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Comparison of cardiac output of both 2 and 3 dimensional transoesophageal echocardiography with transpulmonary thermodilution during cardiac surgery
S29
ABSTRACT PRESENTATIONS
REFERENCE 1. Biscotti M, et al: Comparison of extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation. J Thorac Cardiovasc Surg. 148(5):2410-2415, 2014.
P-26 Portuguese lung transplant program revisited Paulo Nave, F. Aguiar, C. Ramos, I. Fragata Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Portugal Introduction. The Portuguese lung transplant program was started in 2001. Since then, it is coordinated by the Lung Transplant Centre of the Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, the only lung transplant centre in the country. Eight years after its start, a major reorganization of the program and the teams involved, resulted in a significant improvement in hospitals’ response capacity. Methods. Retrospective analysis of the clinical files of the 90 patients treated between January 2009 and July 2015. 9 patients were excluded because of missing data. Eighty one patients were included. Collected data included demographic variables, type of transplant, pre-transplant diagnosis, duration of anaesthetic procedure, type of circulatory support, blood product transfusion requirements, hospital stay and 3 month mortality. Results. A clear enhancement of surgical activity has been seen over the years, from 8 cases of 2009 to 18 cases in 2014. From January to July 2015 we had already 8 cases. In demographic analysis, 45 (55,6%) patients were male and 36 (44,4%) were female with a mean age of 46,1⫾13,19 years. The six most common pre-transplant diagnosis, responsible for more than 80% of the cases, were: pulmonary fibrosis (n¼14), extrinsic allergic alveolitis (n¼13), COPD (n¼13), cystic fibrosis (n¼11), alpha-1 antitrypsin deficiency (n¼9) and bronchiectasis (n¼7). In fifty one cases (63%) was performed single lung transplant and in 30 cases (37%) was performed double lung transplant. Average time for the anaesthetic procedure was 719,33⫾172,1 minutes for double lung transplant and 515,98⫾135,6 minutes for single lung transplant. No cardiopulmonary support was used in 62 (76,5%) patients. Conventional cardiopulmonary bypass was used in 10 (12,3%) patients and ECMO in the remaining 9 (11,1%) patients. Average number of transfused blood products was 2,21⫾2,96 units for packed red blood cells and 1,57⫾1,89 units of fresh frozen plasma. In 73 cases no platelets were used, and the maximum administered were 2 units in only 1 case. Total fibrinogen administration was 5gr. Postoperatively, median time for mechanical ventilation, ICU stay and hospital length of stay was 4, 26 and 41 days, respectively. Overall survival rate at the 3 month was 91,4%. Discussion. This is a retrospective analysis of the data from the only Lung Transplant Centre in Portugal. Lung transplant remains the last resource for patients with end-stage chronic pulmonary disease. Thanks to a multidisciplinary dedicated team, our Centre results pair with the published literature1.
P-27 When a “flu” turns into a cardiac transplant – case report Paulo Nave, C. Ramos, I. Fragata Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Portugal Introduction. Based on the European Society of Cardiology statement1, dilated cardiomyopathy (DCM) is defined by the presence of left ventricular dilatation and left ventricular systolic dysfunction in the absence of abnormal loading conditions or coronary artery disease sufficient to cause global systolic impairment. Among the non-familial causes, myocarditis is one of the most common and is implicated in 9-16% of adult patients with unexplained non-ischaemic DCM. We present a case of a 21 year-old patient who presented with a DCM few days after a flu. Case Presentation. A 21 year-old male was admitted at the emergency room (ER) with flu-like symptoms. He complained of cough, fever and tiredness. He was a healthy subject with irrelevant medical history and no ambulatory medication. Physical examination didn’t show relevant findings. A blood panel was requested and revealed significantly elevated transaminases without any other major finding. He was purposed to further investigation but refused and went home with symptomatic treatment. A few days later, he returned to the ER complaining of extreme tiredness. He was confused and with signs of hypoperfusion. A transthoracic echocardiogram (TTE) revealed a DCM. During the observation he suffered a cardiac arrest. He was promptly resuscitated and transferred for an intensive care unit. TTE revealed severely depressed cardiac function (LVEF 5%; Figure 1), severe dilation of all four chambers and left ventricle spontaneous echo contrast (figure 2). Myocardial biopsy wasn’t performed because of the extremely thin ventricular walls. VAECMO and intra-aortic balloon pump were initiated for circulatory support. At this time his name was already in the national organ transplant waiting list and he was transferred to our Centre. Decision was to place a left ventricular assist device as a bridge to cardiac transplant (figure 3, 4). Twenty five days later, he had his cardiac transplant with no intercurrences. On tenth postoperative day he was transferred to general ward, where he’s still recovering. We’re still waiting for the heart histological result. Conclusion. DCM is a condition with variable clinical course, often requiring ventricular assist devices or even cardiac transplant. Endomyocardial biopsy is essential to define myocarditis as the cause of DCM. In this case, with the epidemiological context and exclusion of other possible causes, we believe this is a DCM secondary to myocarditis. REFERENCE 1. Elliott P, et al: Classification of the cardiomyopathies. European Heart Journal 29:270-276, 2008.
Oral Abstract Presentations 214 Thursday, May 12, 2016 16:30-18:00, Meeting Room 1 OP-35
REFERENCE 1. Gómez FJ, et al; Prognostic factors of morbidity and mortality in the early postoperative period following Lung Transplantation; Arch Bronconeumol 39(8):353-360, 2003.
Comparison of cardiac output of both 2 and 3 dimensional transoesophageal echocardiography with transpulmonary thermodilution during cardiac surgery David Canty1,2,3,4, R. Guha3, T. Pham4, M. Kim1,4, C. Royse1,2
S30
1
Department of Surgery, University of Melbourne, Parkville, Victoria, Australia, 2Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia, 3 Department of Anaesthesia and Pain Management, Monash Medical Centre, Melbourne, Victoria, Australia, 4Department of Anaesthesia and Pain Management, Monash Medical Centre, Melbourne, Victoria, Australia Introduction. Transpulmonary thermodilution (TD) is the most used method for cardiac output (CO) monitoring during cardiac surgery. Although 2D transoesophageal (TOE) measurement of CO using spectral Doppler correlates with TD, 3D TOE more accurately measures left ventricular outflow tract (LVOT) and aortic valve (AV) area, which are used to calculate CO. The aim of this study is to compare the precision of CO measurement between 2D and 3D TOE against TD. Method. After ethics approval, 50 patients aged over 18 years scheduled for on-bypass cardiac surgery were recruited prospectively at two institutions. Exclusion criteria included more than mild valvular regurgitation, and atrial fibrillation. CO was measured simultaneously by TD and TOE before sternotomy and after cardiopulmonary bypass. CO was calculated using TOE by the product of either the LVOT or AV area, the velocity-time integral (VTI) of flow at the same site and heart rate. The LVOT area was assumed circular and calculated using the LVOT diameter for 2D but with planimetry using 3D TOE. The AV area was estimated with planimetry by both 2D and 3D TOE, and VTI with continuous wave Doppler. Both modal and outer edge traces of LVOT VTI were performed with the cursor 0.5 cm from the annulus. Measurements were averaged from 3 consecutive beats by 2 observers. Deming model II regression was used to assess fixed and proportional bias of agreement with TD. Bland-Altman technique was used to assess closeness of fit. Results. CO was measured at 94 time-points (50 before sternotomy, 44 after chest closure) in 50 patients. The 3D methods had better agreement than 2D with TD, with the best agreement with 3D planimetry of the AV (bias -0.04 Lmin-1, SD of difference between the mean 1.37 Lmin-1), followed by 3D LVOT area planimetry (0.14, 1.41), 2D AV area planimetry (0.28, 1.3) and 2D LVOT VTI outer edge trace (-0.59, 1.29). 3D LVOT area planimetry had the best correlation (slope 1.39, 95%CI 0.97-1.82), followed by 2D AV planimetry (1.15, 0.81-1.48), 3D AV planimetry (1.07, 0.76-1.39), and 2D LVOT VTI outer edge trace (0.92, 0.33-1.52), all of which had no proportional or fixed bias. The VTI modal trace model had the worst agreement (-1.59, 1.37) and correlation (0.40, 0.08-0.69) and had proportional but not fixed bias. However the limits of agreement were similar amongst all methods. Tracing the edge of the LVOT VTI rather than the modal line reduced the bias (-0.59, 1.29), and improved correlation (0.92, 0.33-1.52). Discussion. For 2D measurements, tracing around the LVOT VTI rather than through the modal line improved precision. The other 2D and 3D measurements of CO showed absence of fixed or proportional bias, and reasonable agreement with thermodilution as the reference method.
ABSTRACT PRESENTATIONS
Introduction. Demands for training in focused cardiac ultrasound (FCU) in anaesthesia and critical care is increasing and becoming a requirement of training. Traditional teaching methods are not scalable to meet these demands due to dependence on trainers and workshop logistics, and difficulty teaching pathology. A new automated self-directed course overcomes these problems using web-based learning and a VimedixTM simulator [1] that is capable of also teaching pathology. The aim of this study is to determine whether the simulator course is more effective than the traditional course in teaching FCU image acquisition and interpretation. Method. After IRB approval and written consent, 36 anaesthesia and critical care doctors registered in the traditional (iHeartScanTM course[2], n¼18) and simulator (FCU TTE, n¼18) courses were enrolled prospectively in the study. After pre-course eLearning, baseline FCU interpretation was assessed with an MCQ test. After the practical course (learning intervention), image interpretation and acquisition were assessed by MCQ and performance of FCU on a live human. The primary endpoint was differences in image quality scores assessed by two blinded experts (2-tailed independent Student t test). Secondary endpoints included interpretive (repeated measures ANOVA for factor x time interaction) and satisfaction scores (Student t), and number of FCU examinations performed in clinical practice after 3 months (Student t). Results. Out of the 36 participants, 4 simulator group participants did not perform image quality assessment, 1 simulator and 5 traditional group participants did not complete the 3-month assessment (Figure 1). Traditional and simulator groups had comparable baseline FCU expertise as their mean (95%CI) baseline interpretive scores were similar (78⫾6.4%, 82⫾6.4%, P 0.32), as were their level of seniority, (P 0.91) and previous exposure to FCU (P 0.15) or FCU simulators (P 0.09). The image quality scores were higher in the simulator group (83.8 ⫾ 19% vs. 65.1⫾13%, P 0.003). The groups were comparable in interpretation scores after the course (71⫾6.7% vs. 78⫾6.7%, P 0.61). After 3 months the groups also had similar interpretation scores (76⫾8.4% vs. 80⫾8.4%), satisfaction scores (79⫾3% vs. 81⫾%2, P 0.6), and number of times FCU had been used in clinical practice (7.9⫾4.9 vs. 4.5⫾3, P0.21). Figure 1: Participant flow-chart Discussion:
OP-36 Comparison of practical and interpretive focused cardiac ultrasound learning outcomes between a self-directed simulator and traditional live model course David Canty1,2,3, J. Barth1, Y. Yang1, M. Kim1, J Aik. Tan3, C. Royse1 1 Department of Surgery, University of Melbourne, Parkville, Victoria, Australia, 2Department of Medicine, Monash University, Clayton, Victoria, Australia, 3Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
Discussion. The self-directed simulator course provides superior learning of FCU image acquisition skills compared to the traditional course using trainers and models, and may meet increased demands of FCU training.
ABSTRACT PRESENTATIONS
REFERENCE 1. Biscotti M, et al: Comparison of extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation. J Thorac Cardiovasc Surg. 148(5):2410-2415, 2014.
P-26 Portuguese lung transplant program revisited Paulo Nave, F. Aguiar, C. Ramos, I. Fragata Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Portugal Introduction. The Portuguese lung transplant program was started in 2001. Since then, it is coordinated by the Lung Transplant Centre of the Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, the only lung transplant centre in the country. Eight years after its start, a major reorganization of the program and the teams involved, resulted in a significant improvement in hospitals’ response capacity. Methods. Retrospective analysis of the clinical files of the 90 patients treated between January 2009 and July 2015. 9 patients were excluded because of missing data. Eighty one patients were included. Collected data included demographic variables, type of transplant, pre-transplant diagnosis, duration of anaesthetic procedure, type of circulatory support, blood product transfusion requirements, hospital stay and 3 month mortality. Results. A clear enhancement of surgical activity has been seen over the years, from 8 cases of 2009 to 18 cases in 2014. From January to July 2015 we had already 8 cases. In demographic analysis, 45 (55,6%) patients were male and 36 (44,4%) were female with a mean age of 46,1⫾13,19 years. The six most common pre-transplant diagnosis, responsible for more than 80% of the cases, were: pulmonary fibrosis (n¼14), extrinsic allergic alveolitis (n¼13), COPD (n¼13), cystic fibrosis (n¼11), alpha-1 antitrypsin deficiency (n¼9) and bronchiectasis (n¼7). In fifty one cases (63%) was performed single lung transplant and in 30 cases (37%) was performed double lung transplant. Average time for the anaesthetic procedure was 719,33⫾172,1 minutes for double lung transplant and 515,98⫾135,6 minutes for single lung transplant. No cardiopulmonary support was used in 62 (76,5%) patients. Conventional cardiopulmonary bypass was used in 10 (12,3%) patients and ECMO in the remaining 9 (11,1%) patients. Average number of transfused blood products was 2,21⫾2,96 units for packed red blood cells and 1,57⫾1,89 units of fresh frozen plasma. In 73 cases no platelets were used, and the maximum administered were 2 units in only 1 case. Total fibrinogen administration was 5gr. Postoperatively, median time for mechanical ventilation, ICU stay and hospital length of stay was 4, 26 and 41 days, respectively. Overall survival rate at the 3 month was 91,4%. Discussion. This is a retrospective analysis of the data from the only Lung Transplant Centre in Portugal. Lung transplant remains the last resource for patients with end-stage chronic pulmonary disease. Thanks to a multidisciplinary dedicated team, our Centre results pair with the published literature1.
P-27 When a “flu” turns into a cardiac transplant – case report Paulo Nave, C. Ramos, I. Fragata Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Portugal Introduction. Based on the European Society of Cardiology statement1, dilated cardiomyopathy (DCM) is defined by the presence of left ventricular dilatation and left ventricular systolic dysfunction in the absence of abnormal loading conditions or coronary artery disease sufficient to cause global systolic impairment. Among the non-familial causes, myocarditis is one of the most common and is implicated in 9-16% of adult patients with unexplained non-ischaemic DCM. We present a case of a 21 year-old patient who presented with a DCM few days after a flu. Case Presentation. A 21 year-old male was admitted at the emergency room (ER) with flu-like symptoms. He complained of cough, fever and tiredness. He was a healthy subject with irrelevant medical history and no ambulatory medication. Physical examination didn’t show relevant findings. A blood panel was requested and revealed significantly elevated transaminases without any other major finding. He was purposed to further investigation but refused and went home with symptomatic treatment. A few days later, he returned to the ER complaining of extreme tiredness. He was confused and with signs of hypoperfusion. A transthoracic echocardiogram (TTE) revealed a DCM. During the observation he suffered a cardiac arrest. He was promptly resuscitated and transferred for an intensive care unit. TTE revealed severely depressed cardiac function (LVEF 5%; Figure 1), severe dilation of all four chambers and left ventricle spontaneous echo contrast (figure 2). Myocardial biopsy wasn’t performed because of the extremely thin ventricular walls. VAECMO and intra-aortic balloon pump were initiated for circulatory support. At this time his name was already in the national organ transplant waiting list and he was transferred to our Centre. Decision was to place a left ventricular assist device as a bridge to cardiac transplant (figure 3, 4). Twenty five days later, he had his cardiac transplant with no intercurrences. On tenth postoperative day he was transferred to general ward, where he’s still recovering. We’re still waiting for the heart histological result. Conclusion. DCM is a condition with variable clinical course, often requiring ventricular assist devices or even cardiac transplant. Endomyocardial biopsy is essential to define myocarditis as the cause of DCM. In this case, with the epidemiological context and exclusion of other possible causes, we believe this is a DCM secondary to myocarditis. REFERENCE 1. Elliott P, et al: Classification of the cardiomyopathies. European Heart Journal 29:270-276, 2008.
Oral Abstract Presentations 214 Thursday, May 12, 2016 16:30-18:00, Meeting Room 1 OP-35
REFERENCE 1. Gómez FJ, et al; Prognostic factors of morbidity and mortality in the early postoperative period following Lung Transplantation; Arch Bronconeumol 39(8):353-360, 2003.
Comparison of cardiac output of both 2 and 3 dimensional transoesophageal echocardiography with transpulmonary thermodilution during cardiac surgery David Canty1,2,3,4, R. Guha3, T. Pham4, M. Kim1,4, C. Royse1,2
S30
1
Department of Surgery, University of Melbourne, Parkville, Victoria, Australia, 2Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia, 3 Department of Anaesthesia and Pain Management, Monash Medical Centre, Melbourne, Victoria, Australia, 4Department of Anaesthesia and Pain Management, Monash Medical Centre, Melbourne, Victoria, Australia Introduction. Transpulmonary thermodilution (TD) is the most used method for cardiac output (CO) monitoring during cardiac surgery. Although 2D transoesophageal (TOE) measurement of CO using spectral Doppler correlates with TD, 3D TOE more accurately measures left ventricular outflow tract (LVOT) and aortic valve (AV) area, which are used to calculate CO. The aim of this study is to compare the precision of CO measurement between 2D and 3D TOE against TD. Method. After ethics approval, 50 patients aged over 18 years scheduled for on-bypass cardiac surgery were recruited prospectively at two institutions. Exclusion criteria included more than mild valvular regurgitation, and atrial fibrillation. CO was measured simultaneously by TD and TOE before sternotomy and after cardiopulmonary bypass. CO was calculated using TOE by the product of either the LVOT or AV area, the velocity-time integral (VTI) of flow at the same site and heart rate. The LVOT area was assumed circular and calculated using the LVOT diameter for 2D but with planimetry using 3D TOE. The AV area was estimated with planimetry by both 2D and 3D TOE, and VTI with continuous wave Doppler. Both modal and outer edge traces of LVOT VTI were performed with the cursor 0.5 cm from the annulus. Measurements were averaged from 3 consecutive beats by 2 observers. Deming model II regression was used to assess fixed and proportional bias of agreement with TD. Bland-Altman technique was used to assess closeness of fit. Results. CO was measured at 94 time-points (50 before sternotomy, 44 after chest closure) in 50 patients. The 3D methods had better agreement than 2D with TD, with the best agreement with 3D planimetry of the AV (bias -0.04 Lmin-1, SD of difference between the mean 1.37 Lmin-1), followed by 3D LVOT area planimetry (0.14, 1.41), 2D AV area planimetry (0.28, 1.3) and 2D LVOT VTI outer edge trace (-0.59, 1.29). 3D LVOT area planimetry had the best correlation (slope 1.39, 95%CI 0.97-1.82), followed by 2D AV planimetry (1.15, 0.81-1.48), 3D AV planimetry (1.07, 0.76-1.39), and 2D LVOT VTI outer edge trace (0.92, 0.33-1.52), all of which had no proportional or fixed bias. The VTI modal trace model had the worst agreement (-1.59, 1.37) and correlation (0.40, 0.08-0.69) and had proportional but not fixed bias. However the limits of agreement were similar amongst all methods. Tracing the edge of the LVOT VTI rather than the modal line reduced the bias (-0.59, 1.29), and improved correlation (0.92, 0.33-1.52). Discussion. For 2D measurements, tracing around the LVOT VTI rather than through the modal line improved precision. The other 2D and 3D measurements of CO showed absence of fixed or proportional bias, and reasonable agreement with thermodilution as the reference method.
ABSTRACT PRESENTATIONS
Introduction. Demands for training in focused cardiac ultrasound (FCU) in anaesthesia and critical care is increasing and becoming a requirement of training. Traditional teaching methods are not scalable to meet these demands due to dependence on trainers and workshop logistics, and difficulty teaching pathology. A new automated self-directed course overcomes these problems using web-based learning and a VimedixTM simulator [1] that is capable of also teaching pathology. The aim of this study is to determine whether the simulator course is more effective than the traditional course in teaching FCU image acquisition and interpretation. Method. After IRB approval and written consent, 36 anaesthesia and critical care doctors registered in the traditional (iHeartScanTM course[2], n¼18) and simulator (FCU TTE, n¼18) courses were enrolled prospectively in the study. After pre-course eLearning, baseline FCU interpretation was assessed with an MCQ test. After the practical course (learning intervention), image interpretation and acquisition were assessed by MCQ and performance of FCU on a live human. The primary endpoint was differences in image quality scores assessed by two blinded experts (2-tailed independent Student t test). Secondary endpoints included interpretive (repeated measures ANOVA for factor x time interaction) and satisfaction scores (Student t), and number of FCU examinations performed in clinical practice after 3 months (Student t). Results. Out of the 36 participants, 4 simulator group participants did not perform image quality assessment, 1 simulator and 5 traditional group participants did not complete the 3-month assessment (Figure 1). Traditional and simulator groups had comparable baseline FCU expertise as their mean (95%CI) baseline interpretive scores were similar (78⫾6.4%, 82⫾6.4%, P 0.32), as were their level of seniority, (P 0.91) and previous exposure to FCU (P 0.15) or FCU simulators (P 0.09). The image quality scores were higher in the simulator group (83.8 ⫾ 19% vs. 65.1⫾13%, P 0.003). The groups were comparable in interpretation scores after the course (71⫾6.7% vs. 78⫾6.7%, P 0.61). After 3 months the groups also had similar interpretation scores (76⫾8.4% vs. 80⫾8.4%), satisfaction scores (79⫾3% vs. 81⫾%2, P 0.6), and number of times FCU had been used in clinical practice (7.9⫾4.9 vs. 4.5⫾3, P0.21). Figure 1: Participant flow-chart Discussion:
OP-36 Comparison of practical and interpretive focused cardiac ultrasound learning outcomes between a self-directed simulator and traditional live model course David Canty1,2,3, J. Barth1, Y. Yang1, M. Kim1, J Aik. Tan3, C. Royse1 1 Department of Surgery, University of Melbourne, Parkville, Victoria, Australia, 2Department of Medicine, Monash University, Clayton, Victoria, Australia, 3Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
Discussion. The self-directed simulator course provides superior learning of FCU image acquisition skills compared to the traditional course using trainers and models, and may meet increased demands of FCU training.