 different interpretations of how your beam cuts across the valve in 2d and where the center of the LAA is in relation to the commissure?

In reality, we only really have a good 2d idea of where we are at in a ME AV LAX (A2-P2, and only if the beam is cutting through the AV directly in the commissure between the NCC and LCC), and in the ME bicom (P3-A2-P1) when you have a "trapdoor" appearance with visualization of the subvalvular apparatus heading/attaching to both the AL and PM paps, respectively. Anything other than those views or a slight modification of those views and you're likely just guessing.

So what this really means is that without realtime 3D w/color, what is the best way to describe to the surgeon the location of the PVL? In my opinion, the best way is not to use any reference frame which is in relation to the patient's absolute AP or lateral/medial axes. Specifically, what I mean is that saying the PVL is "anterolateral" because at that omniplane angle you usually have the AL commissure is going to fail you much of the time. Notice that in the post-bypass clip I originally posted at 50 deg with the visible PVL, it looks almost nothing like a tradition ME bicom (look at how much of the RV is visible).

So, that really leaves us a couple options. 1. Ignore the omniplane and use visible landmarks. In my case, the orifice to this guy's massive LAA was very clearly visible and most prominent at 50 degrees. At 90 degrees you don't see the appendage at all. I can see the LAA, the surgeon can see the LAA, and since he's already going to put down a ton of pledgeted sutures anyway, if you get him close enough it's gonna get patched. The same applies if you understand where the pre-bypass lesions were. If the original lesion was P1 and you pick up the PVL at the same omniplane, just tell the surgeon that the PVL is where native P1 inserted and they'll (usually) figure it out. The 2nd way? Do the tedious method from one of the PTE masters videos where you designate a perfect ME AV LAX orientation as 12 o'clock on a virtual clock, and then create a mental transposition of the omniplane until you can say the PVL is at 4pm, etc. But beware, if you don't have your surgeon down with this methodology they're probably going to stare at you like you just took a dump on the floor.

 

[dchz]

As dchz says, without the probe in your hand and the ability to identify landmarks, any questions based around 2d omniplane angle are very difficult to answer precisely. We are tempted to think that we know the the location of a scallop lesion or know the location of a paravalvular leak based upon diagrams like the following:

Notice you have 4 different diagrams with 4 different interpretations of how your beam cuts across the valve in 2d and where the center of the LAA is in relation to the commissure?

In reality, we only really have a good 2d idea of where we are at a ME AV LAX (A2-P2, and only if the beam is cutting through the AV directly in the commissure between the NCC and LCC), and in the ME bicom when you have a "trapdoor" appearance with visualization of the subvalvular apparatus heading/attaching to both the AL and PM paps, respectively. Anything other than those views or a slight modification of those views and you're likely just guessing.

So what this really means is that without realtime 3D w/color, what is the best way to describe to the surgeon the location of the PVL? In my opinion, the best way is not to use any reference frame which is in relation to the patient's absolute AP or lateral/media axes. Specifically, what I mean is that saying the PVL is "anterolateral" because at that omniplane angle you usually have the AL commissure is going to fail you much of the time. Notice that in the post-bypass clip I originally posted at 50 deg with the visible PVL, it looks almost nothing like a tradition ME bicom (look at how much of the RV is visible).

So, that really leaves us a couple options. 1. Ignore the omniplane and use visible landmarks. In my case, the orifice to this guy's massive LAA was very clearly visible and most prominent at 50 degrees. At 90 degrees you don't see the appendage at all. I can see the LAA, the surgeon can see the LAA, and since he's already going to put down a ton of pledgeted sutures anyway, if you get him close enough it's gonna get patched. The same applies if you understand where the pre-bypass lesions were. If the original lesion was P1 and you pick up the PVL at the same omniplane, just tell the surgeon that the PVL is where native P1 inserted and they'll (usually) figure it out. The 2nd way? Do the tedious method from one of the PTE masters videos where you make a perfect ME AV LAX orientation 12 o'clock on a virtual clock, and then create a mental transposition of the omniplane until you can say the PVL is at 4pm, etc. But beware, if you don't have your surgeon down with this methodology they're probably going to stare at you like you just took a dump on the floor.

I'm loving this thread! Thanks for doing this. I would have loved stuff like this when I was studying for my Advanced PTE exam!!
Cant' wait to see what comes next.

 

[vector2]

To the first point, agreed with above. It would be difficult without having the probe in hand to identify the specific leaflets on 2-D only. Also, it would probably be frowned upon to call out the location of the PVL with only one view.

Touché as well to the point about On-X. All that can be said from the information given is that there is a prosthetic valve in the mitral position. New post-bypass clip looks like two washing jets (symmetrical, low velocity, short-lived on CFD).

In regard to the On-X question, I would venture to say that we can at least rule in or out whether it's an On-X. Here is a snap I just took from Mathew

Now compare it to the bonus clip

 

[anaesthetic]

.

 

[itwasalladream]

Previous mitral band, not a complete ring. Now with P3 or P2/P3 prolapse/flail.
Post pump, mechanical MVR (dunno about On-X, but clearly mechanical w/ washing jets), significant PVL under the mouth of the LAA. Likely need to go back on for that, but generally weigh another run against the fact that it's a 77yr old re-do, and the circ is running right under where the surgeon will have to place new, difficult-to-see sutures. If on top of that the MV annulus was terrible/visualization extremely difficult, discuss w/ surgeon and consider whether PVL plug is an option. But for this case in particular, try again on clamp because the AV needs to be addressed.
There is severe AI from LCC tethering. In this situation, most likely arising from a stitch through aorto-mitral continuity, catching a cusp.
The TG LV short axis view with possible hypokinesis of the circ distribution is tough. I frequently see mild hypokinesis /WMA in this area immediately after pump for some reason, I feel due to subtle protection issues and V-pacing. Unless it's obviously hypokinetic and pt remains unstable, I usually don't make much of it, and usually improves within a few minutes. If it doesn't improve, patient unstable, ST changes on non-paced rhythm, and surgeon had a difficult time - likelihood of circ damage is a lot higher.

For the PTE exam, should be able to spit out the traditional segments of the mitral based on omniplane, but in real life I think it's more useful to start w/ 3D to locate, and then use 2D to better characterize the problem. Traditional TEE views frequently do not cut the MV at the segments they are supposed to, due to angle/probe details and individual variations in anatomy.

 

[anes121508]

100% agree with ID location of Pvl being difficult in 2D.

IMHO you never truly know where you are and how you are slicing through in 2D.

Simple and quick method for ID location for pvl in my opinion is:

2D X plane ,0 degrees, arrange your 3D Zoom box and color box To include the anterior and posterior annulus on screen left medial and lateral annulus on screen right.

Important step to make sure you are not taking a 3D pic and losing a portion of the annulus and overlooking a pvl.

Hit 3D once you are aligned in 2D and encompassing all of you structure of interest (the ring).

Manipulate to get a surgeons view on 3D and look at your clock face. I think what misleads people with the clock fade nomenclature once they have a 3D pic, is when they have parallax and / or when the z rotation is slightly off like in the OP.

Quantification of the pvl I believe is better in 2D since the spatial / temporal res is obviously better.

So once I ID it in 3D, I go hunting for it in 2D based on where i think it is and further quantify it.

 

[J Peterman]

Multiplanar reconstruction of a full volume 3D color dataset is your friend here for not only quantifying the PVL, but precisely locating it and using the 3D surgeon’s view image to steer them to it...

 

[sevoflurane]

Agree with the comments here. I was between labor epidurals when I first posted to this thread. 2nd clip looked very classic p2 flail to me.

I always start in 2D/2D CFD and think of where the lesion is. 3D zoom with AV at around 12:00 to find exact location of degenerative/functional MR. 3D color can be helpful although not so much with large coandas. Non-coanda MR jets can be cropped down to isolate exact location. I always do that if I think I can show Color 3D to my surgeon. Same goes for PVL mainly because surgeons have a better understanding of 3D en face.

 

[sevoflurane]

Have always been a big 3D proponent. Just better imaging to understand pathology sometimes.

 

[sevoflurane]

And def. imaging of choice in structural heart cases.

It’s just fun to do.

 

[vector2]

Previous mitral band, not a complete ring. Now with P3 or P2/P3 prolapse/flail.
Post pump, mechanical MVR (dunno about On-X, but clearly mechanical w/ washing jets), significant PVL under the mouth of the LAA. Likely need to go back on for that, but generally weigh another run against the fact that it's a 77yr old re-do, and the circ is running right under where the surgeon will have to place new, difficult-to-see sutures. If on top of that the MV annulus was terrible/visualization extremely difficult, discuss w/ surgeon and consider whether PVL plug is an option. But for this case in particular, try again on clamp because the AV needs to be addressed.
There is severe AI from LCC tethering. In this situation, most likely arising from a stitch through aorto-mitral continuity, catching a cusp.
The TG LV short axis view with possible hypokinesis of the circ distribution is tough. I frequently see mild hypokinesis /WMA in this area immediately after pump for some reason, I feel due to subtle protection issues and V-pacing. Unless it's obviously hypokinetic and pt remains unstable, I usually don't make much of it, and usually improves within a few minutes. If it doesn't improve, patient unstable, ST changes on non-paced rhythm, and surgeon had a difficult time - likelihood of circ damage is a lot higher.

For the PTE exam, should be able to spit out the traditional segments of the mitral based on omniplane, but in real life I think it's more useful to start w/ 3D to locate, and then use 2D to better characterize the problem. Traditional TEE views frequently do not cut the MV at the segments they are supposed to, due to angle/probe details and individual variations in anatomy.

Absolutely excellent response, and the kind that a real consultant anesthesiologist would give imo. We know the PVL is bad and that it will pretty much have to be fixed one way or another, but everyone in the room should pause for a moment and consider the things you said vis a vis age, redo status, difficulty of annular exposure, difficulty of re-pledgeting the area in question, coagulopathy, clamp time, inotrope/pressor req etc before automatically saying "go back on." Or, if you are going to go back on, do you simply try to fix the AV and go to cathlab for a plug?


First, answers to the questions asked:

1. Pt's cardiac surgical history was CABG and a partial mitral annuloplasty band (likely a Cosgrove-Edwards type) performed secondary to severe MR

2. Surgeon said deposition material looked like pannus in addition to myxomatous P2/P3 flail when he explanted the band/valve

3. The paravalvular leak was severe. And indeed, a suture in the fibrosa had tethered and restricted the LCC cusp causing likely severe AI. Importantly, even before coming off or looking at the echo you and your surgeon will have an idea of the AI severity because the ventricle will start blowing up about 30 seconds after the clamp is off, even with the LV vent still on high.

Ultimately, we went back on for surgical repair of the AV and PVL

Thoughts? How do you guys think both valves look now based on the limited views?

As far as clinical picture at this point, pt is on rocket fuel but BiV function is adequate. Hct 24. Vasoplegia has been a problem though since toward the end of the first bypass run. Norepi is now at 25+ mcg/min and vaso is at 0.1 u/min. You are considering giapreza +- methylene blue if doesn't improve.

 

[vector2]

Refresher of common ring types

 

[sevoflurane]

Great thread.
Looks like he/she fixed the PVL and made the iatrogenic AI less severe- but still an issue as you can clearly see the LCC not fully coapting with the RCC/NCC.
Tough case considering the amount of support he currently needs.

Do you go back on and chase down the AI? Certainly would increase his immediate mortality to go back on for a third time and would not be a good feeling leaving the room with a aortic valve problem that wasn’t there before.

TAVR isn’t an option here.

 

[sevoflurane]

Wouldn’t mind looking at MVR/AV gradients. VC and P 1/2 time of AI would be useful, but it doesn’t look severe on deep transgastric.
Still a problem though.

 

[urge]

Absolutely excellent response, and the kind that a real consultant anesthesiologist would give imo. We know the PVL is bad and that it will pretty much have to be fixed one way or another, but everyone in the room should pause for a moment and consider the things you said vis a vis age, redo status, difficulty of annular exposure, difficulty of re-pledgeting the area in question, coagulopathy, clamp time, inotrope/pressor req etc before automatically saying "go back on." Or, if you are going to go back on, do you simply try to fix the AV and go to cathlab for a plug?


First, answers to the questions asked:

1. Pt's cardiac surgical history was CABG and a partial mitral annuloplasty band (likely a Cosgrove-Edwards type) performed secondary to severe MR

2. Surgeon said deposition material looked like pannus in addition to myxomatous P2/P3 flail when he explanted the band/valve

3. The paravalvular leak was severe. And indeed, a suture in the fibrosa had tethered and restricted the LCC cusp causing likely severe AI. Importantly, even before coming off or looking at the echo you and your surgeon will have an idea of the AI severity because the ventricle will start blowing up about 30 seconds after the clamp is off, even with the LV vent still on high.

Ultimately, we went back on for surgical repair of the AV and PVL

Thoughts? How do you guys think both valves look now based on the limited views?

As far as clinical picture at this point, pt is on rocket fuel but BiV function is adequate. Hct 24. Vasoplegia has been a problem though since toward the end of the first bypass run. Norepi is now at 25+ mcg/min and vaso is at 0.1 u/min. You are considering giapreza +- methylene blue if doesn't improve.

Looks good enough to leave alone.

Can't confirm the function is adequate.

Nice to see that you have giapreza, we don't. Have you been impressed by it?

 

[pgg]

As far as clinical picture at this point, pt is on rocket fuel but BiV function is adequate. Hct 24. Vasoplegia has been a problem though since toward the end of the first bypass run. Norepi is now at 25+ mcg/min and vaso is at 0.1 u/min. You are considering giapreza +- methylene blue if doesn't improve.

Not on any epi?

By eyeball the MV looks fine and the AI is better, looks survivable. Any numbers? I sure wouldn't subject this guy to more time on pump in the hopes of making "good enough" better. Can't see a lot of the LV except that skewed slice in the deep transgastric view, and the RV isn't impressing me but it's not blowing up. I'd get out while you can.

 

[vector2]

Wouldn’t mind looking at MVR/AV gradients. VC and P 1/2 time of AI would be useful, but it doesn’t look severe on deep transgastric.
Still a problem though.

Gradient through mechanical MV is 4. Largest AI VC I can pick up is ~0.3 although eccentricity is the biggest confounding question because of unilateral leaflet tethering vs classic central AI. PHT is ~470-500.

Looks good enough to leave alone.

Can't confirm the function is adequate.

Nice to see that you have giapreza, we don't. Have you been impressed by it?

I’ve never used it in the heart room. Only in the ICU on pts who were about to die anyway...but it did get the blood pressure up.

Not on any epi?

By eyeball the MV looks fine and the AI is better, looks survivable. Any numbers? I sure wouldn't subject this guy to more time on pump in the hopes of making "good enough" better. Can't see a lot of the LV except that skewed slice in the deep transgastric view, and the RV isn't impressing me but it's not blowing up. I'd get out while you can.

I was referring just to the vasoplegia treatment. Pt is also on epi at 5 mcg/min and milrinone at 0.5. I didn’t mention it in the OP but his SPAP by swan were ~70-80 after we went to sleep. The LV function coming off the second time is the same as this clip here. I subjectively called his RV function mildly reduced.

 

[dchz]

The MR doesn't look bad, the AR from that one view is moderate. As a fellow i'm honestly never sure what the optimal trade off is in this specific scenario and have to defer to attending/surgeon experience.

Are there any good data for this stuff? it seems like a complex decision made in the moment. What is the cumulative pump time now? It might be worth considering TAVR or a redo operation later rather than go on a 3rd time.

 

[sevoflurane]

I wouldn't try a TAVR on that AV. As far as I know, TAVR is not approved for pure AI although it's being looked at. It is "off label" currently.
Problem with this particular patient is the lack of calcium and therefore higher rates of PVL and rocking/embolization.
I have seen this first hadn't and it's not pretty. Jena valve would be one of the only TAVR valves that possibly "could" work currently- not sapien or core valve. And with a p1/2 of 470-500 and a VC of .3... your best bet is to leave it alone.

 

[Ronin786]

Hard to evaluate in those views, but did he bag the circ when he tethered the AV? Would evaluate for any RWMA. But best bet might be to take him out on VA ECMO and let that myocardium rest after a long run. Definitely wouldn't go back on a third time.

 

[anes121508]

Multiplanar reconstruction of a full volume 3D color dataset is your friend here for not only quantifying the PVL, but precisely locating it and using the 3D surgeon’s view image to steer them to it...

Agree. I just like the 3D color right away to give them a quick location, then look 2D, then multiplanar.

I’m a huge fan of multiplanar reconstruction. Many applications.

 

[anes121508]

Agree with the comments here. I was between labor epidurals when I first posted to this thread. 2nd clip looked very classic p2 flail to me.

I always start in 2D/2D CFD and think of where the lesion is. 3D zoom with AV at around 12:00 to find exact location of degenerative/functional MR. 3D color can be helpful although not so much with large coandas. Non-coanda MR jets can be cropped down to isolate exact location. I always do that if I think I can show Color 3D to my surgeon. Same goes for PVL mainly because surgeons have a better understanding of 3D en face.

Can you expand on the Coanda jet and 3d color concept?

 

[anes121508]

And def. imaging of choice in structural heart cases.

It’s just fun to do.

Absolutely excellent response, and the kind that a real consultant anesthesiologist would give imo. We know the PVL is bad and that it will pretty much have to be fixed one way or another, but everyone in the room should pause for a moment and consider the things you said vis a vis age, redo status, difficulty of annular exposure, difficulty of re-pledgeting the area in question, coagulopathy, clamp time, inotrope/pressor req etc before automatically saying "go back on." Or, if you are going to go back on, do you simply try to fix the AV and go to cathlab for a plug?


First, answers to the questions asked:

1. Pt's cardiac surgical history was CABG and a partial mitral annuloplasty band (likely a Cosgrove-Edwards type) performed secondary to severe MR

2. Surgeon said deposition material looked like pannus in addition to myxomatous P2/P3 flail when he explanted the band/valve

3. The paravalvular leak was severe. And indeed, a suture in the fibrosa had tethered and restricted the LCC cusp causing likely severe AI. Importantly, even before coming off or looking at the echo you and your surgeon will have an idea of the AI severity because the ventricle will start blowing up about 30 seconds after the clamp is off, even with the LV vent still on high.

Ultimately, we went back on for surgical repair of the AV and PVL

Thoughts? How do you guys think both valves look now based on the limited views?

As far as clinical picture at this point, pt is on rocket fuel but BiV function is adequate. Hct 24. Vasoplegia has been a problem though since toward the end of the first bypass run. Norepi is now at 25+ mcg/min and vaso is at 0.1 u/min. You are considering giapreza +- methylene blue if doesn't improve.

Thanks for doing this!

Few questions /statements

1. Preop the av doesn’t look totally clean and seems like some calcium towards the annulus

2. Was there any AI at all preop? I didn’t see a lax or sax with color.

3. The cusps preop look pretty symmetric preop, even after the second run they still look assymetric and make me think surgeon didn’t completely fix the problem.

4. The location of the AI looks to be in the same location, just less.

5. I think it’s important to know exactly what the surgeon found or believed to be the cause of the pvl and the AI and exactly what he did to fix it. I find that this discussion sheds light on what direction to go and what might still be causing a problem when we come off again. What did he do? What was his impression?

6. In terms of evaluating the residual AI:
- at first glance looks moderate
- the shape of the Eroa is probably pretty irregular, which makes the VC tough to make a call on. 3D eroa?
- anyone like to use flow reversal in the proximal/distal descending aorta?
- if the svr is still in the tank , is the AI looking less because of the loading conditions compared to the first time coming off?

7. Ultimately, sounds like surgeon went in once already and it didn’t totally resolve the AI, and you are on rocket fuel, so I agree with everyone to get out of the OR while you still can, unless surgeon thinks he knows what might still be causing a problem and it’s a slight adjustment and 5 min fix. Then again, that’s also a slippery slope.

Great case.

 

[urge]

Few questions /statements

7. Ultimately, sounds like surgeon went in once already and it didn’t totally resolve the AI, and you are on rocket fuel, so I agree with everyone to get out of the OR while you still can, unless surgeon thinks he knows what might still be causing a problem and it’s a slight adjustment and 5 min fix. Then again, that’s also a slippery slope.

Great case.

Does anyone think this valve could have been re repaired? Any experience with that?

This one didn't look specially challenging.

 

[sevoflurane]

Can you expand on the Coanda jet and 3d color concept?

For sure...
Frames/clips per second and direction of flow make a difference on cropping down on an en face 3D color flow jet when you are showing your surgeon the area in question after dropping in your lines. Functional MR jets, perforation jets, isolated a1/p1, combined a1/p1 + a3/p3 jets or whatever jets that are directed towards the probe are pretty easy (and fun) to isolate on 3D CFD. Big coandas by definition hug the wall of the atrium and when big enough the en face 3D CFD of the jet would likely distort your exact location because of cutting the jet tangentially instead of across the jet- frames/volumes/bests per second matter here. If your frames per second doesn’t catch it, then it becomes difficult to isolate.

3d w/o color and 2D with and w/o color adds a ton of info. On 3D CFD you can still take the image, crop and rotate towards the lateral and medial commissures, look behind then valve for a jet hunt... but it may not give you the info you need and 3D/2D CFD is probably faster.

IMO, a plain 3D mitral interrogation w/o color plus some good 2D with and w/o CFD is way more valuable than a 3D CFD alone.

 

[sevoflurane]

- the shape of the Eroa is probably pretty irregular, which makes the VC tough to make a call on. 3D eroa?

I think you are on to something there....

3D eroa sounds cool.

 

[itwasalladream]

3D EROA is definitely cool...and it's relatively simple in concept if you are already comfortable with multiplanar reconstruction. I just find in practice that once you get the 3D plane in the vena contracta, the trick is where exactly to trace. At that point with diminishing frame rates and resolution while still dealing with small numbers/distances, you can get pretty wildly different values just depending on a subjective trace or particular frame in the clip. Sometimes it's an obviously large or small VC area, but those are also the cases you don't really need 3D EROA for. There are a bunch of machine settings - Nyquist, shifting the color baseline, color smoothing, line density, color gain, multibeat, etc - that can all affect how nicely the orifice is resolved, but none of these have been standardized and can really affect the size you get (in my own limited experience).

 

[abolt18]

3D EROA is definitely cool...and it's relatively simple in concept if you are already comfortable with multiplanar reconstruction. I just find in practice that once you get the 3D plane in the vena contracta, the trick is where exactly to trace. At that point with diminishing frame rates and resolution while still dealing with small numbers/distances, you can get pretty wildly different values just depending on a subjective trace or particular frame in the clip. Sometimes it's an obviously large or small VC area, but those are also the cases you don't really need 3D EROA for. There are a bunch of machine settings - Nyquist, shifting the color baseline, color smoothing, line density, color gain, multibeat, etc - that can all affect how nicely the orifice is resolved, but none of these have been standardized and can really affect the size you get (in my own limited experience).

My impression from this description is "this is really cool but it's a total crapshoot!"

 

[J Peterman]

A nice method for evaluating Coanda jets with a 3D Color dataset is slowing the replay to 1/4 or 1/2 speed (also great for distinguishing multiple jets, or jets that are dynamic throughout systole), as well as rotating (both rotate Z CCW and trackball tilt away in the Phillips machines) the dataset from the en face surgeon’s view to looking across the plane of coaptation with lateral (LAA) on the bottom of the screen and medial (IAS) on the top, and then vice versa looking medial to lateral. In fact, I do this with every mitral case as a standard view illustrating the pathology to the surgeon where applicable.

Looking along the plane of coaptation using a 3D without color is also a great way to visualize leading edge prolapse where it may not be obvious from looking at the top-down en face view. I don’t find Coanda jets particularly difficult to visualize with 3D.

 

[vector2]

Hard to evaluate in those views, but did he bag the circ when he tethered the AV? Would evaluate for any RWMA. But best bet might be to take him out on VA ECMO and let that myocardium rest after a long run. Definitely wouldn't go back on a third time.

I was bit worried about circ bagging after this clip coming off bypass the 2nd time, but of course the differential was large because of the long pump run, the normal inferior segment(s) RWMA I see many times with our surgeons even after normal runs, RWMA from V pacing, and surgeon being relatively confident of avoiding it

Continued watching it. After another half an hour this is what it looked like

Thanks for doing this!

Few questions /statements

1. Preop the av doesn’t look totally clean and seems like some calcium towards the annulus

2. Was there any AI at all preop? I didn’t see a lax or sax with color.

3. The cusps preop look pretty symmetric preop, even after the second run they still look assymetric and make me think surgeon didn’t completely fix the problem.

4. The location of the AI looks to be in the same location, just less.

5. I think it’s important to know exactly what the surgeon found or believed to be the cause of the pvl and the AI and exactly what he did to fix it. I find that this discussion sheds light on what direction to go and what might still be causing a problem when we come off again. What did he do? What was his impression?

6. In terms of evaluating the residual AI:
- at first glance looks moderate
- the shape of the Eroa is probably pretty irregular, which makes the VC tough to make a call on. 3D eroa?
- anyone like to use flow reversal in the proximal/distal descending aorta?
- if the svr is still in the tank , is the AI looking less because of the loading conditions compared to the first time coming off?

7. Ultimately, sounds like surgeon went in once already and it didn’t totally resolve the AI, and you are on rocket fuel, so I agree with everyone to get out of the OR while you still can, unless surgeon thinks he knows what might still be causing a problem and it’s a slight adjustment and 5 min fix. Then again, that’s also a slippery slope.

Great case.

Pt had aortic sclerosis. No gradient. AI was essentially non-existent preop.

You are correct, the surgeon did not totally fix the problem and the LCC is still tethered. There is no real way to "fix" the tethering because it's almost impossible to determine which exact mitral annular stitch is causing the issue. For the PVL, the surgeon simply added additional pledgeted sutures around the suspected area and prayed there wouldn't be further AV snagging. However, for the AV the best he could do (short of undoing all the mitral annular stitches or replacing the AV, both of which are absurd ideas) was approximate the the leaflets of the LCC to the other two cusps similar to an edge to edge repair and hope the coaptation gets better without causing iatrogenic stenosis or distorting the annulus too much.

Indeed, the AI got better but was still present, and my opinion was that it was on the high side of mild. No significant reversal in arch or descending. MAP was okayish on rocket fuel, sufficient to create a gradient as to not artificially make the AI look better. Unfortunately, I have a lower end machine not capable of doing multibeat acquisition and not capable of 3d with color at a high enough framerate to make live 3d color and MPR worth a ****. Ultimately there was no way on god's green earth we were going back on pump for a third time given the amount of inotropic/vasopressor support the patient was on, and the lack of mechanical support we currently have (other than IABP).

We closed the chest and made it out of the room without an IABP but pt was extremely oozy, vasoplegic, tenuous BiV function. ICU care was less than stellar and he rode with a very borderline MAP (60) and CI (2.1) for a few days (not ideal in an almost 80yo with baseline CKD). Also became volume overloaded. Looked like he was gonna be on the precipice of MODS as his Cr and LFTs were bumping hard but they started leveling off. Vasoplegia got better, CT output leveled off, he responded to lasix drip, and was finally extubated after 5 days to CPAP. Organ function looks good now. LVEF is 36-40% on recent TTE with trivial to mild AI. Most importantly he's neuro intact.

 

[sevoflurane]

Thank you Vector for sharing your case. Super interesting and super fun. Glad things turned out ok.

I had a case a few days ago that reminded me of this thread. These are just pix off of my phone so sorry for the marginal quality. We also have an iE33 that is pretty old at this point (just now starting to trickle in epiq’s into our fleet).


Large p2 flail/several ruptured cords, huge coanda.

3d and 2D CFD together made it pretty easy to make the call. No real need for 3d CFD and pretty fast to acquire the info while you are hustling to get your case moving.

Spent a few seconds reviewing the images with my cardiac surgeon before he scrubbed in and then I decided to try and hunt down the jet in 3d CFD.

Here you can see what I was talking about earlier with regards to large coandas and 3d CFD. The en face coanda view made it hard to isolate exactly where the jet originated from (although I already knew where it was). Rotating the image out of en face so you are looking down the medial or lateral commissures one frame at a time while cropping down on the jet does help locate its origin. Honestly though, in this case, I find the 3d plus 2d CFD more meaningful than 3d CFD alone.

Did the repair and came off without any PVL or other issues. Easy Cheese.









Hopefully these images/clips upload. Might have to follow a link to see them. Not sure.

Anyways, great case. Hope some of you other rockstars bring some more cases like the one Vector presented.

 

[vector2]

Question for you: when you MPR and crop the 3d color of one of these highly eccentric jets (i.e. the VC is essentially orthogonal from standard central MR), do you think you're able to get a frame where you you can trace an accurate vena contracta area?

 

[J Peterman]

Yes. Using MPR on the Philips platform, by convention I’ll put the 5C view in the upper right hand quadrant (red plane) with the midcommissural orthogonal view in the upper left hand corner (green plane). Scan through your systolic frames to find the frame with the largest PISA radius (late systole for degenerative, early or late systole for functional). Move the blue plane in both of those images Perpendicular to the PISA radius such that it cuts through the mitral tissue edges, and then measure the 3D vena contracta area in the blue plane. Never measure anything directly on a 3D image because you’re introducing error due to parallax, only make measurements on the MPR 2D cuts where you’ve chosen exactly what slice you’re measuring from the 3D dataset.

 

[itwasalladream]

Here you can see what I was talking about earlier with regards to large coandas and 3d CFD. The en face coanda view made it hard to isolate exactly where the jet originated from (although I already knew where it was). Rotating the image out of en face so you are looking down the medial or lateral commissures one frame at a time while cropping down on the jet does help locate its origin. Honestly though, in this case, I find the 3d plus 2d CFD more meaningful than 3d CFD alone.

For those 3D CFD where the jet is hard to see because it's all washed out, you can try turning the Nyquist scale as high as it will go, and then gradually turn color gain down until it's recognizable. Not sure about iE33, but it works pretty well on the epic. This can often display some details of the jet(s) and how they relate to the pathology. Occasionally there's a surprise, like a secondary jet going laterally or something, but usually it's not particularly helpful. Ultimately I agree w/ your statement about 3D + 2D CFD being more helpful than 3D CFD.

 

[sevoflurane]

For those 3D CFD where the jet is hard to see because it's all washed out, you can try turning the Nyquist scale as high as it will go, and then gradually turn color gain down until it's recognizable. Not sure about iE33, but it works pretty well on the epic. This can often display some details of the jet(s) and how they relate to the pathology. Occasionally there's a surprise, like a secondary jet going laterally or something, but usually it's not particularly helpful. Ultimately I agree w/ your statement about 3D + 2D CFD being more helpful than 3D CFD.

Good points.