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Anaesthesia for Endoscopic Cardiac Surgery 39
with ECG changes. The patient may need to be
taken to catheter lab for emergency angiogram
and stent placement. Emergency reoperation with
circumflex artery grafting may be required if the
resultant impingement has caused complete
occlusion and loss of blood flow resulting in
failure to wean off bypass.
23 Enhanced Recovery
In the authors institution we use a combination of
day of surgery admission together with an enhanced recovery after surgery (ERAS) programme to improve outcomes.
Our enhanced recovery programme is based
on the following principles:
1. Established Patient pathway and diary
2. Early mobilisation and twice daily physiotherapy
3. Twice daily Enhanced recovery nurse visit
4. ERAS daily targets discussed and set
5. Discharge discussions from outset
6. Care tailored for each patient
7. Post discharge support and hospital point of
contact
8. Nurse, doctor, patient and family education.
The programme resulted in 55–66% mobilised
within 6 h and a reduced length of hospital stay
of 1–1.5 days compared to non- ERAS in minimally invasive cardiac surgery.
The results of this were highlighted by the
Getting it right first time (GIRFT) study in cardiothoracic Surgery in 2018 [16].
• Core recommendation—“more efficient bed
management by ensuring surgery on day of
admission is delivered routinely leading to
reduced delays and time in hospital”
• Good practice case study—Blackpool Teach-
ing Hospitals—same day admissi on (SDA)
– 61% SDA at the same time maintaining
one of lowest average rate of post op
length of stay, average readmission rate
and below average complication rate—day
of surgery admission does not cause
problems later in patient stay
– Same day admission plus improved length
of stay plus reduced cancellations results in
reduced costs
Results of our same day admission programme were presented at Association of Cardiothoracic Anaesthetists meeting in 2015 [17].
We presented a 95% patient satisfaction rating
together with no increased mortality or morbidity
in same day admission program in cardiac
surgery.
References
1. Kirmani B, Knowles A, Saravanan P et al. Establishing minimally invasive cardiac surgery in a lowvolume mitral surgery centre.Ann R Coll Surg Eng
2021;000:1–8
2. Pisano GP, Bohmer RMJ, Edmondson AC. Organizational differences in rates of learning: evidence
from the adoption of minimally invasive cardiac
surgery. Manag Sci 2001; 47:752– 68.
3. Afilalo J, Lauck S, Kim H, et al. Frailty in older
adults undergoing aortic valve replacement. The
Frailty AVR Study. JACC 2017; 70(6):689–700.
4. Knoll H, Ziegeler S, Schreiber JW, et al. Airway
injuries after one-lung ventilation: a comparison
between double-lumen tube and endobronchial
blocker: a randomized, prospective, controlled trial.
Anesthesiology. 2006;105:471–7.
5. Clayton-Smith A, Bennet K, Alston RP, et al.
A comparison of the efficacy and adverse effects of
double lumen tubes and bronchial blockers in
thoracic surgery. JCVA. 2015;29(4):955–66.
6. Green DW, Kunst G. Cerebral oximetry and its role
in adult cardiac, non-cardiac surgery and resuscitation from cardiac arrest. Anaesthesia. 2017;72
(S1):48–57.
7. Deschamps A, Hall R, Grocott H, et al. Cerebral
oximetry monitoring to maintain cerebral oxygen
saturation during high-risk cardiac surgery: a randomised controlled feasibility trail. Anesthesiology.
2016;124:826–36.
8. Hahn RT, Abraham T, Adams MS, et al. Guidelines
for performing a comprehensive echocardiographic
examination: Recommendations from the American
society of Echocardiography and the Society of
Cardiovascular Anaesthesiologists. J Am Soc
Echocardiogr. 2013;26:921–64.
9. Simpson W, Knowles A, Zacharias J, Heggie A,
Saravanan P. Role of transesophageal echocardiography in minimally invasive redo surgery of the
tricuspid valve—a case series. SCTS—ACTA joint
annual meeting. Manchester, 25–27th March 2015.
40 A. Knowles and P. Saravanan
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
10. Yoo JY, Kim DH, Choi H, Kim K, Chae YJ,
Park SY. Disconnection technique with a bronchial
blocker for improving lung deflation: a comparison
with a double lumen tube and bronchial blocker
without disconnection. JCVA. 2014;28(4):904–7.
11. Irisawa Y, Hiraoka A, Totsugawa T, et al. Reexpansion pulmonary oedema after minimally invasive cardiac surgery with right mini thoracotomy.
Eur J Cardiothorac Surg. 2016;49:500–5.
12. Rennera J, Lorenzena U, Borzikowskyb C, et al.
Unilateral pulmonary oedema after minimally invasive mitral valve surgery: a single-centre experience.
Eur J Cardiothorac Surg. 2018;53:764–70.
13. Puehler T, Friedrich C, Georg G, et al. Outcome of
unilateral Pulmonary Edema after minimal-invasive
mitral valve surgery: 10-year follow-up. J Clin Med.
2021;10:2411. https://doi.org/10.3390/jcm10112411.
14. Vohra HA, Salmasi MY, Chien L, et al. On behalf of
the British and Irish Society for Minimally Invasive
Cardiac Surgery. BISMICS consensus statement:
implementing a safe minimally invasive mitral
programme in the UK healthcare setting. Open Heart
2020; 7:e001259. https://doi.org/10.1136/openhrt-
2020-001259
15. Mackie S, Saravanan P. Postoperative care of the
adult cardiac surgical patient. Anaesthesia Intensive
Care Med. 2021;22(5):279–85.
16. Richens D. Cardiothoracic surgery. Getting it right
first time (GIRFT) programme, National specialty
report. NHS Improvement March 2018. Accessed on
line 04 August 2021. https://gettingitrightfirsttime.co.
uk/wp-content/uploads/2018/04/GIRFTCardiothoracic-Report-1.pdf.
17. Williams B, Zacharias J, McAlea B, Saravanan P. Same day admission for cardiac surgery.
Safety and outcomes. SCTS—ACTA joint annual
meeting. Manchester, 25–27th March 2015.
Further Readings
Parnell A, Prince M. Anaesthesia for minimally invasive
cardiac surgery. BJA Education. 2018;18(10):323–30.
Vishwas M, Jha AK, Kapoor PM. Anesthetic challenges
in minimally invasive cardiac surgery: are we moving
in a right direction? Ann Card Anaesth 2016; 19
(3):489–97.
Transoesophageal Echocardiography
for Safe Endoscopic Cardiac Surgery
Palanikumar Saravanan and Andrew Knowles
Abstract
The safe practice of Endoscopic cardiac
surgery is linked with the provision of good
Trans oesophageal images during every stage
of the procedure. One of the reasons for the
slow uptake is likely to be the sporadic
availability of expert TOE operators in a
cardiac surgery theatre. The authors have an
experience of over a decade of developments
in this field and play a very important role is
the provision of this service. This chapter tries
to give the reader a overview of what is
required and what is possible with a particular
focus on the critical role of the TOE operator
in the endoscopic cardiac surgery team.
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_3. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
P. Saravanan (&) A. Knowles
Department of Cardiothoracic Anaesthesia,
Lancashire Cardiac Centre, Blackpool, England
e-mail: Dr.saravanan@nhs.net
Keywords
TOESafe conduct of surgeryQuality
control in endoscopic cardiac surgery
Transoesophageal echocardiography (TOE) is
essential for the safe conduct of endoscopic
cardiac surgery. With limited direct surgical
access into the chest cavity, it allows review and
confirmation of surgical pathology, aids the
placement of various cannulae and has a vital
role in diagnosing and troubleshooting problems
during the procedure. It is usually performed by
cardiac anaesthetists in UK though some centres
around the world will have dedicated cardiologists for this purpose [1].
It is mandatory in the preoperative assessment
to exclude any contraindications for TOE probe
insertion.
Full informed consent from the patient must
detail possible trauma to lips, teeth, pharyngeal
structures and the risk of oesophageal perforation
which may vary from approximately 1 in 1000 to
1in 10000 cases [2].
Insertion of a well lubricated TOE probe is
ideally performed with direct or video laryngoscopy. This may be augmented with anterior
traction on the mandible to open up the
oropharynx and laryngopharynx.
Space for the TOE machine may be limited
with a number of anaesthetic equipment (Fibreoptic bronchoscopy, Video laryngoscopy,
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_3
41
42 P. Saravanan and A. Knowles
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Cerebral oximetry and Defibrillator), surgical
equipment (3D stack and multiple trays needed
for insertion of cannulas) and number of personnel in theatre (cardiologist and anaesthetic
assistants). Arranging the work space to accom modate the devices and personnel will help in
efficient and continuous use of TOE that is
required for these procedures. The TOE screen
should be clearly visible to anaesthetists, surgeons and scrub nurse. The authors use a monitor
to display FOB and Video Laryngoscopy in one
device and the cerebral oximetry is slaved to
anaesthetic monitor. The defibrillator is placed
over and forms part of anaesthetic machine.
Some procedures performed by an endoscopic
approach (Video 1).
1. Left heart procedures
a. Mitral valve repair and replacement
b. Left Ventricular myomectomy
c. Left atrial myxoma.
2. Right heart procedures
a. Tricuspid valve repair and replacement
b. Closure of Atrial septal defect or patent
foramen ovale
c. Closure of Ventricular septal defect
d. Right atrial or ventricular mass lesions.
3. Others as combined procedures
a. LA appendage clipping
b. Atrial fibrillation ablation.
Timing of TOE:
The authors routinely perform TOE immediately
after induction of anaesthesia and intubation.
This will provide confirmation of the pathologies, review of ventricular performance and
suitability of the patient’s anatomy to undergo
endoscopic procedures. If any supporting or new
evidence found at this stage, endoscopic
approach has to be abandoned and sternotomy is
Video 1 Some procedures performed by minimal access (▶ https://doi.org/10.1007/000-a77)
Transoesophageal Echocardiography for Safe Endoscopic Cardiac Surgery 43
performed. This will prevent unnecessary insertion of right arm arterial line for monitoring in
the use of Endo Balloon device or a neck cannula
when indicated. This is important in health care
systems where there may be a long wait from the
time surgical decision is made to patient arrival
in theatre. Some surgeons and some centres
perform TOE after anaesthesia and lines insertion
are complete and prior to start of surgery. This
can be safely done in those centres where the
patient has a recent preoperative Echocardiogram
and when the surgical preference is to use other
forms of aortic occlusion.
Standard TOE assessment during endoscopic
surgery using both 2D and 3D scanning:
1. Routine cardiac surgery standard views to
assess anatomy, physiology and pathology
2. Dynamic assessment of arterial and venous
wire and cannula insertion
3. Safe establishment of cardiopulmonary
bypass flow
4. Endo balloon (intra aortic occlusion balloon)
positioning, inflation and cardioplegia
delivery
5. Assessment of de-airing
6. Separation from cardiopulmonary bypass
(CPB) and assessment of ventricular
performance
7. Assessment of surgical procedures
8. Confirmation of aortic integrity post bypass
and endo balloon usage.
TOE assessment specific for endoscopic surgery in addition to the routine cardiac surgery
standard views includes:
1. Aortic Valve: Mid oesophageal Long axis
(ME LAX) and short axis (ME SAX) views
and Deep Transgastric (DTG) view
Aortic Valve is assessed for its leaflet integrity
and any degree of regurgitation. Any regurg itation must be carefully assessed due to the risk of
ventricular distension during administration of
cardioplegia. A grading more than mild may well
preclude use of an Endo balloon. The vena
contracta measurement in DTG view and flow
reversal pattern in descending thoracic aorta
(DTA) is helpful in decision making.
2. Ascending aorta (AA): ME LAX view, Upper
oesophageal (UE) views
In the ME LAX view reducing the angle closer to
90 and pulling the probe back will give a clear
view of AA. In the UE AA view, using 90 degrees
or using X plane or Biplane views will provide
good assessment of a long segment of AA.
In some patients these views may not provide
satisfactory assessment and we find the views are
better after positioning of the patient. Presence of
severe atheromatous disease or mobile atheroma
will preclude endoballoon use.
AA diameter of less than 40mm at the level of
the pulmonary artery is generally required for
endo balloon usage.
3. Aortic arch & descending thoracic aorta
(DTA): ME and UE views
DTA can be seen well upon rotating the probe
towards the left (posterior) in ME views. Keeping DTA in view, pulling the probe back will
help in assessing the entire length of it. Using X
plane or Biplane views will help in viewing
longitudinal section of DTA alongside the cross
section. If the TOE machine do not provide this
facility, 90 degree angle is used and probe pulled
back. When the proximal part of DTA is reached,
the probe needs to rotated towards right (anterior)
to follow the arch. Ability to obtain these views
are important for placement of Endo balloon.
Presence of intraluminal pathology and/or
atheroma will preclude use of retrograde bypass
and passage of Endo Balloon. Certainly atheroma of Katz grade 4 and 5 in DTA would be a
contraindication for retrograde bypass or guidewire and endoballoon catheter passage.
Routine preoperative aorto femoral CT scan
can also identify this problem (Video 2).
44 P. Saravanan and A. Knowles
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Video 2 Pre bypass TOE (▶ https://doi.org/10.1007/000-a75)
Left ventricle: ME and TG views
1 Standard Assessment of Surgical
Pathology and Other Structures
Overall performance, presence of regional wall
motion abnormalities, degree of dilatation and
hypertrophy of left ventricle is assessed using all
Mitral Valve: All standard views and 3D
the standard views.
views
Assessment of mitral valve which includes leaflet
pathology, mechanism of regurgitation, annular
diameter and length of anterior leaflet assists in
valve repair planning. 3D echo can be used if
available to provide supporting information.
During the initial stages of setting up an endo-
Right ventricle: ME and TG views
Overall performance, degree of dilatation is
assessed using the standard views. Presence of
dilated and impaired right ventricle necessitates
robust plans for myocardial protection strategies
and postoperative management.
scopic program the prolonged nature of surgery
should be considered before undertaking complex mitral surgery. Any abnormal and significant calcification in mitral annulus may also
make surgery by endoscopic approach difficult
even in experienced hands.
Tricuspid Valve: All standard views, ME
coronary sinus view
Tricuspid valve is assessed using standard views.
Annular diameter is measured at the level of
coronary sinus. A diameter greater than 40 mm
Transoesophageal Echocardiography for Safe Endoscopic Cardiac Surgery 45
with or without significant regurgitation is usually considered for annuloplasty surgery.
Cannulation of the superior vena cava via the
internal jugular vein under TOE con trol will be
required as part of bicaval cannulation to facilitate tricuspid surgery.
Atria: All standard views
Assessment of degree of dilatation, left atrial
appendage for thrombus is performed in patients
scheduled for AF ablation and/or clipping of LA
appendage.
Integrity of interatrial septum is assessed and
presence of any PFO or ASD can make the
insertion and placement of femoral venous cannulation tricky. The area of defect needs to be
continuously monitored to avoid the guidewire in
left atrium during IVC cannula inser tion.
Superior vena cava (SVC): (Bicaval view,
upper oesophageal AA view)
Suitability of diameter for placement of drainage
cannulae and Fogarty balloon in tricuspid or
re-do surgery is probably best seen in the bicaval
view.
The circumflex artery blood flow: (two and
four chamber view)
Attempts are made to look for circumflex artery
blood flow in the two chamber view where it can
be usually seen as a small circular structure at the
anterior mitral annulus or along its length in the 4
chamber view. Probe can be tilted and angle
decreased or increased to view this as a tubular
structure. Colour flow Doppler is utilised to view
blood flow.
Pericardial and Pleural spaces: All Standard
views and DTA views
Any fluid collections in pleural spaces need to be
noted. The effusion on left pleura will impair the
ability to safely achieve one lung ventilation
while effusion on right which may be associated
with adhesions can make surgical access difficult
due to failure of lung to collapse and increase the
risk of bleeding postoperatively.
Conduct of surgery
SVC cannulation: Bicaval view
Initially jugular venous guidewire insertion is
performed under ultrasound control. Guidewire
passing down the SVC must be confirmed and
therefore rule out passage of the wire into the
arm. Attempts should be made to pass the
guidewire into inferior vena cava (IVC) to avoid
arrhythmias. After insertion, the cannula is
positioned at the right atrial SVC junction or
within the SVC if caval snaring is to be
undertaken.
Femoral Venous Cannulation: Bicaval view,
TG IVC view
A bicaval view is obtained for guidewire and
cannula positioning. The angle of the probe may
need to decreased to 80 to 90 degrees to visualise
the guidewire as well as small left and right
manipulations to keep the thin guidewire in the
ultrasound beam. This view is used to ensure
initial wire passage into the SVC and not into the
right ventricle via the tricuspid valve or into the
right atrial appendage both of which may be
perforated by the drainage cannula following an
abnormal wire passage.
In presence of an ASD or PFO, additional
precautions are taken to identify and avoid the
wire in left atrium. This is in the form of continuous monitoring of the wire position with
surgical manoeuvres. A cross sectional view of
SVC along with the bicaval view increases
sensitivity. This can be obtained in different
TOE machines as X plane view or Biplane view.
Femoral arterial Cannulation: Short/long
axis of descending aorta
The DTA views are obtained as described in
standard assessment. This is to confirm passage of the guidewire into the descending
aorta and which should be clearly seen moving
freely within the lumen. Every effort is made
to see the J tip as con firmation. Longitudinal
view of DTA alongside the cross sectional view
increases the sensitivity (Video 3).
46 P. Saravanan and A. Knowles
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Video 3 TOE for cannulations (▶ https://doi.org/10.1007/000-a76)
Placement of Endo aortic occlusion balloon
—DTA views, ME LAX view of aortic valve
balloon tip is positioned at the level of pulmonary artery (Video 4).
and ascending aorta
The guidewire of the Endo Balloon is visualised in
the descending thoracic aorta similar to guidewire
of femoral arterial cannula and followed up into
arch and then ascending aorta. The X-plane or
biplane view is used to increase the sensitivity.
Continuous wire passage via the descending, arch
and into the ascending aorta must be con firmed.
Erroneous passage into the arch vessels may result
in vascular spasm within that vessel. The left
subclavian artery is most likely to be affected and
is indicated by drop in left arm pressure.
Following correct position of the wire within
the ascending aorta the balloon catheter is
advanced to be positioned at the level of the main
pulmonary artery. During the passage of the
balloon through the guidewire, the AA is monitored for continuous presence o f J tip of the
guidewire till balloon tip is visualised. The
Commencement of cardiopulmonary
bypass: DTA views
Monitoring DTA during commencement of CPB
allows confirmation of safe retrograde flow and
absence of aortic dissection. The artefacts due to
the mixing of forward flow from myocardial
contraction and retrograde bypass flow may be
visualised and should not be mistaken for aortic
dissection.
If the arterial line pressures are reported as
high on commencement of bypass, the patient is
weaned off bypass, ventilation resumed and
contralateral femoral artery is also cannulated
using TOE guidance. During this time, the
presence of Endo Balloon in DTA should be
taken into account while visualising guidewire.
Attempts are then remade to commence bypass
via both femoral arterial cannulae.
Transoesophageal Echocardiography for Safe Endoscopic Cardiac Surgery 47
Video 4 TOE for Endo Balloon (▶ https://doi.org/10.1007/000-a74)
Balloon inflation: ME LAX of aortic valve
and ascending aorta
The Endo Balloon is placed under direct TOE
guidance into the ascending aorta at the level of
the pulmonary artery. To occlude the ascending
aorta, it is inflated with approximately n mls of
saline (where n was the measured aortic diameter
Delivery of cardioplegia—Long axis of aortic valve and ascending aorta
Delivery of cardioplegia into the aortic root
should be visible with flow from the balloon or
cardioplegia cannula, pressurisation of the root,
competence of the aortic valve and flow seen into
the right coronary artery.
in millimetres). At approximately 15–20 ml of
inflation, 250 lg/kg of adenosine is administered
through the distal lumen of the intra-aortic balloon directly into the partially occluded aortic
root causing cardiac standstill to allow accurate
landing of the balloon. This prevents ventricular
ejection and allowing the full balloon inflation to
occur without movement of the balloon. Once
the balloon is inflated to the required diameter a
drop in the pressure of the endoballoon
manometry line is seen indicating occlusion of
the ascending aorta and isolation from CPB
pressure in the distal aorta.
Inflation of Fogarty catheter in Redo procedures: Bicaval view
In patients undergoing redo tricuspid valve procedures external snaring of the SVC may not be
possible and therefore a Fogarty catheter is used
to occlude the SVC opening from inside the right
atrium. We use a Fogarty balloon which can be
inflated up to 48 mls. The inflation can be visualized in the bicaval view. The SVC drainage
cannula is pulled back to lie approximately 3–
4 cm above the junction of RA/SVC junction.
Adequate drainage is the confirmed by the
48 P. Saravanan and A. Knowles
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Video 5 TOE specific to redo surgery (▶ https://doi.org/10.1007/000-a78)
perfusionist and also in cerebral oximetry readings (Video 5).
AA is examined to confirm aortic integrity.
Following mitral valve surgery, the coaptation
length, valve gradient, presence of Systolic
Deflation of Balloon and deairing: ME LAX
view
Balloon is deflated under vision, aortic integrity
confirmed and positioned close to aortic valve to
aid deairing.
anterior motion (SAM) and circumflex artery
flow are routinely checked.
The Aortic valve integrity is assessed especially following Endo Balloon use. Right coronary artery flow is assessed following tricuspid
valve surgery.
Following CPB: All standard views
Assessment of bivent ricular function is mandatory as separation from CPB occurs.
Then assessment of the surgical procedure is
confirmed using all relevant standard views. The
In contrast to sternotomy cardiac surgery the
right ventricle is only visible by TOE and
therefore this must be assessed during protamine
delivery (Video 6).
views used will depend on the procedure performed.
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