Archive for the ‘Echocardiography’ Category

Video: Aug 2011 lecture Periop Myocardial Ischemia and Infarction

Tuesday, August 23rd, 2011

Medical University of South Carolina Grand Rounds

Dr. John E. Ellis

Start watching video at 2:20

Is preop cards eval dangerous?

Friday, September 17th, 2010

A provocative article from the prolific Toronto group (running neck-and-neck with Rotterdam) that suggests that preop internist/cardiologist consultation before intermediate-high risk surgery leads to more testing. more new beta blockade and statin use, but higher mortality and longer hospital LOS!

Strengths:

  • very large, validated databases
  • sophisticated propensity analysis
  • unmeasured variable that could account for differences would have to be fairly common and have large effects.

Weaknesses:

  • Retrospective study can only show associations, not prove causation
  • The patients that couldn’t matched for propensity analysis were much sicker

From the manuscript’s abstract:

“Conclusions: Medical consultation before major electivenoncardiac surgery is associated with increased mortalityand hospital stay, as well as increases in preoperativepharmacologic interventions and testing. Thesefindings highlight the need to better understand mechanismsby which consultation influences outcomes andto identify efficacious interventions to decrease perioperative risk. ”
Arch Intern Med. 2010;170(15):1365-1374

NCS with severe aortic stenosis: increased periop events, but without death in 30 patient series

Saturday, July 3rd, 2010

Case series from the Mayo Clinic in Scottsdale in Am J Cardiol (time to quote somebody else besides Toronto and Rotterdam)

We studied 30 patients with asymptomatic, severe AS with a mean age of 78 + or – 9 years, an aortic valve area of 0.77 + or – 0.16 cm(2), a mean gradient of 50.1 + or – 9.5 mm Hg, and a peak gradient of 84 + or – 22 mm Hg. They were compared to 60 age-matched (within 2 years) and gender-matched (ratio of 1:2) patients with mild-to-moderate AS (controls).

Combined postoperative events were more common for the patients (n = 10; 33%) than for the controls (n = 14; 23%), but the difference was not statistically significant (p = 0.06).

Intraoperative hypotension requiring vasopressor use was more likely for the patients (n = 9; 30%) than for the controls (n = 10; 17%; odds ratio 2.5; p = 0.11).

The perioperative myocardial infarction rates were similar for both groups (3%; p = 0.74). No deaths, heart failure events, or ventricular arrhythmias occurred in the patients and 1 death and 1 ventricular arrhythmia episode occurred in the controls

MY SYLLABUS FOR 2010 AMERICAN SOCIETY OF ANESTHESIOLOGISTS REFRESHER COURSE

Sunday, June 20th, 2010

Ellis ASA Refresher Course Lecture 2010

Click above to download the syllabus

ROUTINE PREOP ECHO IN VASCULOPATHS IDENTIFIES FREQUENT SUBCLINICAL LV DYSFUNCTION, WHICH CARRIES A POOR PROGNOSIS

Sunday, May 30th, 2010

The prolific folks from Erasmus report on 1005 consecutive vascular surgery patients studied with preop transthoracic echo.  A few salient findings:

  • Periop 30d MACE is roughly twice as common with endovascular compared to open repair (even after “Multivariate analysis adjusted for age, gender, ischemic heart disease, cerebrovascular disease, renal dysfunction, diabetes mellitus, hypertension, hypercholesterolemia, chronic obstructive pulmonary disease, and smoking.)
  • Only 1/2 of the patients had normal LV function
  • Asymptomatic LV dysfunction (either systolic and diastolic) is associated with worse outcome

The results suggest that perhaps routine preop echo should be part of the preop workup before vascular surgery.  However, the authors cannot prove that the knowledge gained would lead to changes in practice that would improve outcome.  They do suggest that patients whose preop echoes identify subclinical LV dysfunction might benefit from having beta blockers and ACEI or ARBs started.

We have an article in press suggesting that there are significant variations in anesthesiologists’ desire for preop echo before vascular surgery.