Epikardiale Echokardiographie

Epicardial echocardiography has been available since the early 1970s as an intraoperative diagnostic modality to assess ventricular and valvular function. With this technique, an ultrasonic transducer is placed directly on the epicardial surface of the heart, following sternotomy and pericardiotomy. Under the guidance of the cardiac anesthesiologist, the surgeon places the transducer so that the desired views of cardiac structures and great vessels can be obtained. The anesthesiologist performs the acquisition, analysis and interpretation of the echocardiographic images. Despite the feasibility of epicardial echocardiography, transesophageal echocardiography (TEE) has emerged over the last two decades as the main form of intraoperative echocardiography. Although TEE allows continuous monitoring of cardiac and valvular function without interruption of the surgical procedure, placement of a TEE probe may be difficult or contraindicated in some patients. In such cases, epicardial echocardiography may be the optimal ultrasonographic imaging modality to assess ventricular and valvular function during cardiac surgery. We describe the use of epicardial echocardiography for intraoperative assessment of valvular function in two patients where TEE was either contraindicated or probe placement could not be performed safely. The first patient underwent surgical repair of the mitral valve for severe mitral regurgitation. After weaning the patient from cardiopulmonary bypass (CPB), epicardial echocardiography was used to confirm successful reconstruction of the valve and to exclude residual mitral regurgitation. The second patient was scheduled for coronary artery bypass grafting (CABG). Prior to the initiation of CPB, the presence of moderate aortic stenosis was confirmed using Doppler echocardiography via an epicardial approach.     

Intraoperative Echokardiographie

Since the introduction of intraoperative echocardiography into clinical practice in the 1970’s its use and utility in the perioperative period has become increasingly more evident. Especially in patients undergoing cardiac surgical procedures intraoperative echocardiography has gained great diagnostic importance. Intraoperative transesophageal echocardiography (TEE) and epiaortic ultrasound are two important and complementing diagnostic modalities in this patient population. The clinical information obtained with intraoperative TEE in certain cases might have a direct impact on surgical decision-making and therefore may positively influence patient outcome. In patients undergoing non-cardiac surgical procedures, TEE can be a valuable tool in high-risk patients, in patients experiencing hemodynamic instability or in those suffering intraoperative cardiac arrest. Intraoperative TEE might allow a primary diagnosis of the underlying etiology and facilitate the institution of further therapeutic interventions. In addition TEE can be performed during ongoing cardiopulmonary resuscitation and does not interfere with patient management. This review introduces the clinician to the current evidence of the impact of intraoperative echocardiography on intraoperative surgical decisions during surgical procedures. It helps the clinician to identify indications and realize the potential applications of intraoperative echocardiography.     

Echokardiographie in der Notaufnahme

Detection of acute cardiac dysfunction and differential diagnosis of low cardiac output syndrome is challenging for emergency physicians. For the critical ill patient it is essential to rapidly identify the underlying disease to initiate the correct therapy and optimize patient outcome. Echocardiography is the diagnostic tool of choice for the evaluation of low cardiac output states. In the setting of the emergency department the use of focused echocardiography instead of detailed echocardiographic studies of cardiologists is appropriate and should be provided for emergency care. The differentiation in preserved versus reduced left ventricular ejection fraction as a first assessment is helpful, particularly for physicians not well trained in echocardiography. The structured and focused approach to evaluate or exclude differential diagnoses of cardiac dysfunction is the key for optimal management of acute and critically ill patients with low cardiac output.     

Transthorakale Echokardiographie bei thorakaler Messerstichverletzung

Penetrating chest trauma involving the heart is usually known with a high mortality rate. Neither the absence of hemodynamic depression nor ECG changes exclude a potential fatal injury to the heart. We report on the diagnosis and definitive treatment of a stab wound injury with transected coronary artery, concomittant ventricular penetration, and pulmonary injury.A 37-year-old female was admitted to our emergency room with multiple left-sided gashes (cheek, neck, upper extremity) and a single stab wound in the left thorax. At the scene of the accident the patient's hemodynamic condition was stable with no signs of shock or shortness of breath. Auscultation revealed regular respiratory sound on both lung sides. Hospital transfer by ground was uneventful. Chest X-ray showed left pleural effusion with no signs of pneumothorax. ECG demonstrated regular sinus rhythm without repolarization changes or low voltage. Transthoracic echocardiography revealed pericardial effusion with a swinging heart. The patient was electively intubated in the emergency room and transferred to the operating room for pericardial paracentesis. Median sternotomy was necessary due to extensive bleeding in the drain. Examination of the heart showed a laceration of the left coronary artery (LAD), left ventricle, and upper lobe of the left lung. Cardiopulmonary bypass was instituted and the LAD was ligated proximal to the penetration. The left internal thoracic artery was used for coronary revascularization of the LAD. Postoperative ECG and creatine kinase evaluations excluded myocardial ischemia. The patient was discharged from hospital at POD 10 fully recovered. Transthoracic echocardiography in the emergency room is the diagnostic tool of choice to exclude/confirm a potential cardiac injury. In the case of pericardial effusion, paracentesis sometimes followed by thoracotomy should be performed. The importance of rapid diagnosis and intervention should be emphasized to reduce mortality due to cardiac tamponade or acute myocardial infarction as illustrated by this case.     

Trans?sophageale Echokardiographie Perioperative Beurteilung der Herzklappen Perioperative Beurteilung der Herzklappen

Der hohe Stellenwert der trans?sophagealen Echokardiographie (TEE) in der perioperativen Medizin ist unumstritten. Die TEE gestattet eine direkte bildgebende Darstellung von pathologischen Ver?nderungen des Herzens. Daher ist die TEE das Verfahren der Wahl zur Diagnose und Graduierung von Herzklappenerkrankungen. über die direkte bildliche Darstellung hinaus erlaubt die TEE eine objektivierbare h?modynamische Beurteilung der Klappen- und Ventrikelfunktion. Durch Messung von Blutflussgeschwindigkeiten werden Druckgradienten über stenotischen Klappen ermittelt. Unter Anwendung der Kontinuit?tsgleichung oder der Planimetrie lassen sich Klappen?ffnungsfl?chen bestimmen. Bei einer Klappeninsuffizienz wird der Schweregrad mittels color flow, continuous oder pulsed-wave Doppler abgesch?tzt.     

Transösophageale Echokardiographie für Herzchirurgen

The transesophageal echocardiography (TEE) is invaluable in contemporary cardiac surgery. Two-dimensional and Doppler TEE confirm and complement the preoperative diagnosis and offer additional information, which may be useful for the final planning of the operation. Immediately after surgery, TEE can be used to check the results and, if necessary, prompts revision. TEE has the most favorable cost-benefit ratio in case of valve repair, complex operations, high-risk patients as well as in emergencies. TEE can also be used to monitor ventricular and hemodynamic function and enables quick and reliable diagnosis in situations of difficult weaning from the heart-lung machine and postoperative hemodynamic instability. The introduction of real-time 3-dimensional TEE will further enhance the diagnostic capability of perioperative echocardiography.     

Grundlagen der transthorakalen Echokardiographie beim herzchirurgischen Patienten

Echocardiography has emerged as an increasingly utilized tool to estimate the clinical status of patients in the emergency department. A specialized toolset that meets the specific requirements in an emergency department is commonly referred to as focused echocardiography. It is the overall aim of this article to give a step-by-step guidance of how to apply these basic tools in order to estimate the hemodynamics of a patient’s circulation. Focused echocardiography is mainly based on defined 2-D and color Doppler analyses. Furthermore, these are complemented by spectral Doppler analyses in order to gain information on crucial hemodynamic parameters, such as systolic pressure in the pulmonary artery (sPAP), increase in left ventricular (LV) filling pressure, stroke volume (SV) and therefore impacting cardiac output (HZV) and system vascular resistance (SVR).     

Echokardiographie bei akuter hämodynamischer Instabilität

In light of the growing proportion of illness in the general population, the complexity of modern surgery requires precise perioperative hemodynamic monitoring. Echocardiography has emerged over the past 15 years as an especially valuable diagnostic instrument for intensive medicine. No other monitoring technique provides in such a short time, with so little invasiveness, so much additional anatomic information for determining the cause of acute hemodynamic instability. There is of course the possibility of proceeding transthoracally at first, with poor imaging quality but noninvasively, or transesophageally. However, perioperative hemodynamic monitoring allows even less experienced operators to detect the various differential diagnoses of acute hemodynamic instability with an easily managed number of standard images. Starting from the first standard settings, depending on pathology the imaging should continue selectively with transthoracal echocardiography in the short parasternal axis or transesophageal echocardiography in the transgastral short midpapillary axis.     

Nachweis von Markembolien wÄhrend Oberschenkelmarknagelungen mittels transösophagealer Echokardiographie

Kardiopulmonale Komplikationen nach Marknagelosteosynthesen, insbesondere am Oberschenkel, sind bekannt. WÄhrend der Nagelung einer Oberschenkelquerfraktur mit einem, geschlossenen distalen Fragment konnten durch transsophageale Echokardiographie im rechten Herzen durchströmende echogene Partikel nachgewiesen werden. Das intrakardiale Auftreten dieser Partikel stand in engem zeitlichen Zusammenhang mit dem Aufbohren der femoralen Markhöhle und kann als Nachweis verschleppter Marksubstanz gedeutet werden. Die intraoperative Echokardiographie bietet sich an, Untersuchungen über die Pathophysiologie kardiopulmonaler VerÄnderungen nach Marknagel osteosynthesen durchzuführen und die EffektivitÄt einer Druckentlastung der Markhöhle, z. B. in. Form eines Bohrloches, zu beurteilen.     

TEE in Anästhesie und Intensivmedizin Der diagnostische Stellenwert der transösophagealen Echokardiographie

Transoesophageal echocardiography (TEE) is recognised as a semi-invasive technique that has an increasing impact as a diagnostic tool in anaesthesia and intensive care medicine. However, adequate assessment of TEE is based on knowledge of basic echocardiographic principles and their limitations and sufficient educational training of the user. TEE has an established role in various clinical circumstances. It often saves time-consuming investigations for the diagnosis of aortic injuries in trauma patients. It is also useful in patients undergoing cardiac valve repair or congenital heart surgery with regard to assessment of the operative success. In patients with severe hypotension TEE may identify the cause, and thereby facilitate successful patient management. Moreover, TEE has an impact on the diagnosis of endocarditis and pathologic findings within the heart and pericardial sac. TEE-associated diagnosis and decision-making may lead to an improved clinical outcome, which in turn may lead to subsequent cost reduction.     

Perioperative Inflammation

Die Anaesthesiologie - Chirurgische Eingriffe und invasive Verfahren können beim Patienten eine inflammatorische Reaktion auslösen. Diese entzündliche Reaktion ist eine...     

Perioperative Schmerztherapie

Scientific studies have proven without doubt that an optimized perioperative pain therapy will improve patient comfort, reduce postoperative complications, enhance postoperative recovery and shorten the length of postoperative hospital stay. It is necessary to incorporate the acute pain therapy into a perioperative multimodal and interdisciplinary therapeutic concept. Local or regional anesthesia will provide the best analgesic effect after surgery and should be considered in all patients. Optimal treatment of patients with peripheral nerve blocks, spinal or epidural analgesia should be treated by a specialized acute pain service. However, only 15?C20% of all surgical cases will be taken care of by such a pain service. Therefore, most surgical patients will only receive adequate analgesia if surgeons are familiar with the principles of postoperative pain therapy. Regular assessment of pain perception is the cornerstone of optimized pain therapy. Furthermore, pain assessment will allow the administration and to some extent dosage of analgesic therapy to be delegated to nursing personnel.