Early detection of patients at risk of sternal complications is essential to facilitate prevention and optimize timely intervention. A systematic review and meta-analysis was conducted to identify ...risk factors associated with sternal complications. The review included 17 full-text studies, of which 10 were entered into meta-analyses. Female gender, diabetes mellitus, obesity, bilateral internal mammary artery grafts, reoperation for postoperative complications, and blood product requirement were reported as significant predictors of sternal infection. The compilation of these risk factors may help to screen and stratify patients at risk of impaired sternal healing and warrants further investigation.
Abstract Introduction The objectives of the study are to identify the most reliably imaged regions of the diaphragm, to evaluate the correlation of movement between different parts of each ...hemidiaphragm, and to assess the agreement between liver or spleen displacement and movement of the ipsilateral hemidiaphragm. Methods Images of the diaphragm, liver, and spleen were obtained using 2-dimensional ultrasound. Acceptable agreement between regions of the diaphragm, liver, and spleen was defined as an absence of fixed or proportional bias using Deming regression analysis and limits of agreement of 2 SDs of the difference less than 30% of the mean value. Results We included 90 critically ill patients. The medial (87%) and middle (73%) regions of the right hemidiaphragm, liver (87.7%), and spleen (81%) and medial (71%) and middle regions (51%) of the left hemidiaphragm were most frequently imaged. In nonintubated patients, acceptable agreement was present for comparisons of the left middle and medial, right middle and medial, and left middle regions and spleen displacement. In intubated patients and in all patients when combined, acceptable agreement was only present for comparisons of the left middle and medial and right middle and medial regions of the diaphragm. Acceptable agreement was not present for intubated and all patients for diaphragmatic and solid organ movement. Conclusion The diaphragm medial part is visualized in the majority of studied patients. The medial and middle thirds may be used interchangeably to assess hemidiaphragm movement. Acceptable agreement does not exist for diaphragm and solid organ movement, other than for the left middle region and the spleen.
The dislodgement of atheroma from the ascending aorta and proximal arch is a major cause of stroke and neurological injury following cardiac surgery. The accurate detection of atheroma prior to ...aortic manipulation is necessary to facilitate surgical strategies to reduce the risk of embolisation. The traditional method for atheroma detection is manual palpation by the surgeon. This technique misses about half the number of the atheroma lesions, as the soft (non-calcified) lesions offer little resistance to the surgeon's fingers. Trans-oesophageal echocardiography (TOE) is commonly used in cardiac surgery, but the interposition of the bronchus between the aorta and the oesophagus causes an ultrasound ‘blind spot’ in the ascending aorta and proximal arch, such that it does not offer improved detection compared to manual palpation. Accurate detection of atheroma requires direct ultrasound assessment using epiaortic scanning, with a high-frequency, linear-array probe. This allows the surgeon to correctly assess and localise any atheroma. In this article, a suggested epiaortic examination sequence is described and strategies for surgeons to avoid atheroma are discussed.
Background Radial artery harvest for coronary artery surgery leads to chronically elevated blood flow in the remaining ulnar artery. This study examined the ulnar artery for evidence of increased ...atherosclerosis compared with the contralateral ulnar artery where the radial artery had not been harvested. Methods Patients were enrolled at least seven years after unilateral radial artery harvest. Anatomical and flow data were acquired using a high-frequency ultrasound probe. Maximal forearm blood flow was measured after repeated hand grip with concurrent brachial artery occlusion to induce forearm ischemia. Results Eighty five patients, 71 males at age 71 ± 9 years (43 to 88) were assessed at 8.4 ± 1.0 years (7.2 to 11.1). There was no patient with ulnar artery atheroma on either side. Mild ulnar calcification was present in four patients bilaterally. The ulnar diameter after radial artery harvest was greater (2.8 ± 0.5 vs 2.4 ± 0.4 mm; p < 0.001), as was flow at rest (111 ± 64 vs 59 ± 41 mL/min; p < 0.001). However, the brachial artery flow was not different between the two sides at rest (169 ± 90 vs 176 ± 87 mL/min; p = 0.060) or after ischemic exercise (714 ± 294 vs 753 ± 315 mL/min; p = 0.485). Conclusions At an average of eight years after radial artery harvest, the remaining ulnar artery does not have evidence of increased atheroma and the maximal forearm blood flow is preserved.
The haemodynamic state refers to the integration of myocardial and vascular systems, and involves both left and right hearts, and systolic and diastolic phases. The assessment of the haemodynamic ...state can be performed with echocardiography, and provides a higher level of diagnosis than conventional pressure- and flow-based monitoring. Whilst hypotension alerts the practitioner about the existence of haemodynamic abnormality, it does not provide sufficient information to identify the cause or the underlying haemodynamic state. The premise of haemodynamic state monitoring is that better diagnosis will lead to more rational therapy, which in turn may improve the outcome. The haemodynamic state can be classified into seven broad categories: normal, empty, vasodilation, systolic failure, primary diastolic failure, systolic and diastolic failure and right ventricular failure. These are identified as patterns based upon ventricular size, ventricular function and left atrial (LA) filling pressure. Patients may have an abnormal haemodynamic state (such a systolic failure), but may not need active treatment if they are haemodynamically stable. However, if treatment is required, it can be directed according to the underlying haemodynamic state. For example, a patient with systolic failure may benefit from inotrope support, whereas an empty state acquires volume infusion and vasodilation requires vasopressor support.
Objective To assess the feasibility and correlation between tissue Doppler and speckle tracking imaging when measuring myocardial velocity, strain, and strain rate with transesophageal ...echocardiography. Design A prospective, observational study. Setting An academic tertiary-referral hospital. Participants Patients undergoing elective heart surgery. Interventions None. Measurements and Main Results Velocity, strain, and strain rate were measured using both techniques in the inferior and anterior walls in transgastric views for radial motion and in the lateral, septal, anterior, and inferior walls in midesophageal views for longitudinal motion. Nineteen patients and 304 myocardial segments were studied. Overall, tissue Doppler was found to be more successful than speckle tracking in measuring myocardial velocity, whereas strain and strain rate measurements were achieved with comparable success using either method. Tissue Doppler was more successful than speckle tracking for radial cardiac motion, and the highest success rates were achieved with this method (93.4% v 59.2% for velocity, p < 0.001; 78.9% v 59.2% for strain, p = 0.01; and 73.7% v 59.2% for strain rate, p = 0.09). Good correlation between tissue Doppler and speckle tracking was shown in 4 myocardial segments: radial midinferior, radial basal inferior, radial basal anterior, and longitudinal basal septum ( R = 0.6-0.82, p < 0.05). Conclusions The correlation between tissue Doppler and speckle tracking with transesophageal echocardiography appears valid when predominantly confined to segments moving in a radial direction adjacent to the ultrasound transducer. Tissue Doppler echocardiography of radial cardiac motion appears to be the most feasible technique of measuring myocardial velocity, strain, and strain rate during cardiac surgery.
The use of echocardiography in anaesthesia and critical care started with transoesophageal echocardiography, whereas transthoracic echocardiography was largely the domain of the cardiologist. In ...recent times, there has been a change in focus towards transthoracic echocardiography owing to the development of small and portable, yet high-fidelity, echocardiography machines. The cost has reduced, thereby increasing the availability of equipment. A parallel development has been the concept of limited transthoracic echocardiography that can be performed by practitioners with limited experience. The basis of these examinations is to provide the practising clinician with immediate information to help guide management with a focus on haemodynamic evaluation, and limited structural (valve) assessment to categorise whether there is a valve disorder that may or may not cause haemodynamic instability. The limited examination is therefore goal directed. A number of named examinations exist which differ in their scope and views. All of these require a limited knowledge base, and are designed for the clinician to recognise patterns consistent with haemodynamic or anatomical abnormalities. They range from very limited two-dimensional assessments of ventricular function to more complex (yet presently limited) studies such as HEART (haemodynamic echocardiography assessment in real time) scan, which is designed to provide haemodynamic state, as well as basic valvular and pericardial assessment. It is suitable for goal-directed examination in the operating theatre, emergency department or intensive care unit (ICU) and for preoperative screening.
A 54 year-old man without prior cardiac history was involved in a motor vehicle accident. His heart rate was 100/min and blood pressure 128/78 mmHg. He complained of anterior chest pain, and on ...examination had a loud pan-systolic murmur with no clinical signs of heart failure. Three-dimensional trans-oesophageal echocardiography (3D-TOE) demonstrated partial rupture of the inferior head of the anterior papillary muscle (when 2D-TOE did not), causing severe tricuspid regurgitation. This was successfully repaired. Tricuspid valve insufficiency is a rare, but well documented, complication of blunt chest trauma. The majority of cases of tricuspid regurgitation caused by blunt trauma are diagnosed and treated late after the traumatic event. Acute diagnosis is less common but possible with a high level of vigilance, and is greatly aided by clinical indicators of cardiac injury. We describe a case of acute repair of traumatic tricuspid insufficiency, in which diagnosis and surgical planning were greatly aided by 3D-TOE.
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