| Echocardiographic finding | Implications for the anesthesiologist |
| LV and RV systolic function | Use this information to plan: - Monitoring strategies (eg, whether to use TEE and/or a PAC)
- Choices of anesthetic and inotropic agents
- Potential need for perioperative mechanical circulatory support
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| LV diastolic function | - Patients with milder degrees of LV diastolic dysfunction (ie, impaired relaxation) may benefit from enhanced preload and a longer diastolic time to allow more time for ventricular relaxation and filling. Thus, a slow heart rate (eg, 55 to 70 bpm) may be beneficial in these patients.
- Patients with more advanced degrees of diastolic dysfunction (ie, restrictive filling) have poor ventricular compliance and a fixed stroke volume. These patients typically need a normal heart rate (eg, 70 to 85 bpm) to generate an adequate cardiac output[1].
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| RWMAs | - Necessary for assessment of new RWMAs that may develop during surgery, as detected with TEE monitoring. Although new intraoperative RWMAs are not predictive of early graft failure[2], they are associated with increased risk for adverse cardiac events in the long term[3].
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| Ventricular dimensions | - The failing left or right ventricle undergoes compensatory chamber dilatation (ie, above-normal values for ventricular internal diameter and/or area measurements[4]) in order to maintain stroke volume. Chamber dilatation leads to increased systolic wall stress. These patients are less sensitive to preload than those without chamber dilatation but are exquisitely sensitive to increases in afterload.
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| Valvular lesions | - The presence and severity of valvular lesions (eg, mitral regurgitation, aortic stenosis) affects intraoperative hemodynamic goals and resultant anesthetic management.
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| Aortic atheroma | - The presence of large or mobile atheroma in the ascending or descending aorta has been associated with a higher incidence of postoperative stroke.
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| Pericardial disease or effusion | - While small pericardial effusions are generally well tolerated, a large effusion may indicate pericardial tamponade. Induction of anesthesia in a patient with cardiac tamponade may cause life-threatening cardiovascular collapse due to effects of anesthetic agents (eg, systemic vasodilation, decreased preload, and direct myocardial depression). Necessary planning requires communication among team members and preparation of induction agents with minimal myocardial depressant effects (eg, etomidate) and inotropic and/or vasopressor drugs.
- Cardiac surgery in patients with pericarditis or pericardial constriction typically results in significant blood loss.
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| Anatomic defects (eg, ASD or VSD) | - A large ASD and/or VSD typically results in RV volume overload and increased PAP, with resultant reduced pulmonary compliance and increased work of breathing. Patients may be asymptomatic or may exhibit varying degrees of heart failure and/or pulmonary edema.
- Presence of a septal defect should prompt thorough intraoperative TEE evaluation for associated congenital cardiac anomalies (eg, coronary sinus defects, partial anomalous venous connection, or cleft anterior mitral valve leaflet).
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| Atrial or mural thrombi | - The presence of thrombus in the left atrial appendage or apex of the left ventricle may alter the surgical plan (eg, thrombectomy or ligation of left atrial appendage). Intraoperative TEE is necessary to confirm whether the thrombus is still present before, during, and after surgery.
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