Measurement of Tricuspid AnnularPlane Systolic Excursion in Transesophageal Echocardiography
Condition: Right Heart Dysfunction
MeSH terms: Systolic Murmurs
Study type: Observational

Summary: 
      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.
    

Detailed description: 
      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
    

Observational model: Case-Control
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        Patients scheduled for coronary artery bypass surgery at National university hospital are
        included in the study
      
Keywords: TAPSE; Right heart function