Right Heart Dysfunction Clinical Trial
Official title:
Measurement of Tricuspid Annular Plane Systolic Excursion in Transesophageal Echocardiography Using Two Deep Transgastric Views
The aim of this study is to measure TAPSE in TEE using two deep transgastric views. This is a
prospective comparative diagnostic study where 21 CABG patients who are enrolled for the
study will be studied during the intraoperative period. The choice of general anaesthesia,
hemodynamic management will be at the discretion of the anaesthesiologist in charge of the
patient. The monitoring technique is standard as per any cardiac surgery with cardiopulmonary
bypass. After induction of anaesthesia, TEE probe will be inserted by the PI or the
Co-Investigator and the required TEE standard views and deep TG view of the right heart at
zero degree and Deep TG view at 100-150 degrees will be acquired TAPSE will be measured in
both the views using Mmode.
The measurement will be done as follows: After acquiring the deep TG views the M mode cursor
is aligned with the longitudinal motion the lateral tricuspid annulus. Once the Mmode picks
up a good signal, 3 cycles are chosen and measured using calipers, and an average reading is
taken. TAPSE will be used to evaluate the right heart function during the intraoperative
period so that the patients with deteriorating right heart function can be identified and
treatment started early. The potential benefits include the simplicity and reproducibility of
the technique.
Right ventricular failure(RVF) is an important cause of postoperative morbidity and mortality
after cardiac surgery. Severe refractory RVF requiring prolonged inotropic support or RV
assist device occurs in approximately 0.1% of patients after cardiotomy and in 20-30% of
patients after left ventricular failure. The survival rate in these patients may be as low as
25 to 30%. Early diagnosis and prompt instituition of therapy may improve survival. In the
intraoperative setting TEE is becoming the mainstay in the assessment of right ventricular
function. However, presently it is not systematic and objective assessment of RV is not
uniformly carried out. This is partly due to the enormous attention given to the evaluation
of the left ventricle and the echo challenges of right heart imaging during intraoperative
period.
In 2010 the ASE released the guidelines on Right heart. It recommends Fractional Area change,
Tricuspid Annular Plane Systolic Excursion(TAPSE) and Peak Systolic tissue velocity of
tricuspid annulus as simple reproducible measurements that can be done in all the patients.
The guidelines are based on Transthoracic Echocardiography measurements. The Transesophageal
echocardiography which is used during cardiac surgery poses unique challenges when assessing
the right heart. The right ventricle lies in the far field where the resolution is not good,
and is made worse by the extensive apical trabeculations ; these factors make endocardial
border tracing difficult. In addition, the tissue Doppler and M mode alignment of the
tricuspid annulus is not possible in the mid oesophageal views. Recently, a deep trans
gastric view more than 120-150 degrees has been suggested by Denault et al which would give
an alignment for tissue and pulse wave Doppler but TAPSE hasn't been studied using this view.
The investigators have found a novel Deep trans gastric right heart view at zero degrees ,
which provides a good alignment for Doppler and M mode from which TAPSE, Peak systolic tissue
velocity of the Tricuspid annulus, and Right ventricular performance index can be readily
measured. We believe that this single view which can be easily acquired in most patients can
comprehensively assess the systolic and diastolic function of the right heart during the
intraoperative period.
The investigators propose that TAPSE can be accurately measured using M mode in the deep
transgastric right heart view at zero degrees because it provides perfect alignment with
longitudinal excursion of the lateral tricuspid annulus. Since the frame rate of M mode is
very high, distance can be more accurately measured than any other technique.
The aim of this study is to compare TAPSE measurement using Mmode in the two Deep
transgastric views: Deep TG view at 120- 150 degrees
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