Feasibility of basic transesophageal echocardiography in hemorrhagic shock: potential applications during resuscitative endovascular balloon occlusion of the aorta (REBOA)

Abstract

BackgroundThere are numerous studies in the cardiovascular literature that have employed transesophageal echocardiography (TEE) in swine models, but data regarding the use of basic TEE in swine models is limited. The primary aim of this study is to describe an echocardiographic method that can be used with relative ease to qualitatively assess cardiovascular function in a porcine hemorrhagic shock model using resuscitative endovascular balloon occlusion of the aorta (REBOA).MethodsMultiplane basic TEE exams were performed in 15 during an experimental hemorrhage model using REBOA. Cardiac anatomical structure and functional measurements were obtained. In a convenience sample (two animals from each group), advanced functional cardiovascular measurements were obtained before and after REBOA inflation for comparison with qualitative assessments.ResultsBasic TEE exams were performed in 15 swine. Appropriate REBOA placement was confirmed using TEE in all animals and verified with fluoroscopy. Left ventricular volume was decreased in all animals, and left ventricular systolic function increased following REBOA inflation. Right ventricular systolic function and volume remained normal prior to and after hemorrhage and REBOA use. Mean ejection fraction (EF) decreased from 64% (S.D. 9.6) to 62.1 (S.D. 16.8) after hemorrhage and REBOA inflation (p = 0.76); fractional area of change (FAC) decreased from 49.8 (S.D. 9.0) to 48.5 (S.D. 13.6) after hemorrhage and REBOA inflation (p = 0.82).ConclusionBasic TEE, which requires less training than advanced TEE, may be employed by laboratory investigators and practitioners across a wide spectrum of experimental and clinical settings.

The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA

“…However, the extent of this change has never been rigorously quantified, nor has the difference in afterload augmentation between pREBOA and fREBOA been described precisely. Echocardiography has been used to show changes in cardiac function with full REBOA in swine ( Teeter et al, 2018 ), but this is only an estimate within a narrow scope of cardiac biomechanical functional parameters. Other research has demonstrated that Esmolol during REBOA reduces myocardial injury ( Hoareau et al, 2020 ), suggesting that increased afterload is responsible for the cardiovascular effects and injury and that afterload modulation may be an approach to ameliorating the myocardial injury.…”

Establishment of teaching and training model for transesophageal echocardiography based on swine

“…At the mid-esophageal level, the probe was adjusted for ante exion and right rotation, and then, the left and right pulmonary vein views could be achieved at 30-50° and 100-120° respectively, and color Doppler was usually needed to assist in determining the acquisition of pulmonary veins. (7) At the mid-esophagus, other views could be acquired. From the long-axis view described in the preamble, advancing the probe could get the aortic valve LAX view when the aortic valve was put in the center of the frame with the angle range of 70-100°, and the aortic valve SAX view could be obtained at the angle of 30-50°.…”

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Looking Back, Moving Forward

“…Transesophageal echocardiography (TEE) and transthoracic echocardiography can provide important information regarding volume status, regional wall motion abnormalities, early diastolic dysfunction, and depressed contractility. 31 TEE can be included as part of an acute endovascular service, in the prehospital setting or used in austere environments when other imaging equipment is unavailable. TEE can specifically be used to evaluate aortic injury, cardiac tamponade, and identify the REBOA catheter tip location, which can facilitate placement in the operating room.…”

“…TEE can specifically be used to evaluate aortic injury, cardiac tamponade, and identify the REBOA catheter tip location, which can facilitate placement in the operating room. 31 The midesophageal inflow/outflow long and short view can identify the balloon position, demonstrate aortic dissection with identification of a false lumen, and assist the surgeon in safely deflating the balloon under direct visualization. 31 Prehospital healthcare providers should continue to focus on expedient transfer to the nearest endovascular or trauma facility.…”

“…31 The midesophageal inflow/outflow long and short view can identify the balloon position, demonstrate aortic dissection with identification of a false lumen, and assist the surgeon in safely deflating the balloon under direct visualization. 31 Prehospital healthcare providers should continue to focus on expedient transfer to the nearest endovascular or trauma facility. TEE should not take priority over immediate blood product transfusion and damage control resuscitation but offer feedback on ongoing decisions and cardiac function.…”