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October 2021 A&A Video Summary: Featured Articles

Video Author: Daniel Mount and Jeanette Esau
Published on: 09.14.2021
Associated with: Anesthesia & Analgesia. 133(4):894-902, October 2021

Video summary covering three featured articles in the October 2021 issue of Anesthesia & Analgesia.

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Renal Cyst
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Renal sinus cyst.
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Transesophageal probe position to obtain a transgastric view of the left kidney using Vimedix Simulator from CAE Healthcare
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Transesophageal probe position to obtain a transgastric view of the left kidney using Vimedix Simulator from CAE Healthcare. Color Doppler image of the left kidney. The initial pulsed wave Doppler of renal vein flow was continuous but then became pulsatile from an elevated right atrial pressure. Following the administration of 75 ug of epoprostenol by inhalation and 60 ug of intravenous nitroglycerine, the venous Doppler velocity became normal. (With permission of Beaubien-Souligny et al.20)
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Transgastric Abdominal Ultrasonography View #10
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Animated description on the technique to obtain splenic vein Doppler interrogation under the pancreas using the Vimedix Simulator from CAE Healthcare. With permission of Denault et al. for the international study on the clinical significance of portal hypertension after cardiac surgery (NCT03656263).
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Transgastric Abdominal Ultrasonography View #10
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Transgastric abdominal ultrasonography view of the pancreas using a transverse view. Note the position of the splenic vein under the pancreas.
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Splenic Vein Pulsatility and Right Ventricular Failure
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Transgastric abdominal ultrasonography view at 0o with color Doppler (Nyquist 8 cm/s) of the splenic vein shows alternative to and fro splenic venous flow.
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Splenic Vein Pulsatility and Right Ventricular Failure
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This abnormality was associated with only mild tricuspid regurgitation as seen from a mid-esophageal modified right ventricular inflow view.
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Portal Vein and Hepatic Duct
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Video 1: RV strain measurement using the Epiq7 System (Philips, Andover, MA, USA)
Creator: Massimiliano Meineri, MD
Duration: 1:16
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A ME long axis view and a ME four chamber view are selected and analyzed using the Cardiac Motion Quantification (CMQ) analysis software package. First the aortic valve closure is identified and aortic valve closure time set. The ME four chamber is then selected and the LV long axis strain model is applied to the RV to allow correct labeling of septal segments. Tracking is qualitatively assessed and manually adjusted to capture the myocardium. The RV is divided into seven segments and the global strain is measured at – 29.8% with regional peak variability with all segments within limits of normal. RV Septum is de-selected to obtain RV free wall strain that is measured at -31.4%.
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Video 2: RV strain measurement using the Vivid E9 System (GE, Chicago, IL, USA)
Creator: Massimiliano Meineri, MD
Duration: 1:15
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The ME four chamber view is analyzed using the Automated Function Imaging (AFI) software package. The LV long axis strain model is applied to the RV to allow correct labeling of septal segments. Tracking quality is automatically assessed for each segment (green: good or red: poor). Parametric display provides measurements for each of the six RV and global strain. The latter is normal at – 22.3% with regional peak variability with basal segments below normal limits. RV myocardial region of interest is redefined and the septum de-selected to obtain RV free wall strain that is measured at approximately -22%
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Video 3: RV strain measurement using the SC2000 System (Siemens, Erlangen, Germany)
Creator: Massimiliano Meineri, MD
Duration: 0:48
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A ME long axis view and a ME four chamber view are selected and analyzed using the Velocity Vector Imaging (VVI) software package. First the aortic valve and mitral valve closures are identified using anatomical M Mode on a static 2D image. The ME four chamber is then selected, the RV strain model is applied and the endocardium traced excluding trabeculations and the moderator band. Tracking is qualitatively assessed. Parametric display provides measurements for each of the six RV, global strain and quantification of RV apical rocking. The latter is a measurement of apical myocardial transverse motion and it is increased with dyssynchrony. Peak global strain is normal and measures -29.5%. Regional peak variability can be appreciated with the mid septal segment being the only one below normal limits. The septum de-selected to obtain global RV free wall strain that is negative 36.
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September 2017 A&A Video Summary
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Real-time ultrasound-guided right supraclavicular approach to the central vein
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Identify the right jugular vein and carotid artery at the level of the thyroid cartilage on the short-axis view. Then, the probe is moved caudally following the internal jugular vein in the center of the monitor. Once the probe has reached the clavicle, it is inclined following the internal jugular vein to identify where it merges with the right subclavian vein and the underlying pleura on the long-axis view. The puncture needle is inserted using the long-axis view and advanced while identifying the needle point in real-time, until it reaches the right brachiocephalic vein.
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Avalon catheter repositioning
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Video clip 2. 2D-TEE analysis of the right coronary artery and tricuspid valve
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Duration: 0:24
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First part: The ME view, obtained by slightly withdrawing the probe from the modified ME 5-chamber view in video clip 1, demonstrates two cardiac masses (“proximal” and “distal”), with the RCA penetrating the left side of the distal mass. Second part: Color flow Doppler reveals laminar blood flow in the RCA. Third part: Simultaneous orthogonal planes to the RCA based on the ME aortic valve short axis view. Fourth part: Simultaneous orthogonal planes to the tricuspid valve based on the modified trans-gastric RV inflow-outflow view.
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Cardiac Venous System – Retrograde Blood Cardioplegia.
Creator: Luiz F Maracaja MD
Duration: 0:15
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1. Starting with ME 2-chamber view, activate the orthogonal imaging by aiming the cursor into the atrioventricular groove underneath the left atrial appendage lateral to the CX. 2. Activate CFD with a low-velocity scale (15–30 cm/s). Then, by moving the CFD sector over the atrioventricular groove lateral to the CX, one can display an image of the great cardiac vein (GCV) 3. The orthogonal plane displays retrograde blood cardioplegia flowing anteriorly from the coronary sinus (CS) to GCV and tributaries. The GCV wraps around the left side of the heart and posteriorly merges with the CS.
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How to Perform Focused Cardiovascular Ultrasound
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 23:23
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A brief, screen-in-screen review of the techniques required to perform bedside cardiac ultrasound at the parasternal, apical, and subcostal windows.
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Video 1: Normal parasternal long axis
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:08
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The right ventricle is under the transducer. There is normal excursion and coaptation of the aortic and mitral valves. The chambers are normal in size. There is brisk excursion of the aortic root, brisk opening of the mitral valve, a normal descent of the base of the MV, and normal thickening of the left ventricular segments.
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Video 2: Significant aortic stenosis seen in the PLAX
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:06
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The aortic valve is heavily calcified and does not open well. The degree of stenosis cannot be quantified from this view, but with excursion this limited the assumption should be that the patient has severe stenosis until it is proven otherwise. In addition to aortic valve calcification, the mitral annulus is heavily calcified, there is left ventricular hypertrophy, and the left atrium is enlarged.
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Video 3: Mitral valve prolapse seen in the PLAX
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:06
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In systole, the body of both mitral leaflets is above the level of the mitral annulus.
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Video 4: Dilated cardiomyopathy seen in the PLAX
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:08
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The RVOT, LA, and LV are all dilated and appear proportionally large compared to the aortic annulus and root. Compare the relative sizes with Video 1 (normal PLAX.) There is evidence of decreased LV systolic function, with decreased motion of the aortic root, decreased excursion of the anterior mitral leaflet, decreased mitral annular excursion, and decreased thickening of the left ventricular segments. There is also a left pleural effusion.
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Video 5: Rheumatic mitral disease seen in the PLAX
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:05
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Left ventricular and aortic valve function appear normal. There is thickening of the tips of the mitral leaflets, with diastolic bowing seen particularly in the anterior mitral leaflet (the “hockey stick” appearance). The left atrium appears enlarged as well, consistent with elevated left atrial pressure from mitral stenosis.
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Video 6: Systolic anterior motion of the anterior mitral leaflet in the PLAX
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:07
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Multiple beats are shown in this clip and the image does not remain still because the patient was severely dyspneic. The patient has significant hypertrophy of the anterioseptal wall of the left ventricle. In multiple cardiac cycles the anterior mitral leaflet can be seen to impinge on the left ventricular outflow tract.
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Video 7: Both pleural and pericardial effusions seen in the PLAX
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:05
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The descending thoracic aorta is outside the pericardium, and a pericardial effusion will be seen extending between the heart and the aorta in this view while a pleural effusion will be seen deep and lateral to the aorta.
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Video 8: Normal parasternal short axis (PSAX.)
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:07
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The right ventricle is seen to the left of the screen, with the anterior portion of the left ventricle closest to the probe. The papillary muscles are seen, identifying this as the mid-portion of the left ventricle. Six segments of the left ventricle are seen, representing all three main coronary artery territories.
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Video 9: Parasternal short axis (PSAX) with akinesis of the inferior segment
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:06
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The thinning of this segment suggests a scar consistent with previous myocardial infarction.
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Video 10: Parasternal short axis (PSAX) showing a pericardial effusion
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:07
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A pericardial effusion around the heart, hyperdynamic left ventricular systolic function, and decreased LV filling in diastole.
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Video 11: Parasternal short axis (PSAX) in a patient with septic shock.
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:07
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Septic shock, decreased left ventricular (LV) afterload, and increased cardiac output. The LV is full in diastole and empty in systole, consistent with the patient’s low-afterload state.
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Video 12: Parasternal short axis (PSAX) showing RV pressure overload
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:08
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The interventricular septum (IVS) is normally convex with respect to the left left ventricle throughout the cardiac cycle. In this case the IVS is flat in both systole and diastole, suggesting that the right and left ventricular pressures are similar (near systemic pulmonary artery pressures.)
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Video 13: Normal apical four chamber (A4).
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:08
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The apex of the left ventricle is directly under the ultrasound transducer. All four chambers can be visualized. There is normal global and regional biventricular systolic function, normal excursion and coaptation of the mitral and tricuspid valves, and normal chamber sizes.
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Video 15: Apical four chamber showing prolapse
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:09
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Prolapse of both anterior and posterior mitral leaflets with left atrial enlargement.
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Video 16: Apical 4 chamber showing an abnormal mitral valve opening in a patient with rheumatic heart disease
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:09
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Abnormal mitral valve opening in a patient with rheumatic heart disease. The tips of the mitral leaflets are thickened. The left atrium appears qualitatively enlarged compared with the size of the left ventricle.
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Video 17: Apical four chamber showing an enlarged right ventricle with decreased RV systolic function
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:09
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Enlarged right ventricle with decreased RV systolic function in a patient with a history of chronic severe pulmonary hypertension.
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Video 19: Normal subcostal four chamber (SC4)
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:10
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At the top of the image is the liver. The right atrium and right ventricle are seen well, as is the left ventricle. There is normal global biventricular systolic function. It is important to remember that, while this view often shows all four cardiac chambers, the cross section is not exactly the same as the apical four chamber.
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Video 20: Subcostal four chamber with right ventricular dilation and hypertrophy
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:10
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Subcostal four chamber with right ventricular dilation and hypertrophy. The free wall of the RV appears as thick as the left ventricle. The RV appears larger than the LV, suggesting significant enlargement.
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Video 21: Subcostal four chamber in a patient with pericardial effusion and tamponade.
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:11
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Subcostal four chamber in a patient with pericardial effusion and tamponade. The effusion is seen as a large echolucent space around the heart. The right atrium appears collapsed in ventricular systole and the right ventricle appears compressed in ventricular diastole. These findings are both consistent with tamponade physiology.
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Video 23: Subcostal IVC in a patient with cardiac tamponade
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:10
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Subcostal IVC in a patient with cardiac tamponade. The IVC appears dilated and does not collapse as the patient sniffs.
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Video 24: Subcostal IVC in a patient with hypovolemia
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:14
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Subcostal IVC in a patient with hypovolemia. The IVC is small and collapses completely as the patient breathes.
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August 2016 A&A Video Summary
Creator: Jeanette Esau
Duration:
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Video summary of featured articles in Anesthesia & Analgesia for August 2016.
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January 2015 A&A Video Summary
Creator: Steven Sayre
Duration: 3:08
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Video summary of featured articles in Anesthesia & Analgesia for January 2015
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May 2013 A&A Video Summary
Creator: Edward C. Nemergut, MD
Duration: 5:42
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Video summary of featured articles in Anesthesia & Analgesia for May 2013.
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How to Perform Focused Cardiovascular Ultrasound
Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 23:23
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A brief, screen-in-screen review of the techniques required to perform bedside cardiac ultrasound at the parasternal, apical, and subcostal windows.
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