Share
array:24 [ "pii" => "S2341192920301347" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.06.006" "estado" => "S300" "fechaPublicacion" => "2020-10-01" "aid" => "1173" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "pgl" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2020;67:446-79" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935620301511" "issn" => "00349356" "doi" => "10.1016/j.redar.2020.06.001" "estado" => "S300" "fechaPublicacion" => "2020-10-01" "aid" => "1173" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2020;67:446-80" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Revisión</span>" "titulo" => "Ecocardiografía transesofágica intraoperatoria en cirugía cardiovascular. Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE)" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "446" "paginaFinal" => "480" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Intraoperative transesophageal echocardiography in cardiovascular surgery. Consensus document from the Spanish Society of Anesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE)" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0055" "etiqueta" => "Figura 11" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr11.jpeg" "Alto" => 961 "Ancho" => 1344 "Tamanyo" => 99706 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Plano medioesofágico dos cámaras tras recambio de válvula mitral. Se observa chorro de regurgitación periprotésica en región anular a nivel de orejuela izquierda.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Carmona García, R. García Fuster, E. Mateo, S. Badía Gamarra, M. López Cantero, E. Gutiérrez Carretero, M.L. Maestre, V. Legname, G. Fita, M. Vives, T. Koller Bernhard, E. Sánchez Pérez, J. Miralles Bagán, S. Italiano, B. Darias-Delbey, J.M. Barrio, J. Hortal, J.I. Sáez de Ibarra, A. Hernández" "autores" => array:19 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Carmona García" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "García Fuster" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Mateo" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Badía Gamarra" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "López Cantero" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Gutiérrez Carretero" ] 6 => array:2 [ "nombre" => "M.L." "apellidos" => "Maestre" ] 7 => array:2 [ "nombre" => "V." "apellidos" => "Legname" ] 8 => array:2 [ "nombre" => "G." "apellidos" => "Fita" ] 9 => array:2 [ "nombre" => "M." "apellidos" => "Vives" ] 10 => array:2 [ "nombre" => "T." "apellidos" => "Koller Bernhard" ] 11 => array:2 [ "nombre" => "E." "apellidos" => "Sánchez Pérez" ] 12 => array:2 [ "nombre" => "J." "apellidos" => "Miralles Bagán" ] 13 => array:2 [ "nombre" => "S." "apellidos" => "Italiano" ] 14 => array:2 [ "nombre" => "B." "apellidos" => "Darias-Delbey" ] 15 => array:2 [ "nombre" => "J.M." "apellidos" => "Barrio" ] 16 => array:2 [ "nombre" => "J." "apellidos" => "Hortal" ] 17 => array:2 [ "nombre" => "J.I." "apellidos" => "Sáez de Ibarra" ] 18 => array:2 [ "nombre" => "A." "apellidos" => "Hernández" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192920301347" "doi" => "10.1016/j.redare.2020.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920301347?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620301511?idApp=UINPBA00004N" "url" => "/00349356/0000006700000008/v1_202009250649/S0034935620301511/v1_202009250649/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192920301190" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.06.005" "estado" => "S300" "fechaPublicacion" => "2020-10-01" "aid" => "1189" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2020;67:481-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "Respiratory physiotherapy with vibration belts in the critical patient Covid-19 in the prone position" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "481" "paginaFinal" => "482" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fisioterapia respiratoria con cinturones de vibración en el paciente crítico COVID-19 en posición de prono" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 891 "Ancho" => 1250 "Tamanyo" => 120365 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Definitive placement of the autonomous vibratory belt in critically ill patients with COVID-19 infection in the prone position.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P.T. Sancho, P.A. Gandarias, R.S. González, A.A. Gurumeta" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P.T." "apellidos" => "Sancho" ] 1 => array:2 [ "nombre" => "P.A." "apellidos" => "Gandarias" ] 2 => array:2 [ "nombre" => "R.S." "apellidos" => "González" ] 3 => array:2 [ "nombre" => "A.A." "apellidos" => "Gurumeta" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S003493562030181X" "doi" => "10.1016/j.redar.2020.06.014" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493562030181X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920301190?idApp=UINPBA00004N" "url" => "/23411929/0000006700000008/v1_202011120617/S2341192920301190/v1_202011120617/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192920301153" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.06.002" "estado" => "S300" "fechaPublicacion" => "2020-10-01" "aid" => "1183" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2020;67:438-45" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Practical recommendations in the obstetrical patient with a COVID-19 infection" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "438" "paginaFinal" => "445" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones prácticas en la paciente obstétrica con infección por COVID-19" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2131 "Ancho" => 2925 "Tamanyo" => 365174 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diagnostic-therapeutic algorithm for SARS-CoV2 infection in the parturient. AF: amniotic fluid; ARDS: respiratory distress; CO: cardiac output; ECMO: extracorporeal oxygenation; GA: general anaesthesia; LV: left ventricle; PTE: pulmonary thromboembolism; RA: regional anaesthesia; RV: right ventricle; SVR: systemic vascular resistance.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Guasch, N. Brogly, S. Manrique" "autores" => array:3 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Guasch" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Brogly" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Manrique" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935620301754" "doi" => "10.1016/j.redar.2020.06.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620301754?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920301153?idApp=UINPBA00004N" "url" => "/23411929/0000006700000008/v1_202011120617/S2341192920301153/v1_202011120617/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CONSENSUS STATEMENT</span>" "titulo" => "Intraoperative transoesophageal echocardiography in Cardiovascular Surgery. Consensus document from the Spanish Society of Anaesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "446" "paginaFinal" => "479" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Carmona García, R. García Fuster, E. Mateo, S. Badía Gamarra, M. López Cantero, E. Gutiérrez Carretero, M.L. Maestre, V. Legname, G. Fita, M. Vives, T. Koller Bernhard, E. Sánchez Pérez, J. Miralles Bagán, S. Italiano, B. Darias-Delbey, J.M. Barrio, J. Hortal, J.I. Sáez de Ibarra, A. Hernández" "autores" => array:19 [ 0 => array:3 [ "nombre" => "P." "apellidos" => "Carmona García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "R." "apellidos" => "García Fuster" "email" => array:1 [ 0 => "garciafusterrafael@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Mateo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "S." "apellidos" => "Badía Gamarra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "López Cantero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "E." "apellidos" => "Gutiérrez Carretero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 6 => array:3 [ "nombre" => "M.L." "apellidos" => "Maestre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 7 => array:3 [ "nombre" => "V." "apellidos" => "Legname" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 8 => array:3 [ "nombre" => "G." "apellidos" => "Fita" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] ] ] 9 => array:3 [ "nombre" => "M." "apellidos" => "Vives" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] 10 => array:3 [ "nombre" => "T." "apellidos" => "Koller Bernhard" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">k</span>" "identificador" => "aff0055" ] ] ] 11 => array:3 [ "nombre" => "E." "apellidos" => "Sánchez Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">l</span>" "identificador" => "aff0060" ] ] ] 12 => array:3 [ "nombre" => "J." "apellidos" => "Miralles Bagán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">m</span>" "identificador" => "aff0065" ] ] ] 13 => array:3 [ "nombre" => "S." "apellidos" => "Italiano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">k</span>" "identificador" => "aff0055" ] ] ] 14 => array:3 [ "nombre" => "B." "apellidos" => "Darias-Delbey" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">n</span>" "identificador" => "aff0070" ] ] ] 15 => array:3 [ "nombre" => "J.M." "apellidos" => "Barrio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">o</span>" "identificador" => "aff0075" ] ] ] 16 => array:3 [ "nombre" => "J." "apellidos" => "Hortal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">p</span>" "identificador" => "aff0080" ] ] ] 17 => array:3 [ "nombre" => "J.I." "apellidos" => "Sáez de Ibarra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">q</span>" "identificador" => "aff0085" ] ] ] 18 => array:3 [ "nombre" => "A." "apellidos" => "Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">r</span>" "identificador" => "aff0090" ] ] ] ] "afiliaciones" => array:18 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario la Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Cardiaca, Consorcio Hospital General Universitario de Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cirugía Cardiaca, Hospital Universitario Trías y Pujol, Badalona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario la Fe, Valencia, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Sección Cardiotorácica, Servicio de Anestesiología y Reanimación, Hospital Sant Pau, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Cirugía Cardiaca, Centro Médico Teknon, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Sección Cardiotorácica, Servicio de Anestesiología y Reanimación. Hospital Clínic, Barcelona, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "DESA. Sección Cardiotorácica, Servicio de Anestesiología y Reanimación, Hospital Universitario Dr Josep Trueta de Girona, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Sección Cardiotorácica, Servicio de Anestesiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "EDAIC. Sección de Cirugía Cardiaca, Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Sección Cardiotorácica, Servicio Anestesiología y Reanimación, Hospital Sant Pau, Barcelona, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] 13 => array:3 [ "entidad" => "Servicio Anestesiología y Reanimación, Proceso del Paciente, Cardioquirúrgico, Complejo Hospitalario Universitario de Canarias, Santa Cruz de Tenerife, Spain" "etiqueta" => "n" "identificador" => "aff0070" ] 14 => array:3 [ "entidad" => "Sección Anestesia y Reanimación Cardiovascular, Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "o" "identificador" => "aff0075" ] 15 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital General. Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "p" "identificador" => "aff0080" ] 16 => array:3 [ "entidad" => "Servicio de Cirugía Cardiaca, Hospital Universitario Son Espases, Palma de Mallorca, Spain" "etiqueta" => "q" "identificador" => "aff0085" ] 17 => array:3 [ "entidad" => "Departamento de Anestesia y Cuidados Intensivos, Grupo Policlínica, Ibiza, Spain" "etiqueta" => "r" "identificador" => "aff0090" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ecocardiografía transesofágica intraoperatoria en cirugíacardiovascular. Documento de consenso de la Sociedad Española deAnestesiología y Reanimación (SEDAR) y Sociedad Española de CirugíaCardiovascular y Endovascular (SECCE)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 967 "Ancho" => 1260 "Tamanyo" => 84076 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transgastric short axis view. LV with large end-diastolic and end-systolic diameter.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The use of transoesophageal ultrasound dates back to 1971, when it was used to measure blood flow in the aortic arch. Following this, M mode was introduced in 1976, and the two-dimensional mode (2D) in 1977. The modern era of transoesophageal echocardiography (TOE) began in 1982 with the introduction of flexible probes that could be oriented in different planes to obtain both two-dimensional (2D) and three-dimensional (3D) images. TOE is a semi-invasive technique that permits real-time evaluation of cardiac morphology and function. Nowadays, it is a quality standard in cardiovascular surgery interventions, and has been shown to favourably influence the postoperative prognosis of cardiac surgery patients.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> TOE is a fundamental tool for both monitoring and diagnosis in the perioperative period because it allows clinicians to correctly plan the intervention and evaluate the response of the cardiovascular system to surgical and pharmacological interventions.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The widespread use of TOE in cardiovascular surgery has led some authors to report that in 6%-7.7% of patients new findings were reported in the pre-cardiopulmonary bypass (pre-CPB) ultrasound examination, requiring the surgical plan to be modified in 43.8% of these cases.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a> These findings can be explained by the better image quality of TOE compared to transthoracic ultrasound (TTE) and/or the time elapsed between the preoperative TOE and the date of surgery. According to these same studies, as a result of unexpected post-CPB findings, bypass was restarted in half of these cases.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8,9</span></a> The usefulness and indication of TOE has now been extended to different perioperative contexts and other types of intervention, such as thoracic, vascular or liver surgery.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Given this situation, the Spanish Society of Anaesthesiology and Critical Care (SEDAR) and the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) saw the need draw up a consensus document based on international guidelines and standard practice to respond to the following questions<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>: Who should perform TOE during cardiac surgery? Is it always indicated? When is it contraindicated? How should it be performed - should a standard TOE protocol be followed in cardiac surgery interventions? What information should be provided in each procedure?</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this document is to provide an evidence-based consensus on when and how perioperative TOE should be performed, its use in the intraoperative setting, who should perform it, and how the information obtained during the study should be transmitted. The recommendations have been drawn up following a systematic review of international guidelines, review articles and clinical trials.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Who should perform intraoperative TOE in cardiovascular surgery? Training and accreditation</span><p id="par0025" class="elsevierStylePara elsevierViewall">Due to the speed with which advances in the diagnosis and treatment of patients with cardiovascular diseases are made, anaesthesiologists and other specialists involved in perioperative care need to acquire specific training in TOE and regularly update their skills. Solid training in ultrasound management is now an essential element in the comprehensive training of cardiovascular surgeons, and these specialists need to start receiving extensive training and experience in this technique during their specialist training.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Formal TOE accreditation is a standard for all cardiac anaesthesiologists in Canada, the UK, Australia and the USA. In Europe, the European Society of Cardiothoracic Anaesthesiology (EACTA) has launched various accreditation programmes, including one in professional competences, in which certification is based on real clinical practice, acknowledging the career-long achievements of clinicians and promoting their professional development. The EACTA recently published a consensus document defining the competencies needed for enrolment in their fellowship programme in cardiovascular anaesthesia. The programme includes the acquisition of TOE certification from the European Association for Cardiovascular Imaging and the European Society for Cardiothoracic Anaesthesia (EACVI/EACTA). These associations have identified the competencies that clinicians must have and the good practices they must bring to bear in their job, as well as the evidence and examinations needed to certify these competences. They recommend obtaining official TOE certification (EACVI / EACTA) for independent practice as a cardiac anaesthesiologist in Europe. The document states that: “Interpretation and communication of (pathological) findings related to adult TOE is an integral part of cardiac anaesthesia. Thus, EACTA and the CTVA Fellowship Programme directors consider the acquisition of advanced TOE knowledge and skills an obligatory requirement for CTVA Fellows with core training in advanced cardiac anaesthesia”.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In Spain, the SEDAR and its Cardiovascular Anaesthesiology Division, being the institution that represents cardiovascular anaesthesiologists in Spain, endorse the EACTA recommendations as a means of increasing the safety and quality of care of patients undergoing cardiac surgery. In addition to certification, training in TOE must be continuous and constantly updated. For this reason, it is important to maintain contact with cardiac imaging units attached to different cardiology services. It is essential to communicate either in person or online with the hospital’s cardiology service to receive support and resolve any doubts related to decision-making. Taking wrong decisions based on an incorrect interpretation of ultrasound findings can be harmful for the patient and increase the risk of legal action.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In Spain, specific training through fellowship programmes in echocardiography and/or cardiac anaesthesia is not widespread, although an increasing number of face-to-face and online courses and specific rotations in this field have been organized by both anaesthesiologists and cardiologists specializing in imaging techniques.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, we consider that the performance of TOE in the perioperative setting of cardiac surgery is the responsibility of the treating anaesthesiologist, who must have specific training in perioperative cardiovascular anaesthesia and TOE. However, depending on their level of competence, training and experience, the anaesthesiologist may require the support of the cardiologist.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Indications and main clinical applications</span><p id="par0050" class="elsevierStylePara elsevierViewall">The latest guidelines published in 2013 and 2014 by the American Society of Echocardiography (ASE),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the American Society of Cardiovascular Anesthesiologists (SCA),<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and the European Association for Cardiovascular Imaging (EACVI)<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> establish that intraoperative TOE should be performed in:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">All open heart surgery and thoracic aortic surgery procedures</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">All coronary artery bypass graft surgery</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Intracardiac transcatheter procedures: transcatheter aortic valve implantation (TAVI), mitral clip, atrial appendage closure, atrial defect closure, implantation of a ventricular assist device, and extracorporeal membrane oxygenation (ECMO).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">In general, monitoring with TOE during cardiovascular surgery is currently recommended in all patients undergoing cardiac surgery unless contraindicated.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">General applications in conventional cardiac surgery</span><p id="par0075" class="elsevierStylePara elsevierViewall">Evaluation in the different stages of cardiac surgery.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pre-CPB</span><p id="par0080" class="elsevierStylePara elsevierViewall">The following should be assessed before starting CPB:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Global and regional contractility of both ventricles.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">Volaemia/cardiac preload/output, pulmonary arterial pressures and left ventricular filling (LV).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Anatomical and functional evaluation of valves, ruling out associated and previously undiagnosed valvular alterations.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Evaluation of the presence of left-right shunts (patent foramen ovale, atrial septal defect (ASD), ventricular septal defect).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Evaluation of the presence of thrombi, masses, catheters or vegetations.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Study of the pericardium: effusion or calcification.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">Detection of atheroma plaques in the aorta that may require predetermined sites for cannulation or aortic clamping to be changed.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">Specific surgical parameters. Obtaining parameters and measurements that are useful to the surgical strategy (aortic annulus, sinuses of Valsalva, sinotubular junction, ascending aorta, mitral annulus, tricuspid annulus, length of mitral leaflets, septal thickness, etc.).</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Evaluation of the correct placement of the venous catheter in the inferior vena cava and the retrograde cardioplegia catheter in the coronary sinus.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">Detection of pleural effusion and atelectasis and consolidations.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">Left atrium contractility.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">Comparison with the preoperative study.</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">During and after CPB</span><p id="par0145" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0150" class="elsevierStylePara elsevierViewall">Detection of intracavitary air to guide de-airing manoeuvres.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">Evaluation of preload to guide volume replacement therapy.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0160" class="elsevierStylePara elsevierViewall">Evaluation of ventricular function to guide the delivery of drugs and mechanical assistance.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0165" class="elsevierStylePara elsevierViewall">Detection of new wall motion abnormalities.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">Detection of valve alterations not present before CPB.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">Confirmation of the absence of catheter-induced periaortic haematoma or other injuries secondary to surgical manipulation.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">•</span><p id="par0180" class="elsevierStylePara elsevierViewall">Left atrium contractility</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">•</span><p id="par0185" class="elsevierStylePara elsevierViewall">Evaluation of surgical outcomes.</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">•</span><p id="par0190" class="elsevierStylePara elsevierViewall">Evaluation of the normal position of the distal end of the IABC.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">•</span><p id="par0195" class="elsevierStylePara elsevierViewall">Evaluation of lung (atelectasis) and pleura (pleural effusion). Transoesophageal lung ultrasound (TOLU).</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Applications in specific procedures</span><p id="par0200" class="elsevierStylePara elsevierViewall">In addition to the information obtained from basic monitoring, a specific evaluation will be required, depending on the type of surgery performed.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Valve surgery: repair and replacement</span><p id="par0205" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">•</span><p id="par0210" class="elsevierStylePara elsevierViewall">Correct insertion and stability of the prosthesis.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">•</span><p id="par0215" class="elsevierStylePara elsevierViewall">Evaluation of coronary artery ostia</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">•</span><p id="par0220" class="elsevierStylePara elsevierViewall">Measurement of transprosthetic velocity and gradients.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">•</span><p id="par0225" class="elsevierStylePara elsevierViewall">Presence of intra- or periprosthetic leaks.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall">Evaluation of functional competence: overall opening and presence of residual insufficiency or post-repair stenosis.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">•</span><p id="par0235" class="elsevierStylePara elsevierViewall">Presence of dynamic obstruction in the LV outflow tract with or without mitral insufficiency (MI).</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">•</span><p id="par0240" class="elsevierStylePara elsevierViewall">Evaluation of residual iatrogenic ASD.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Hypertrophic obstructive cardiomyopathy surgery</span><p id="par0245" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">•</span><p id="par0250" class="elsevierStylePara elsevierViewall">Presence of residual systolic anterior movement (SAM).</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">Confirmation of the absence of residual ventricular septal defect.</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Aortic surgery</span><p id="par0260" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">•</span><p id="par0265" class="elsevierStylePara elsevierViewall">Evaluation of dissection entry/exit tears and and true/false lumens.</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">•</span><p id="par0270" class="elsevierStylePara elsevierViewall">Competence of the aortic valve (AV).</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Coronary artery surgery with and without CPB</span><p id="par0275" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">•</span><p id="par0280" class="elsevierStylePara elsevierViewall">Basic monitoring parameters and assessment of global and regional contractility before and after revascularization.</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Other off-pump procedures</span><p id="par0285" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">1</span><p id="par0290" class="elsevierStylePara elsevierViewall">Placement of ventricular assist devices.</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">•</span><p id="par0295" class="elsevierStylePara elsevierViewall">Verification of the normal position of intracardiac catheters.</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">•</span><p id="par0300" class="elsevierStylePara elsevierViewall">Haemodynamic control during ventricular assist device management. Information on ventricular distension, hypovolaemia or thrombotic complications.</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">2</span><p id="par0305" class="elsevierStylePara elsevierViewall">Transvenous removal of electrodes from cardiac pacing devices.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">•</span><p id="par0310" class="elsevierStylePara elsevierViewall">Follow-up of the procedure.</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">•</span><p id="par0315" class="elsevierStylePara elsevierViewall">Early diagnosis of complications: pericardial effusion, cardiac rupture, tricuspid insufficiency.</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">3</span><p id="par0320" class="elsevierStylePara elsevierViewall">Removal of intracardiac tumours.</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">4</span><p id="par0325" class="elsevierStylePara elsevierViewall">Ventricular aneurysm repair.</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">5</span><p id="par0330" class="elsevierStylePara elsevierViewall">Pulmonary thromboendarterectomy.</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">6</span><p id="par0335" class="elsevierStylePara elsevierViewall">New endovascular procedures (TAVI, endovascular mitral or tricuspid clip, periprosthetic leak closure, ASD closure, left atrial appendage closure)</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">7</span><p id="par0340" class="elsevierStylePara elsevierViewall">Transapical procedures by thoracotomy (TAVI, neochord implantation, closure of periprosthetic leaks).</p></li></ul></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Clinical safety. Contraindications. Complications</span><p id="par0345" class="elsevierStylePara elsevierViewall">TOE is a semi-invasive technique with a low risk of complications. However, the type of incidents associated with its use and predisposing factors must be taken into account to prevent their appearance. In the pre-anaesthesia consultation, any possible contraindications for TOE study should be investigated and taken into consideration in the surgical plan. The main contraindications are related to pathologies of the oropharynx, oesophagus or stomach. Absolute and relative contraindications are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Despite being considered a relative contraindication, patients with grade 1 or 2 oesophageal varices, without recent bleeding episodes, can safely undergo TOE, but the real need for transgastric views should be assessed and avoided if not strictly necessary in order to minimize unnecessary risks.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0350" class="elsevierStylePara elsevierViewall">Complications are related to direct airway trauma, mainly during TOE insertion and oesophageal warming during the use of TOE, which can cause a certain degree of ulceration. The risk of possible thermal or mechanical complications must always be taken into account, and the risk of TOE must be weighed up against the benefit of the information that can be obtained. The most frequent complications are: odynophagia (0.1%), dental injury (0.03%), mobilization of the endotracheal tube (0.03%) and upper gastrointestinal bleeding (0.03%-0.08%).<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> Some hospitals include complications associated with echocardiography in the informed consent for anaesthesia for cardiac surgery; this is a practice we recommend.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">TOE study technical aspects</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Insertion of the probe</span><p id="par0355" class="elsevierStylePara elsevierViewall">Care must be taken to properly secure the endotracheal tube to prevent it becoming dislodged during insertion of the probe. A bite block must always be used. This will prevent the appearance of dental, lingual or gum damage, as well as damage to the probe. Slight resistance may be felt at the level of the cuff of the endotracheal tube or glottic structures, so the probe must be inserted carefully to avoid injury and abundant lubrication is always recommended. Difficulty in passing through the hypopharynx is usually resolved by lifting the mandible anteriorly and caudally, anteflexion of the probe, and slight left flexing due to the disposition of the oesophagus; on some occasions direct laryngoscopy may be required. The gastric contents should be aspirated before inserting the TOE probe in order to optimize the ultrasound image, especially in the deepest views.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Basic TOE views</span><p id="par0360" class="elsevierStylePara elsevierViewall">Once the TOE probe has been inserted, management consists of advancing, withdrawing and rotating the probe. The 4 most widely used echocardiographic positions, measured from the dental arch, are: upper oesophageal view (20−25 cm), mid-oesophageal view (30−40 cm), transgastric view (40−45 cm) and deep transgastric view (45−50 cm). The theoretical distance between the ultrasound views is approximate, although in practice it is highly variable. Several views can be obtained at each position. The distal end of the probe is flexible and the proximal end, which is fixed, is equipped with 2 control mechanisms that allow the probe to be moved in anteflexion and retroflexion, as well as lateral displacements. The tip of the probe is positioned using the control knobs, considering the position of the cardiac chambers with respect to the oesophagus, so that the ultrasound beam can be pointed in the direction needed to identify each cardiac structure. All these movements, together with manual rotation of the probe clockwise and counter-clockwise, make it possible to obtain most of echocardiographic slices.</p><p id="par0365" class="elsevierStylePara elsevierViewall">Scientific societies recommend conducting a systematic study that includes exploring the heart chambers, major vessels and valves in two-dimensional mode (2 D), in M-mode, and in colour and spectral Doppler mode, leaving 3D-Echo for more experienced echocardiographers. Twenty study planes have been established, described according to the depth of the probe in the digestive tract: a) upper oesophageal, b) mid-oesophageal (MO), c) transgastric (TG), and the image plane (short and long axis relative to the transverse and longitudinal plane of the ultrasound beam).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,16,19</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">Eight planes have been added to complete the comprehensive exploration of key structures in surgical decision making. The main views, their utility and their study technique are detailed below, bearing in mind that variations in patients anthropometrics or clinical circumstances may slightly vary the angle or flexion of the probe required to acquire the most suitable plane for evaluation (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2, 3 and 4</a>). A systematic examination using all planes and placement of a continuous electrocardiogram monitor is recommended whenever possible. As a quality of care standard, it is recommended, to record images for review whenever possible, as this will facilitate teaching and learning and maximise quality of care, making it possible to compare before and after studies in the same patient, analyse the different stages of the intervention and understand the evolutionary clinical changes during the postoperative period.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ultrasound examination of cardiac structures: mitral valve</span><p id="par0375" class="elsevierStylePara elsevierViewall">The ultrasound study of the mitral valve is performed as part of the exploration of the mitral valve apparatus, composed of the mitral annulus, leaflets (anterior and posterior), chordae tendineae, and LV papillary muscles. The anterior and posterior leaflets have been divided according to Carpentier's classification into segments A1, A2, A3 and P1, P2, P 3, respectively, with A1 and P1 being the most anterior.</p><p id="par0380" class="elsevierStylePara elsevierViewall">The anatomical characteristics of the mitral valve apparatus must be analysed and described, the lesion or lesions identified, and the causative mechanism and degree of insufficiency determined (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0385" class="elsevierStylePara elsevierViewall">The mitral valve is explored in the following views:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">•</span><p id="par0390" class="elsevierStylePara elsevierViewall">mid-oesophageal 4-chamber view This view is used to evaluate the anterior and posterior leaflet (A3-A2 and P2-P1), the point of coaptation of these, and explore the chordae tendineae and papillary muscles. In this view, the tenting area and height can be measured in cases of ischaemic or functional MI, and prolapses can be identified. Colour Doppler and spectral Doppler can be used to analyse inflow and outflow velocity as well as valve gradient.</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">•</span><p id="par0395" class="elsevierStylePara elsevierViewall">mid-oesophageal 5-chamber view This is used to observe the LVOT and mitral valve with segments A1-A2 and P1-P2.</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">•</span><p id="par0400" class="elsevierStylePara elsevierViewall">mid-oesophageal 2-chamber view This is used to identify the different segments of the anterior and posterior leaflet</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">•</span><p id="par0405" class="elsevierStylePara elsevierViewall">mid-oesophageal bicommissural view. This is used to identify segments P1-A2-P3 from right to left.</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">•</span><p id="par0410" class="elsevierStylePara elsevierViewall">mid-oesophageal long axis view. This identifies segments P2-A2. In this plane, the length of A2 can be measured to estimate the mitral annulus. The mitral annulus is measured in this plane from the insertion of the posterior leaflet to the base of the AV in systole. Diameters greater than 40 mm indicate dilation.</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">•</span><p id="par0415" class="elsevierStylePara elsevierViewall">Transgastric basal 0° view.</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">•</span><p id="par0420" class="elsevierStylePara elsevierViewall">Transgastric long axis 2-chamber view</p></li></ul></p><p id="par0425" class="elsevierStylePara elsevierViewall">Exploration of the mitral valve should include an evaluation of biventricular function, the function and morphology of the tricuspid valve (TV), and an estimation of pulmonary systolic pressures. Outflow mechanisms are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.</p><p id="par0430" class="elsevierStylePara elsevierViewall">Identification of intra-atrial masses is an indication for their removal in mitral surgery.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Aortic valve</span><p id="par0435" class="elsevierStylePara elsevierViewall">The AV is part of the aortic root that extends from the annulus of the AV to the sinotubular junction, with the sinuses of Valsalva lying between these structures. Pathology can affect any of these components and also the LV outflow tract. The root and AV are examined using the following planes:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">•</span><p id="par0440" class="elsevierStylePara elsevierViewall">mid-oesophageal AV short axis view. This is used to analyse the anatomy of the 3 valve leaflets, the origin of the left main coronary artery, and less frequently the origin of the right main coronary artery in a slightly higher position.</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">•</span><p id="par0445" class="elsevierStylePara elsevierViewall">mid-oesophageal AV long axis view This is used to analyse the interventricular septum, LVOT, the aortic root (including the annulus, valve, sinuses of Valsalva and sinotubular junction) and ascending aorta. In this view, colour Doppler examination is used to analyse regurgitant or turbulent flows together with their direction and severity. All the elements involved can be measured, and the leaflet motion and the relationship between them can be determined to identify prolapse or restrictions. The diameter of the LVOT is measured 5 mm below the aortic annulus.</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">•</span><p id="par0450" class="elsevierStylePara elsevierViewall">Deep transgastric 5-chamber view. This plane is used for colour and spectral Doppler evaluation of the AV, since the image is aligned with the blood flow and yields measurements of valve gradients and beat by beat stroke volume.</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">•</span><p id="par0455" class="elsevierStylePara elsevierViewall">Transgastric long axis view. In this plane the probe is aligned with the blood flow to measure velocities.</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">•</span><p id="par0460" class="elsevierStylePara elsevierViewall">The ascending aorta is evaluated using views of the major vessels and the MO AV long axis view. Colour Doppler examination identifies abnormal flows and characterises pathology such as aortic dissection, intramural haematomas, and complex atheromatous plaques.</p></li></ul></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Tricuspid valve</span><p id="par0465" class="elsevierStylePara elsevierViewall">The TV is examined in the following views:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">•</span><p id="par0470" class="elsevierStylePara elsevierViewall">mid-oesophageal 4-chamber view. In this view it is sometimes necessary to slightly advance and anteflex the probe to obtain a correct view of the TV. It is recommended to measure the diameter of the tricuspid annulus below the level of the diaphragm. In this view the anterior or posterior leaflet can be seen, with the septal leaflet to the right.</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">•</span><p id="par0475" class="elsevierStylePara elsevierViewall">A view of the TV can also be obtained In the bicaval plane, and colour Doppler can be used to identify regurgitant or stenotic flows. To measure regurgitant flows using spectral Doppler the probe is aligned with the blood flow to obtain a qualitative assessment and estimation of pulmonary systolic pressure.</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">•</span><p id="par0480" class="elsevierStylePara elsevierViewall">The TV can also be observed and its anterior/septal and posterior leaflets identified in the MO LV inflow and outflow tract view.</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">•</span><p id="par0485" class="elsevierStylePara elsevierViewall">Transgastric, TG RV inflow, and TG TV short axis views can also be used to analyse the anatomy and mobility of its 3 leaflets.</p></li></ul></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Pulmonary valve</span><p id="par0490" class="elsevierStylePara elsevierViewall">TOE ultrasound evaluation of the PV is difficult. It is carried out in the following planes:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">•</span><p id="par0495" class="elsevierStylePara elsevierViewall">mid-oesophageal RV inflow and outflow tract view. In this plane, the RV outflow tract is evaluated as well as the leaflets of the pulmonary valve.</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">•</span><p id="par0500" class="elsevierStylePara elsevierViewall">Transgastric RV inflow and outflow tract view.</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">•</span><p id="par0505" class="elsevierStylePara elsevierViewall">MO ascending aorta short and long axis view and upper oesophageal aortic arch short axis view. In these views the pulmonary valve and origin of the main pulmonary artery can be seen, although they are difficult to identify. Once identified, alignment with blood flow is usually favourable, and therefore velocity measurements can be performed.</p></li></ul></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Left ventricle</span><p id="par0510" class="elsevierStylePara elsevierViewall">It is important to evaluate LV morphology and function during the intraoperative period. The degree of ventricular dysfunction is not only a predictor of clinical outcomes, but also aids in risk stratification and therapeutic decision-making. TOE can provide an evaluation of overall and regional function by analysing segmental thickening, sizes and volumes.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> It is recommended to carry out quantitative and qualitative studies of LV function.</p><p id="par0515" class="elsevierStylePara elsevierViewall">The LV is evaluated using the following views:<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">•</span><p id="par0520" class="elsevierStylePara elsevierViewall">mid-oesophageal 4-chamber view</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">•</span><p id="par0525" class="elsevierStylePara elsevierViewall">mid-oesophageal 2-chamber view</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">•</span><p id="par0530" class="elsevierStylePara elsevierViewall">mid-oesophageal 3-chamber view</p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">•</span><p id="par0535" class="elsevierStylePara elsevierViewall">Transgastric short axis view: in this plane, at the mid level, the regions supplied by the 3 main vessels can be seen.</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">•</span><p id="par0540" class="elsevierStylePara elsevierViewall">Transgastric long axis view.</p></li></ul></p><p id="par0545" class="elsevierStylePara elsevierViewall">All regions in the indicated view should be studied in order to detect alterations in regional contractility by correctly visualising the endocardium and avoiding apical shortening.</p><p id="par0550" class="elsevierStylePara elsevierViewall">The methods most frequently used to quantify systolic function are the estimation of the ejection fraction using the Simpson method, the shortening fraction, the area change fraction, and methods that quantify the myocardial tissue velocity using tissue Doppler.</p><p id="par0555" class="elsevierStylePara elsevierViewall">In 2016, the American Society of Echocardiography and the European Association of Cardiovascular Imaging created a consensus document on the evaluation of diastolic function. This simplified the procedure by providing algorithms that made intraoperative assessment simpler and more efficient.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The authors recommend studying LV diastolic function to identify patients with high filling pressures.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> These algorithms offer an optimal combination of indices to classify diastolic function and are based on the determination of echocardiographic parameters in 2 groups of patients: patients with preserved LVEF and patients with depressed LVEF. Diastolic dysfunction has been shown to be a predictor of increased perioperative mortality, prolonged mechanical ventilation, and prolonged ICU stay, regardless of systolic function, after cardiac surgery.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0560" class="elsevierStylePara elsevierViewall">The echocardiographic parameters of diastolic function that are currently used are:<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">•</span><p id="par0565" class="elsevierStylePara elsevierViewall">Transmitral pulsed Doppler flow, measured in the LV, at the opening of the mitral leaflets: velocity of E and A waves.</p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">•</span><p id="par0570" class="elsevierStylePara elsevierViewall">Mitral annulus tissue Doppler: <span class="elsevierStyleItalic">mitral annulus excursion velocity (e').</span></p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">•</span><p id="par0575" class="elsevierStylePara elsevierViewall">Pulsed Doppler of pulmonary veins: flow pattern.</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">•</span><p id="par0580" class="elsevierStylePara elsevierViewall">Transtricuspid flow Doppler: tricuspid regurgitant jet velocity</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">•</span><p id="par0585" class="elsevierStylePara elsevierViewall">Left atrial volume index (mL/m<span class="elsevierStyleSup">2</span>)</p></li></ul></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right ventricle</span><p id="par0590" class="elsevierStylePara elsevierViewall">Because of its irregular triangular shape and interior trabeculation that obscures the endocardium, ultrasound evaluation of the morphology and function of the RV is difficult.</p><p id="par0595" class="elsevierStylePara elsevierViewall">The RV is evaluated in the following views:<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">•</span><p id="par0600" class="elsevierStylePara elsevierViewall">mid-oesophageal 4-chamber view. The RV free wall is visualized.</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">•</span><p id="par0605" class="elsevierStylePara elsevierViewall">mid-oesophageal RV inflow and outflow tract view.</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">•</span><p id="par0610" class="elsevierStylePara elsevierViewall">mid-oesophageal bicaval plane.</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">•</span><p id="par0615" class="elsevierStylePara elsevierViewall">Transgastric short and long axis view focused on RV, where the RV, TV and subvalvular apparatus can be seen.</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">•</span><p id="par0620" class="elsevierStylePara elsevierViewall">Deep transgastric RV inflow tract view.</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">•</span><p id="par0625" class="elsevierStylePara elsevierViewall">Deep transgastric view focused on RV.</p></li></ul></p><p id="par0630" class="elsevierStylePara elsevierViewall">Systolic function is evaluated using quantitative measurements of overall systolic function, such as fractional area change (FAC), longitudinal shortening, such as tricuspid annular plane systolic excursion (TAPSE), and measurement of systolic velocity by ring tissue Doppler (S´). It is important to note that TAPSE and S´ quantification after CPB cannot be used to quantify overall RV function.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a></p><p id="par0635" class="elsevierStylePara elsevierViewall">Evaluation of right ventricular diameters, septal movement, and the position of the apex are indirect indicators of RV function intraoperatively after disconnection from CPB.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Study parameters</span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Usefulness during the period prior to cardiopulmonary bypass</span><p id="par0640" class="elsevierStylePara elsevierViewall">Confirmation of the pathology to be treated and detection of other alterations.</p><p id="par0645" class="elsevierStylePara elsevierViewall">A good pre-CPB or pre-intervention echocardiographic examination can validate the preoperative indication for surgery and detect new intervention-related findings.</p><p id="par0650" class="elsevierStylePara elsevierViewall">Depending on the type of surgery, the following should be taken into consideration:<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">•</span><p id="par0655" class="elsevierStylePara elsevierViewall">Pre-CPB TOE can be used to detect new pathological findings that may call for a change in the surgical plan, In addition, alterations that can compel surgeons to modify their usual practice should be explored: the presence of more than mild aortic insufficiency (AI) may render the anterograde administration of cardioplegic solution for myocardial protection ineffective, and other strategies such as retrograde administration through the coronary sinus may be necessary.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The identification of concentric or eccentric hypertrophy and basal systolic and diastolic function is essential to predict post-CPB difficulties and to optimise pharmacological treatment and myocardial protection by cardioplegia.</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">•</span><p id="par0660" class="elsevierStylePara elsevierViewall">Neurological damage is one of the most important complications after cardiac surgery. Its aetiology is multifactorial, and TOE is essential for detecting aortic atheromatous plaques, since it is more sensitive than palpation of the aorta.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27,28</span></a> The presence of large plaques with mobile elements can require a change in the surgical strategy, changes in the site of aortic cannulation and aortic clamping, the use of arterial line filters, and even the performance of off-pump surgery or no clamping, if feasible. One of the limitations of TOE is the limited visualisation of the distal segment of the ascending aorta and the proximal segment of the aortic arch, which are obscured by the trachea and the left main bronchus.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The presence of significant plaques in the descending aorta may rule out IABP placement or require peripheral cannulation for CPB.</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">•</span><p id="par0665" class="elsevierStylePara elsevierViewall">Mitral valve disease. It is essential to corroborate the mechanism of MI and to determine the segments affected. Quantification of MI by pre-CPB TOE is highly correlated with preoperative transthoracic echocardiography (TTE) findings when the mechanism of injury is a tendon or papillary muscle rupture, but this concordance is lower when the mechanism of injury is predominantly degenerative or functional. The haemodynamic conditions associated with general anaesthesia lead to underestimation of MI, particularly in patients with ischaemic MI, and this must be taken into account during TOE<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,31</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Administration of fluids and vasoconstrictors (phenylephrine or ephedrine) can restore physiological conditions and allow the severity and originating mechanism to be correctly evaluated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">•</span><p id="par0670" class="elsevierStylePara elsevierViewall">Aortic valve disease. In patients with severe aortic stenosis, diagnosis will be confirmed by analysing the valve using 2 D echocardiography in the mid-oesophageal short axis and transgastric views to estimate the gradients. The mid-oesophageal AV long axis view can provide information on the LVOT, the AV and the root of the aorta, and can differentiate between supra- and sub-valvular pathology, ruling out subaortic membranes and septal hypertrophy that can cause subaortic gradients secondary to the procedure itself. Quantification of AI by pre-CPB TOE is partially consistent with preoperative TTE, but evaluating the mechanism of AI by assessing leaflet motion and the direction of the regurgitant jet is highly reliable.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32,33</span></a> The determination of prolapses, fenestrations, commissural asymmetry and calcium build-up are important variables to predict the reparability of the AV.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">•</span><p id="par0675" class="elsevierStylePara elsevierViewall">In ascending aortic aneurysm surgery, pre-CPB TOE in the mid-oesophageal long axis view confirms aortic dilatation and whether this is associated with AI, and can also be used to measure the annulus, sinuses of Valsalva and sinotubular junction.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In type A aortic dissections, it identifies the intimal flap, the entry tear, differentiates the true from the false lumen, and detects intramural thrombus. Dissection-related complications such as pericardial effusion that can lead to tamponade should also be evaluated, together with the presence and severity of AI and alterations in regional contractility due to coronary artery involvement.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">•</span><p id="par0680" class="elsevierStylePara elsevierViewall">In minimally invasive surgery, TOE is useful in correcting the placement of venous catheters in the inferior and superior vena cava by showing the guide wires and catheters in the mid-oesophageal bicaval view. Visualization of the guide wire in the descending aorta confirms the correct insertion of the femoral artery line.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37,38</span></a></p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">•</span><p id="par0685" class="elsevierStylePara elsevierViewall">The detection of thrombi in the left atrial appendage could call for their extraction if the surgery involves opening cavities or even closure of the appendage in patients with risk factors, although this systematic indication is controversial.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></li></ul></p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Useful pre-CPB intraoperative ultrasound measurements</span><p id="par0690" class="elsevierStylePara elsevierViewall">The following ultrasound measurements are recommended, according to the type of surgery performed:<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">•</span><p id="par0695" class="elsevierStylePara elsevierViewall">In mitral repair surgery, the following measurements should be taken: length of anterior mitral leaflet (A2) in the mid-oesophageal long axis view, which correlates with the size of the annulus to be implanted.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">•</span><p id="par0700" class="elsevierStylePara elsevierViewall">In ischaemic MI, measuring the tenting height and area and the length of the annulus helps predict the success of the repair.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">•</span><p id="par0705" class="elsevierStylePara elsevierViewall">It is essential to determine predictors of mitral repair failure and complications with SAM secondary to LVOT obstruction. The following measurements should be taken: the distance between the septum and the point of coaptation (risk predictor when < 2.5 cm), posterior leaflet length (in MO 5-chambers long axis view > 1.5 cm) and A/P leaflet length ratio < 1.4 cm, septal hypertrophy (> 1.5) with small ventricular cavity (diameter < 4.5 cm).<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">•</span><p id="par0710" class="elsevierStylePara elsevierViewall">When the diameter of the tricuspid annulus in end diastole in a mid-oesophageal 4-chamber 0° view below the diaphragm is greater than 40 mm or 21 mm/m<span class="elsevierStyleSup">2</span> tricuspid repair is indicated, even though significant insufficiency is not present.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">•</span><p id="par0715" class="elsevierStylePara elsevierViewall">Measurement of the aortic annulus in mid-oesophageal long axis view correlates reasonably with anatomical dimensions.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></li></ul></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Usefulness in the post-cardiopulmonary bypass (post-CPB) period</span><p id="par0720" class="elsevierStylePara elsevierViewall">Performing TOE after disconnection from CPB and in patients with haemodynamic instability is of vital importance for diagnosing the causes and administering targeted treatment.</p><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Usefulness in postcardiotomy shock</span><p id="par0725" class="elsevierStylePara elsevierViewall">Using TOE to evaluate the patient’s haemodynamic status will provide information on the aetiology of haemodynamic instability (hypovolaemia, myocardial depression, valve dysfunction), guide the therapeutic strategy (volume load, use of inotropics or vasoconstrictors, new bypass or surgical correction of a defective prosthesis or suboptimal repair) and predict response to treatment<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0730" class="elsevierStylePara elsevierViewall">Many patients undergoing cardiac surgery present ventricular dysfunction prior to surgery, and others with normal ventricular function may present transient or permanent alterations after the procedure, so it is essential to perform a baseline evaluation of biventricular systolic and diastolic function.</p><p id="par0735" class="elsevierStylePara elsevierViewall">Different diagnoses must be considered if both left and right <span class="elsevierStyleItalic">de novo</span> ventricular dysfunction appears after disconnection from CPB (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>).</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0740" class="elsevierStylePara elsevierViewall">If ventricular dysfunction is accompanied by alterations in regional contractility or new defects appear without marked systolic dysfunction, the diagnoses list in <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a> must be considered.</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><p id="par0745" class="elsevierStylePara elsevierViewall">Once the cardiotomy is closed, de-airing is important to avoid coronary embolisms that can cause transient ventricular dysfunctions, alterations in regional contractility, and severe haemodynamic instability (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0750" class="elsevierStylePara elsevierViewall">Devices such as an IABC or mechanical ventricular assistance (e.g. ECMO) must be used in the event of severe ventricular dysfunctions with poor response to inotropic drugs. In these cases, TOE can guide catheter placement and confirm the correct functioning of the device. The best plane is the mid-oesophageal descending aorta view, which will show whether the IABC is correctly placed few centimetres below the origin of the left subclavian artery.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Special considerations regarding evaluation of volaemia</span><p id="par0755" class="elsevierStylePara elsevierViewall">TOE is an excellent tool for evaluating intraoperative blood volume.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> A common causes of instability after disconnection from CPB is volume depletion. The following are the main parameters used to evaluate blood volume by TOE<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47,48</span></a>:<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">1</span><p id="par0760" class="elsevierStylePara elsevierViewall">Static volume measurement indices:</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">•</span><p id="par0765" class="elsevierStylePara elsevierViewall">Reduction of LV diameters and areas: changes in LV end-diastolic (LVED) area (in the midpapillary transgastric short axis) correlate well with changes in stroke volume in patients with hypovolaemia, even those with low ejection fraction.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">•</span><p id="par0770" class="elsevierStylePara elsevierViewall">Vigorous LV contractility, which together with the reduction in the end-systolic surface area gives the typical “kissing walls” or “kissing paps” sign (obliteration of the cavity, with walls touching). Hypovolaemia can give the false impression of ventricular hypertrophy (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 5</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">•</span><p id="par0775" class="elsevierStylePara elsevierViewall">Considerable inter-atrial septal oscillation over 2 respiratory cycles.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">•</span><p id="par0780" class="elsevierStylePara elsevierViewall">Indirect measurements of elevated pressure in AI<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>:<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0505"><p id="par0785" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0510"><span class="elsevierStyleLabel">o</span><p id="par0790" class="elsevierStylePara elsevierViewall">E wave (transmitral pattern) < 60 cm/s correlates with low end-diastolic pressures.</p></li><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">o</span><p id="par0795" class="elsevierStylePara elsevierViewall">E/E’ ratio > 15 correlates with LVED pressure > 15 mmHg.</p></li></ul></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">2</span><p id="par0800" class="elsevierStylePara elsevierViewall">Dynamic fluid response indices</p></li></ul></p><p id="par0805" class="elsevierStylePara elsevierViewall">Dynamic preload markers to predict fluid responsiveness are based on cardiopulmonary interaction secondary to mechanical ventilation, and can predict whether the administration of volume will increase cardiac output.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> These parameters cannot be evaluated during surgery involving sternotomy, but they can be measured postoperatively. It is important to bear in mind that the proposed parameters are not reliable in patients with severe RV dysfunction.</p><p id="par0810" class="elsevierStylePara elsevierViewall">The most widely used indices are the size and collapsibility of the inferior vena cava (transgastric views oriented towards the RV and IVC)<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>):<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">o</span><p id="par0815" class="elsevierStylePara elsevierViewall">IVC collapsibility index: Dmax-Dmin/Dmax100 > 36%</p></li><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">o</span><p id="par0820" class="elsevierStylePara elsevierViewall">IVC variation: Dmax-Dmin/Dmean × 100 > 12%</p></li><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">o</span><p id="par0825" class="elsevierStylePara elsevierViewall">IVC distensibility index: Dmax-Dmin/Dmin × 100 > 18%</p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">o</span><p id="par0830" class="elsevierStylePara elsevierViewall">Superior vena cava (in the bicaval or long axis ascending aorta view)</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">o</span><p id="par0835" class="elsevierStylePara elsevierViewall">SVC collapsibility index: Dmax-Dmin/Dmax × 100 > 36%</p></li><li class="elsevierStyleListItem" id="lsti0550"><span class="elsevierStyleLabel">o</span><p id="par0840" class="elsevierStylePara elsevierViewall">Aortic flow variability. Cardiac output can be estimated by measuring the integral time velocity (ITV) using pulsed Doppler to measure LVOT and its diameter (CO = SV [ITVlvot × diameter lvot] × HR).</p></li></ul></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0845" class="elsevierStylePara elsevierViewall">Respiratory changes in aortic flow velocity is calculated using the following formula: [ΔVpeak = 100 3 (Vpeakmax - Vpeakmin)/[Vpeakmax + Vpeakmin)/2]. A change of >12% is indicative of a positive response to volume administration<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0850" class="elsevierStylePara elsevierViewall">Haemodynamic instability is sometimes characterised by marked hypotension without ventricular dysfunction. In these cases, occult surgical field bleeding must be ruled out and the pleural cavity must be evaluated, since large amounts of volume often accumulate in these spaces. Transoesophageal lung ultrasonography (TOLU) in posterior mid-oesophageal and transgastric views may be helpful. The left pleura is seen at the level of the descending aorta, and visualisation of the anechoic space that corresponds to the pleural fluid without first visualising the aorta is indicative of right pleural effusion (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>). Another cause of postcardiotomy hypotension with preserved systolic function and correct blood volume is vasoplegia, the echocardiographic signs of which will be evidence of hyperdynamic, small end-systolic diameter ventricles and high cardiac output. Although it is common to observe a positive response to volume, these patients can also be treated with low doses of NA, thus avoiding fluid overload and the corresponding haemodilution. Intermittent monitoring of cardiac output will clarify the picture and guide therapy in dynamic situations.</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0855" class="elsevierStylePara elsevierViewall">After closure of the sternotomy, blood can rapidly accumulate in the posterior pericardial sac with local cavitary involvement, and can lead to significant haemodynamic repercussions (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>).</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0860" class="elsevierStylePara elsevierViewall">An uncommon but important cause to consider is an aorta-related complication. All cardiac surgery involving manipulation of the aorta (cannulation, clamping) carries a risk of aorta dissection or intramural haematomas at the site of clamping or administration of cardioplegic solutions; therefore, TOE evaluation is needed before closure. This is performed in the mid-oesophageal long axis view for the ascending aorta and the posterior mid-oesophageal views for the descending aorta (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10</a>).</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Considerations in specific procedures</span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Evaluation of prosthetic valve replacement</span><p id="par0865" class="elsevierStylePara elsevierViewall">In patients undergoing valve replacement, post-CPB TOE is to mainly used to verify the mobility of the prosthetic discs, to measure gradients, and to rule out the presence of significant periprosthetic or intraprosthetic leaks.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> This requires a complete evaluation of the valve under study using all views. Prosthesis-patient mismatch after valve replacement, though uncommon, can have highly important consequences.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> However, elevated intraprosthetic gradients must be interpreted with caution, given the unique haemodynamic situation that exists after CPB. The use of echocardiographic measurements irrespective of the haemodynamic status may be useful in this context. Measurements such as the maximum velocity or integral time velocity ratio between the LVOT and the AV (ITV LVOT/ ITV AV < 0.35) are indicative of significant stenosis, regardless of haemodynamic status.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a></p><p id="par0870" class="elsevierStylePara elsevierViewall">During examination of valve prostheses it is important to rule out the presence of significant periprosthetic leakage that would require further correction (<a class="elsevierStyleCrossRef" href="#fig0055">Fig. 11</a>). In these cases, information on the exact site of periprosthetic dehiscence is helpful to the surgeon, since once the cavity is opened it is more difficult to locate it. Nevertheless, periprosthetic leaks, though significant, are not usually the cause of significant post-CPB haemodynamic instability.<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">58,59</span></a></p><elsevierMultimedia ident="fig0055"></elsevierMultimedia><p id="par0875" class="elsevierStylePara elsevierViewall">TOE exploration can sometimes detect an increase in subaortic gradients causing haemodynamic instability during disconnection from CPB after aortic valve replacement. If this situation is associated with significant septal hypertrophy with dynamic obstruction of the outflow tract and even SAM with MI, it may be necessary to reconnect CPB to perform myectomy if the situation does not improve with volume replacement and withdrawal of inotropic drugs<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> (<a class="elsevierStyleCrossRef" href="#fig0060">Fig. 12</a>).</p><elsevierMultimedia ident="fig0060"></elsevierMultimedia></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Evaluation in mitral valve repair surgery</span><p id="par0880" class="elsevierStylePara elsevierViewall">Post-CPB TOE can evaluate the quality of mitral valve repair. The presence of suboptimal repair and the indication for reconnection of CPB should be evaluated individually, taking into account the baseline risks, aortic clamping times and the possibilities of improving the repair. The severity of the suboptimal repair should be evaluated in the most favourable haemodynamic conditions.</p><p id="par0885" class="elsevierStylePara elsevierViewall">Complications associated with mitral repair that can lead to haemodynamic instability after CPB disconnection are shown in <a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>.</p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><p id="par0890" class="elsevierStylePara elsevierViewall">Up to 8% of patients will need CPB reconnection due to significant residual MI after mitral repair.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> Approximately 1.6% of patient present mitral stenosis with a high transmitral pressure gradient after repair.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> SAM occurs after mitral repair in 1% and 16% of cases (<a class="elsevierStyleCrossRefs" href="#fig0065">Figs. 13 and 14</a>). If this complication persists after adequate haemodynamic management (withdrawal of inotropics, administration of vasopressors and fluids to achieve normovolaemia), surgical correction or even mitral valve replacement would be necessary.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> The severity of residual MI is evaluated qualitatively with colour Doppler mapping of the vena contracta and the characteristics of the regurgitant jet.</p><elsevierMultimedia ident="fig0065"></elsevierMultimedia><elsevierMultimedia ident="fig0070"></elsevierMultimedia><p id="par0895" class="elsevierStylePara elsevierViewall">Circumflex artery occlusion or distortion can occur during mitral valve repair or replacement, and can occur in up to 2% of cases.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> Coronary compromise can be due to direct occlusion or distortion of the valve caused by suture of the annulus, and can cause myocardial infarction if not diagnosed promptly. The post-CPB echocardiographic study will show segmental contractual abnormalities in the territory supplied by this artery.</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Evaluation in aortic valve repair surgery</span><p id="par0900" class="elsevierStylePara elsevierViewall">In aortic repair, the initial post-CPB evaluation focuses on evaluating the competence of the valve and the existence of residual regurgitation. The following should be assessed after repair<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">64,65</span></a>:<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">•</span><p id="par0905" class="elsevierStylePara elsevierViewall">Level of coaptation of the leaflets in a mid-oesophageal long axis view must be above the aortic annulus.</p></li><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">•</span><p id="par0910" class="elsevierStylePara elsevierViewall">Presence, degree of severity, and direction of the residual regurgitation jet. Residual AI greater than moderate can cause haemodynamic instability and CPB disconnection difficulties due to LV volume overload (<a class="elsevierStyleCrossRef" href="#fig0075">Fig. 15</a>).</p><elsevierMultimedia ident="fig0075"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">•</span><p id="par0915" class="elsevierStylePara elsevierViewall">Measurement of the length of the coaptation surface of the leaflets. A coaptation length < 4 mm is a strong predictor of postoperative AI recurrence. Other authors have defined the term coaptation height as the distance from the line of insertion of the leaflets to the highest point of coaptation, establishing a height of 9−10 mm as optimal for reducing the risk of prolapse recurrence.</p></li><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">•</span><p id="par0920" class="elsevierStylePara elsevierViewall">Measurement of transvalvular gradients: peak gradients greater than 30 mmHg or mean gradients greater than 15 mmHg are considered inadequate, and are associated with an increased risk of developing significant aortic stenosis. These gradients can be highly influenced by flow, which will be determined by the haemodynamic situation of the patient at disconnection from CPB, so the evaluation must be individualized. Independent measurements of haemodynamic status can be useful in these cases.</p></li><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel">•</span><p id="par0925" class="elsevierStylePara elsevierViewall">In addition to the morphological and functional assessment of the valve, the decision to attempt a new repair of a suboptimal repair will depend on the mechanism of the AI, the quality of the valve tissue, and patient-related factors (age, comorbidity, ventricular function, etc.).</p></li></ul></p></span></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Echocardiographic considerations in coronary artery surgery</span><p id="par0930" class="elsevierStylePara elsevierViewall">TOE can be performed before disconnection from CPB in myocardial revascularization surgery for all the reasons mentioned in the previous section, and can also be used to evaluate ventricular contractility in revascularized territories in order to rule out the presence of technical problems that limit coronary flow and may require CPB reconnection.</p><p id="par0935" class="elsevierStylePara elsevierViewall">The causes of <span class="elsevierStyleItalic">de novo</span> segmental contractility disorders after surgery are identical to those given in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.</p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Considerations in off-pump coronary artery surgery</span><p id="par0940" class="elsevierStylePara elsevierViewall">Intraoperative monitoring by TOE in off-pump coronary artery surgery provides information before, during, and after the coronary artery grafts have been performed.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> Of particular interest is the evaluation of LV systolic function and segmental wall motion alterations, together with the evaluation of right ventricular and valvular function. Haemodynamic instability during this type of surgery can be due to: myocardial ischaemia during manipulation, poor ventricular preload, cardiac compression, baseline ventricular dysfunction, acute MI due to manipulation of the cavities and distortion of the mitral annulus, or a combination of these causes.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> Mid-oesophageal views can be used to evaluate all segments of the left ventricle, and the appearance of MI can be evaluated by applying colour Doppler to the MV. Image quality is often poor, particularly in transgastric views during certain phases of the surgery due to the vertical position of the heart and the placement of compresses under the heart.</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Intraoperative examination of the lung by transoesophageal echocardiography. Transoesophageal lung ultrasound (TOLU)</span><p id="par0945" class="elsevierStylePara elsevierViewall">Although transoesophageal lung ultrasound, unlike the transthoracic echocardiography, has not yet been validated and findings cannot be extrapolated, it can be a useful tool in the intraoperative period of cardiovascular surgery. It can be particularly useful in identifying causes of hypoxaemia, a frequent occurrence after CPB disconnection.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> In cardiac surgery, TOLU is usually used to visualise pleural spaces and perform a qualitative (exudates, blood, organized effusions) and quantitative evaluation of effusions (measuring the sectional area and multiplying it by the axial length).<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> It can also be very useful in the diagnosis of consolidations, since atelectasis is common in the perioperative period, and ultrasound can be used to optimize ventilation and assess the efficacy of recruitment manoeuvres and diagnose causes of hypoxaemia.<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69,70</span></a> The appearance of homogeneous, bilateral B lines in dependent regions is associated with pulmonary oedema. TOLU, together with an evaluation of cardiac function, permits early management and continuous monitoring of the response to treatment. In pneumothorax, however, in which TTE plays an important role in diagnosis, TOLU has no diagnostic value, because air tends to accumulate in non-dependent regions (anterior fields) which are not properly explored. Nevertheless, it may be useful for evaluating indirect signs of increased intrathoracic pressure, such as right cavity collapse.</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Considerations in new endovascular procedures (TAVI, transcatheter mitral valve repair)</span><p id="par0950" class="elsevierStylePara elsevierViewall">The current increase in both the number and frequency of minimally invasive and endovascular procedures opens up a new and important field where echocardiography is a fundamental tool both in the cath lab, and in the hybrid and/or conventional operating room. A survey conducted by the Spanish Society of Cardiovascular Surgeons in 2019 showed that 83% of centres routinely perform echocardiography in almost all their procedures, and this percentage increases in the case of endovascular procedures.</p><p id="par0955" class="elsevierStylePara elsevierViewall">In most hospitals, echocardiography is performed by expert echocardiographers, and few anaesthesiologist have as yet received the training required. The gradual extension of these procedures to hybrid operating rooms could make it necessary for anaesthesiologists to receive specific training in these techniques.</p><p id="par0960" class="elsevierStylePara elsevierViewall">The most common techniques are, in summary: TAVI, percutaneous mitral repair, atrial appendage closure, closure of atrial septal defects, closure of periprosthetic leaks, implantation of ventricular assist devices and extracorporeal membrane oxygenation (ECMO).</p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">TOE during TAVI and post-implant control</span><p id="par0965" class="elsevierStylePara elsevierViewall">In TAVI, the use of preoperative TOE is essential for visualising the degree of aortic stenosis, the degree of leaflet asymmetry and the degree of calcification. Determining the degree and geometric distribution of calcifications can predict the appearance of complications, such as periprosthetic leak, obstruction of coronary arteries or even annular rupture, and can also indicate the right valve size.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">71,72</span></a> Two-D TOE underestimates valve sizes and distances, particularly when the annulus is asymmetrical.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">73,74</span></a> The measurement is taken in the long axis of the aorta at the mid-oesophageal level at 120°. In asymmetric annulae, this diameter is not representative of the area, so 3-D TOE, which correlates more closely with measurements obtained by CT, is better in this case.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0970" class="elsevierStylePara elsevierViewall">In most hospitals, manoeuvres such as advancing the guide wire through the AV, performing balloon valvuloplasty, positioning and deploying prosthetic devices are performed under fluoroscopy, not TOE, because the latter allows the procedure to be performed without general anaesthesia. However, TTE is still essential for evaluating the performance of the prosthesis once it has been implanted. TTE can be used to measure transprosthetic gradients and correctly define the location of periprosthetic leaks, a function not available under fluoroscopy. Under TOE, a periprosthetic leak is defined as severe if it is caused by a regurgitant orifice occupying > 20% of valve circumference (>72°) on the short axis.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> The leak site can be more accurately located using 3-D TOE. A new balloon valvuloplasty will be performed if the leak is due to insufficient expansion of the prosthesis, and a new prosthesis will be implanted if leak arises because the prosthesis is the wrong size.</p><p id="par0975" class="elsevierStylePara elsevierViewall">Other post-implant complications that can be visualized by TOE are: aortic dissection, cardiac tamponade due to guide wire perforation of both the LV and RV or atria, ventricular dysfunction, or occlusion of the coronary artery outlet.</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">TOE during transcatheter mitral valve repair</span><p id="par0980" class="elsevierStylePara elsevierViewall">Patients with severe functional mitral insufficiency or regurgitation due to prolapse that are not candidates for surgery and/or present a high surgical risk can undergo endovascular mitral valve repair using an edge-to-edge clip, called an Alfieri stitch. Studies such as EVEREST and EVEREST II have shown that this technique safely reduced regurgitation in most patients included in a select series<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">76,77</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a>).</p><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><p id="par0985" class="elsevierStylePara elsevierViewall">In this intervention, TOE is essential to establish the indication and feasibility of the technique, to guide the procedure, and to check the outcome. Clinical trials such as Everest II have established criteria that must be met to ensure the success of the technique (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> These are purely echocardiographic criteria, since this is the method used to characterize valve morphology and select patients that are suitable for this technique<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a>).</p><p id="par0990" class="elsevierStylePara elsevierViewall">The main steps to monitor with TOE during mitral valve repair are:<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">•</span><p id="par0995" class="elsevierStylePara elsevierViewall">Trans-septal puncture: bicaval plane (115°-130°) and short axis (30°-60°)</p></li><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">•</span><p id="par1000" class="elsevierStylePara elsevierViewall">Correct positioning of the clip: intercommissural (55°-75°) for mediolateral alignment, and visualisation of the LV outflow tract (120°-150°) for anteroposterior alignment.<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78,79</span></a></p></li></ul></p><p id="par1005" class="elsevierStylePara elsevierViewall">Ideally, 3D echocardiography should be used to ensure the clip is perpendicular to the line of coaptation, but if this is not an option 2D TOE in a transgastric short axis can be used, and the view should be repeated once the probe has advanced towards the ventricle. It is important to record a long video sequence of the alignment to serve as a road map that can be revisited whenever needed to correct errors. If the clip is not correctly positioned the device may fail due to leakage of one of the leaflets.</p><p id="par1010" class="elsevierStylePara elsevierViewall">Once the clip is in place, 2D and/or 3D colour Doppler<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> should be used to evaluate the degree of MI caused by the 2 remaining holes, lateral and medial, and the degree of residual stenosis caused by the anteroposterior position of the clip. This is because a second clip is sometimes needed to gradually reduce the degree of insufficiency, provided this will not increase residual stenosis.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a></p><p id="par1015" class="elsevierStylePara elsevierViewall">Complications to take into account with this procedure include failure to capture the leaflet due to poor positioning, rupture of the mitral leaflet, rupture of the chords, left ventricular free wall rupture, or ASD.</p></span></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Information management: verbal and written report</span><p id="par1020" class="elsevierStylePara elsevierViewall">We believe that the operator who performs the intraoperative TOE should always prepare a standardised report recording their main findings and conclusions. This will convey the information to the rest of the medical team, facilitate patient follow-up, and allow studies performed by different operators in different centres to be compared.</p><p id="par1025" class="elsevierStylePara elsevierViewall">Any discrepancies between the preoperative report and the intraoperative findings prior to surgery should be verbally reported. Scientific societies recommend recording the pre- and post-CPB findings in writing using standardized models.</p><p id="par1030" class="elsevierStylePara elsevierViewall">In the case of an urgent procedure without a preoperative study, information should first be given verbally and then in writing in more detail.</p><p id="par1035" class="elsevierStylePara elsevierViewall">The perioperative ultrasound report serves the following purposes<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a>:<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">•</span><p id="par1040" class="elsevierStylePara elsevierViewall">It aids surgical decision-making by confirming the diagnosis and supporting the need for changes in the surgical plan, if appropriate, such as changes in haemodynamic management strategies and the need for more invasive measures.</p></li><li class="elsevierStyleListItem" id="lsti0595"><span class="elsevierStyleLabel">•</span><p id="par1045" class="elsevierStylePara elsevierViewall">It records intraoperative findings for postoperative evaluations.</p></li><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">•</span><p id="par1050" class="elsevierStylePara elsevierViewall">The information must be easily understood by other professionals involved in the subsequent management of the patient who are not specialist echocardiographers.</p></li><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">•</span><p id="par1055" class="elsevierStylePara elsevierViewall">The report is a medico-legal document, so all incidents and findings must be recorded.</p></li><li class="elsevierStyleListItem" id="lsti0610"><span class="elsevierStyleLabel">•</span><p id="par1060" class="elsevierStylePara elsevierViewall">Issuing ultrasound reports is part of the training and accreditation required for TOE specialists.</p></li><li class="elsevierStyleListItem" id="lsti0615"><span class="elsevierStyleLabel">•</span><p id="par1065" class="elsevierStylePara elsevierViewall">It is a useful source of information for prospective and retrospective clinical studies.</p></li></ul></p><p id="par1070" class="elsevierStylePara elsevierViewall">Recommendations for writing a report are as follows<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a>: First, identify the patient (data that identify the patient, their characteristics, the diagnosis, and indication for study). Second, describe the morphological study and determination of the overall function of both ventricles, including the most relevant descriptions of the cardiac chambers, the thoracic aorta morphology, and pre- and post-CPB valve function. It is essential to describe any relevant acute or persistent changes in right or left ventricular function during the surgical procedure. In valve surgery, summarise both native and prosthetic valve function. In valve repair surgery (including annuloplasty), specify the degree of residual insufficiency. It is essential to perform an intraoperative TOE examination after mitral valve repair in order to decide whether the procedure has been successful or the valve must be replaced. Report the degree of residual insufficiency and the coaptation surface area, and rule out complications such as mitral stenosis, SAM with LVOT obstruction, and ventricular dysfunction. Report whether the prosthetic valve is functioning correctly, whether it maintains normal gradients, and the presence or absence of periprosthetic leaks. If leaks are observed, report their severity and location as accurately as possible.</p><p id="par1075" class="elsevierStylePara elsevierViewall">Finally, report the conclusions drawn from the study:<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0620"><span class="elsevierStyleLabel">1</span><p id="par1080" class="elsevierStylePara elsevierViewall">Summarise the preoperative echocardiographic findings, in order of relevance.</p></li><li class="elsevierStyleListItem" id="lsti0625"><span class="elsevierStyleLabel">2</span><p id="par1085" class="elsevierStylePara elsevierViewall">Describe the surgical procedure performed.</p></li><li class="elsevierStyleListItem" id="lsti0630"><span class="elsevierStyleLabel">3</span><p id="par1090" class="elsevierStylePara elsevierViewall">Postoperative study.</p></li></ul></p><p id="par1095" class="elsevierStylePara elsevierViewall">We suggest using the data collection protocol proposed by the EACTA (see attached document in Appendix <a class="elsevierStyleCrossRef" href="#sec0220">B</a> additional material) as a model for this report.</p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Conclusions</span><p id="par1100" class="elsevierStylePara elsevierViewall">The introduction and widespread use of TOE has allowed clinicians to perform real time anatomical and functional monitoring of the heart, making it an essential, irreplaceable monitoring tool in cardiovascular surgery. The interpretation and reporting of pathological findings by TOE is an integral part of cardiac anaesthesia. We believe that perioperative TOE in cardiac surgery should be performed by the treating anaesthesiologist, who must be adequately trained and/or accredited in cardiovascular anaesthesia and TOE for the perioperative context. However, depending on their level of competence, training and experience, the anaesthesiologist may require the support of the cardiologist.</p><p id="par1105" class="elsevierStylePara elsevierViewall">We describe the standardized protocol accepted by all scientific societies for the anatomical and functional study of patients at each stage of surgery. This examination provides useful qualitative and quantitative information for each procedure, facilitates intraoperative decision-making, and guides changes in the surgical plan, if needed. TOE is even more important in less invasive procedures, as it can be used to guide certain stages of the intervention, and for this reason greater skill and experience in this echocardiographic technique are required. It is essential to communicate the findings obtained by preparing first a verbal and later a written report of the study carried out.</p></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Conflict of interests</span><p id="par1110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">.</span><p id="par1115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,23</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1412442" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1292608" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1412443" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1292609" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Who should perform intraoperative TOE in cardiovascular surgery? Training and accreditation" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Indications and main clinical applications" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "General applications in conventional cardiac surgery" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Pre-CPB" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "During and after CPB" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Applications in specific procedures" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Valve surgery: repair and replacement" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Hypertrophic obstructive cardiomyopathy surgery" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Aortic surgery" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Coronary artery surgery with and without CPB" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Other off-pump procedures" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Clinical safety. Contraindications. Complications" ] 8 => array:3 [ "identificador" => "sec0070" "titulo" => "TOE study technical aspects" "secciones" => array:18 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Insertion of the probe" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Basic TOE views" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Ultrasound examination of cardiac structures: mitral valve" ] 3 => array:2 [ "identificador" => "sec0090" "titulo" => "Aortic valve" ] 4 => array:2 [ "identificador" => "sec0095" "titulo" => "Tricuspid valve" ] 5 => array:2 [ "identificador" => "sec0100" "titulo" => "Pulmonary valve" ] 6 => array:2 [ "identificador" => "sec0105" "titulo" => "Left ventricle" ] 7 => array:2 [ "identificador" => "sec0110" "titulo" => "Right ventricle" ] 8 => array:3 [ "identificador" => "sec0115" "titulo" => "Study parameters" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0120" "titulo" => "Usefulness during the period prior to cardiopulmonary bypass" ] ] ] 9 => array:2 [ "identificador" => "sec0125" "titulo" => "Useful pre-CPB intraoperative ultrasound measurements" ] 10 => array:3 [ "identificador" => "sec0130" "titulo" => "Usefulness in the post-cardiopulmonary bypass (post-CPB) period" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0135" "titulo" => "Usefulness in postcardiotomy shock" ] 1 => array:2 [ "identificador" => "sec0140" "titulo" => "Special considerations regarding evaluation of volaemia" ] ] ] 11 => array:3 [ "identificador" => "sec0145" "titulo" => "Considerations in specific procedures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0150" "titulo" => "Evaluation of prosthetic valve replacement" ] 1 => array:2 [ "identificador" => "sec0155" "titulo" => "Evaluation in mitral valve repair surgery" ] 2 => array:2 [ "identificador" => "sec0160" "titulo" => "Evaluation in aortic valve repair surgery" ] ] ] 12 => array:2 [ "identificador" => "sec0165" "titulo" => "Echocardiographic considerations in coronary artery surgery" ] 13 => array:2 [ "identificador" => "sec0170" "titulo" => "Considerations in off-pump coronary artery surgery" ] 14 => array:2 [ "identificador" => "sec0175" "titulo" => "Intraoperative examination of the lung by transoesophageal echocardiography. Transoesophageal lung ultrasound (TOLU)" ] 15 => array:2 [ "identificador" => "sec0180" "titulo" => "Considerations in new endovascular procedures (TAVI, transcatheter mitral valve repair)" ] 16 => array:2 [ "identificador" => "sec0185" "titulo" => "TOE during TAVI and post-implant control" ] 17 => array:2 [ "identificador" => "sec0190" "titulo" => "TOE during transcatheter mitral valve repair" ] ] ] 9 => array:2 [ "identificador" => "sec0195" "titulo" => "Information management: verbal and written report" ] 10 => array:2 [ "identificador" => "sec0200" "titulo" => "Conclusions" ] 11 => array:2 [ "identificador" => "sec0205" "titulo" => "Conflict of interests" ] 12 => array:2 [ "identificador" => "sec0210" "titulo" => "." ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-05" "fechaAceptado" => "2020-06-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1292608" "palabras" => array:4 [ 0 => "Cardiovascular surgery" 1 => "Transesophageal echocardiography" 2 => "Intraoperative" 3 => "Hemodynamic monitoring" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1292609" "palabras" => array:4 [ 0 => "Cirugía cardiovascular" 1 => "Ecocardiografía transesofágica" 2 => "Intraoperatorio" 3 => "Monitorización hemodinámica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0170" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiacmorphology and function in real time and it is a quality standard in cardiovascular surgery. It has becomea fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide thecorrect surgical planning and pharmacological management.</p><p id="spar0175" class="elsevierStyleSimplePara elsevierViewall">The goal of this document is to answer the questions of when and how the perioperative TEE shouldbe performed in cardiovascular surgery, what are their applications in the intraoperative, who shouldperform it and how the information should be transmitted. The authors made a systematic review ofinternational guidelines, review articles and clinical trials to answer by consensus to these questions.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0180" class="elsevierStyleSimplePara elsevierViewall">La ecocardiografía transesfofágica es una técnica semiinvasiva que permite una evaluación de la mor-fología y función cardiaca a tiempo real y que constituye, a día de hoy, un estándar de calidad en lasintervenciones de cirugía cardiovascular. Se ha convertido en una herramienta fundamental tanto demonitorización como de diagnóstico en el perioperatorio que permite la correcta planificación quirúrgicay manejo farmacológico dirigido.</p><p id="spar0185" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este documento es dar respuesta de forma consensuada y avalada por la evidenciacientífica de cuándo y cómo debe hacerse la ecocardiografía transesfofágica intraoperatoria en cirugíacardiovascular, qué aplicaciones tiene en el intraoperatorio, quién debe realizarla y cómo debe transmi-tirse la información obtenida durante el estudio. Los autores han hecho una revisión sistemática de lasguías internacionales, artículos de revisión y ensayos clínicos para dar respuesta a estas preguntas.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Carmona García P, García Fuster R, Mateo E, Badía Gamarra S, López Cantero M, Gutiérrez Carretero E, et al. Ecocardiografía transesofágica intraoperatoria en cirugíacardiovascular. Documento de consenso de la Sociedad Española deAnestesiología y Reanimación (SEDAR) y Sociedad Española de CirugíaCardiovascular y Endovascular (SECCE). Rev Esp Anestesiol Reanim. 2020;67:446–480.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par1125" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0220" ] ] ] ] "multimedia" => array:56 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1650 "Ancho" => 2091 "Tamanyo" => 270424 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Parameters used to describe functional and degenerative mitral insufficiency.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 864 "Ancho" => 1261 "Tamanyo" => 70691 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mid-oesophageal AV modified short axis view showing a large bubble in the LA. TOE helps guide de-airing.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 947 "Ancho" => 1260 "Tamanyo" => 83211 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transgastric short axis view. LV is observed with severe hypertrophy and signs of obliteration of the intraventricular cavity, a typical kissing wall sign.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 967 "Ancho" => 1260 "Tamanyo" => 84076 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transgastric short axis view. LV with large end-diastolic and end-systolic diameter.</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 710 "Ancho" => 1344 "Tamanyo" => 87763 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transgastric short axis view of RA with IVC unction. Respiratory collapse of IVC is observed.</p>" ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1059 "Ancho" => 1344 "Tamanyo" => 119914 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Pulsed spectral Doppler at the LVOT level. Changes in stroke volume during respiratory cycles can be observed through the AV.</p>" ] ] 6 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 959 "Ancho" => 1344 "Tamanyo" => 82906 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Transgastric 0° view towards the right hemithorax. Pleural effusion with passive atelectasis of the right lung is observed.</p>" ] ] 7 => array:8 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 918 "Ancho" => 1344 "Tamanyo" => 88922 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Four-chamber mid-oesophageal 0° view. Pericardial effusion is observed at the level of the LA, with compression of the LA lateral wall.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">AI = left aorta, AD = right atrium, VD = right ventricle, VI = left ventricle.</p>" ] ] 8 => array:8 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 921 "Ancho" => 1344 "Tamanyo" => 76817 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Mid-oesophageal AV long axis view. A large haematoma is observed on the posterior wall of the aorta, compressing the LA.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AI = left aorta, TSVI = left ventricular outflow tract, VI = left ventricle</p>" ] ] 9 => array:8 [ "identificador" => "fig0050" "etiqueta" => "Figure 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 914 "Ancho" => 1344 "Tamanyo" => 113349 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure 1" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Mid-oesophageal 0° view of the mitral valve. Colour Doppler shows a massive regurgitation jet in the direction of the LA caused by limited mobility of one of the discs of the mitral prosthesis.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">AI = left aorta, AD = right aorta, VD = right ventricle, VI = left ventricle, TIV = intraventricular septum.</p>" ] ] 10 => array:8 [ "identificador" => "fig0055" "etiqueta" => "Figure 11" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr11.jpeg" "Alto" => 961 "Ancho" => 1344 "Tamanyo" => 99706 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Figure 1" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Two-chamber mid-oesophageal view after mitral valve replacement. A periprosthetic regurgitation jet is observed in the annular region at the level of the left atrial appendage.</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">AI = left aorta, VI = left ventricle, OI = left atrial appendage.</p>" ] ] 11 => array:8 [ "identificador" => "fig0060" "etiqueta" => "Figure 12" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr12.jpeg" "Alto" => 799 "Ancho" => 1344 "Tamanyo" => 88701 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Figure 1" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Mid-oesophageal 4-chamber 0° view. Mitral valvuloplasty is observed. The septal hypertrophy observed may constitute a risk factor for the development of SAM.</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AI = left aorta, AD = right aorta, VD = right ventricle, VI = left ventricle.</p>" ] ] 12 => array:8 [ "identificador" => "fig0065" "etiqueta" => "Figure 13" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr13.jpeg" "Alto" => 819 "Ancho" => 1344 "Tamanyo" => 92250 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Figure 1" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Three-chamber mid-oesophageal view. A mitral regurgitation jet secondary to SAM is evident after mitral repair.</p>" ] ] 13 => array:8 [ "identificador" => "fig0070" "etiqueta" => "Figure 14" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr14.jpeg" "Alto" => 925 "Ancho" => 1344 "Tamanyo" => 106376 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Figure 1" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Mid-oesophageal AV long axis view after performing aortic valvuloplasty and disconnection from CPB. Colour Doppler shows an eccentric aortic regurgitation jet in the direction of the mitral valve.</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">AI = left aorta, VI = left ventricle, AoAsc = ascending aorta.</p>" ] ] 14 => array:8 [ "identificador" => "fig0075" "etiqueta" => "Figure 15" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr15.jpeg" "Alto" => 1192 "Ancho" => 2175 "Tamanyo" => 325330 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Figure 1" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Algorithm for postcardiotomy echocardiographic diagnosis of shock.</p>" ] ] 15 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Absolute \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Relative \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recent oesophageal surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptomatic hiatus hernia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Giant oesophageal diverticulum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe oesophagitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oesophageal stricture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe coagulopathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oesophageal tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oesophageal varices \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Upper gastrointestinal bleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intestinal bleeding under study \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422962.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Contraindications for TOE insertion.</p>" ] ] 16 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0085" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Views \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Angle level \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Manoeuvre \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Structures \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5-chamber<elsevierMultimedia ident="202011120618134631"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-10MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advance the probe into the oesophagus and perform slight anteflexion to include the LVOT in the 4-chamber view. The view appears practically alone. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AVLVOTLA/RA/RV/LVIV septumTVMV (A<span class="elsevierStyleInf">2</span>A<span class="elsevierStyleInf">1</span>-P<span class="elsevierStyleInf">1</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4-chamber<elsevierMultimedia ident="202011120618134632"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-10MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advance the probe and optimize the LV apex by slight retroflexion. The LVOT and AV will disappear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LA/RAIA septumRVLV: Walls IS<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>ALIV septumMV (A<span class="elsevierStyleInf">3</span>A<span class="elsevierStyleInf">2</span>-P<span class="elsevierStyleInf">2</span>P<span class="elsevierStyleInf">1</span>)TV (ant/postseptal) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Commissural mitral<elsevierMultimedia ident="202011120618134633"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50-70MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desde el 4<span class="elsevierStyleHsp" style=""></span>From the 4-chamber view, maintain the same position with the MV in the centre. Rotate the view angle 50-70 until the LA and RV disappear. Flex back to obtain the LV apex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RACoronary sinusLVMV (P<span class="elsevierStyleInf">3</span>-A<span class="elsevierStyleInf">2</span>-P<span class="elsevierStyleInf">1</span>)Papillary muscleChordae tendineaeCircumflex A.Mitral evaluation (intercommissural ring measurement) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2-chamber<elsevierMultimedia ident="202011120618134634"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80-100MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the previous view, rotate 80-100. Retroflex the probe tip to obtain the true LV apex, adjust depth to view the entire LV apex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RALAACoronary sinusLV (ant and inf septum)MV (P<span class="elsevierStyleInf">3</span>-A<span class="elsevierStyleInf">3</span> A<span class="elsevierStyleInf">2</span>A<span class="elsevierStyleInf">1</span>)“oumadin ridge” separating the LAA and LSPVMitral assessment (A-P annulus measurement) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3-chamber<elsevierMultimedia ident="202011120618134635"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120-140MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Slight anteflexion and rotation from 120. Adjust depth to keep all VI structures in view \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LA/LVLVOTRVOTAVAortic rootMV (A<span class="elsevierStyleInf">2</span>-P<span class="elsevierStyleInf">2</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MO AV long axis<elsevierMultimedia ident="202011120618134636"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120-140MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the anterior plane, withdrawing outward to focus on the aortic root \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RALVOTRVOTMV (A<span class="elsevierStyleInf">2</span>-P<span class="elsevierStyleInf">2</span>)AV and aortic rootAortic prosthesis evaluation, measurement of the annulus, LVOT diameter, STJ and rest of the aortic rootSAM evaluation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MO Asc. A. long axis<elsevierMultimedia ident="202011120618134637"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90-110UO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the MO AV long axis view (120), withdrawing the probe to bring the pulmonary artery into view. Decrease the angle of view slightly by 10-20 so that the aortic wall is symmetrical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mid Asc. A. (long axis)Right PAAneurysm evaluation and antegrade cannulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MO Asc. A short axis<elsevierMultimedia ident="202011120618134638"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-30UO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the MO AV short axis or long axis view, withdraw the probe (short axis ascending aorta) rotating to 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mid Asc. A (short axis)Branching PASuperior vena cava \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MO AV short axis<elsevierMultimedia ident="202011120618134639"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20-40MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Slight anteflexion of the probe, the AV appears in the centre of the screen in the transverse axis view \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aortic valve and leaflets, tricuspid valveRA, LA and RVLA septumPulmonary valveCoronary arteries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MO RV inflow and outflow tract<elsevierMultimedia ident="2020111206181346310"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60-75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the AV short axis view, advance the probe to approximately 70 to reveal the RV inflow and outflow tract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LA, RA, AV, Tricuspid V. (anterior/septal and posterior leaflet), Pulmonary V, and RV inflow and outflow tract \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Modified BICAVAL<elsevierMultimedia ident="2020111206181346311"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50-70MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the bicaval view, increase the angle to 120 rotating the probe clockwise. Try to centre the TV in the screen. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RA/RVTVIA septum (mid)Inf. and Sup. vena cavaCoronary sinusFunctional evaluation of TV, flow, and estimation of PASP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bicaval<elsevierMultimedia ident="2020111206181346312"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90-110MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From 2-chamber MO (90) rotating clockwise (to the right)Change the angle or rotate the probe slightly to view both the IVC (left) and SVC (right) simultaneously \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LALIA septumCavasR appendageEustachian valve (EV) (junction of IVC/RA)Terminal crest (TC) (junction of SVC/RA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">UO, PVs<elsevierMultimedia ident="2020111206181346313"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90-110UO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Withdrawing towards UO, turn to the right for right PVs and vice versa for left PVs. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PVsArteria pulmonar (eje corto)Pulmonary artery (short axis)Measurement of abnormal flows and drains \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MO Left appendage<elsevierMultimedia ident="2020111206181346314"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90-110MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From 2-chamber MO view (90) identify the MV and rotate the probe to the left while decreasing the depth. Identify the LAA in the long axis and withdraw the probe to explore the LSPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LAALSPV (reverse flow, velocity…)Evaluate AAAAssess severity of MI using LAA reverse flow \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Mid-or upper-oesophageal views (MO UO).</p>" ] ] 17 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0090" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Views \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Angle level \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Manoeuvre \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Structures \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG basal short axis view<elsevierMultimedia ident="2020111206181346315"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-20TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advance to the stomach and perform anteflexion until LV and MV are visualized with both leaflets as symmetrical as possible \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Basal LVBasal RVMV (short axis)(TV short axis)Complete with MV evaluation and contractility alterations. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG mid papillary short axis view<elsevierMultimedia ident="2020111206181346316"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-20TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advancing from the previous view, centre the LV by turning the probe to the right or left. Both papillary muscles will be visualized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVPapillary musclesRVEvaluation of segmental contractility disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG hepatic vein<elsevierMultimedia ident="2020111206181346317"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-20TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the stomach, rotating to the right, locate the liver and identify the IVC. Use colour Doppler with a low Nyquist limit to identify flow. Withdrawing the probe will show the IVC draining into the RA, and when angled at 40 the hepatic vein draining into the IVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IVC (cannula position, respiratory variation, thrombus or intravascular mass)Evaluate severe TI (systolic inversion) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG Basal VT<elsevierMultimedia ident="2020111206181346318"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-20TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Look for the TG basal view, anteflexion and right slight rotation to centre the RV, and adjust the angle to between 0 and 30 to target the TV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV (mid)RV (mid)RVOTTVPV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG RV inflow-outflow<elsevierMultimedia ident="2020111206181346319"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-40TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the stomach, look for the TG basal short axis view and rotate the probe to the right with right flexing and a 0-40 angle. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RATVRVRVOTPVProximal PAEvaluate Doppler flows \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep TG 5-chamber<elsevierMultimedia ident="2020111206181346320"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-20TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flex to the left, advance the probe and anteflex around the gastric mucosa until the LV apex is visible at the top of the screen. Excessive anteflexion obtains an image of the superior plane through the base of the heart \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV and RV (partial)IV septumLVOTAV and aortic rootMVLAEvaluate ITV of the LVOTEvaluate leaks, VSD, LVEF \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Two-chamber TG long axis<elsevierMultimedia ident="2020111206181346321"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90-110TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the TG mid short axis view, rotate the transducer 90-100 with enough anteflexion to view the LV horizontally \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVLAMVLeft appendageComplete MV evaluation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG RV inflow<elsevierMultimedia ident="2020111206181346322"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90-110TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the TG mid view (0) rotate the probe clockwise to centre the RVRotate to 90Anteflex until RV is horizontal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RVRATVComplete VT evaluation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG long axis<elsevierMultimedia ident="2020111206181346323"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120-140TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From 2-chamber TG view (90), rotate counter-clockwise to 110-120The AV will be shown on the right side of the screen, adjusting the depth \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVLVOTAVMVAortic rootRV (partial)(Equivalent to the parasternal plane in TTE) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422965.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desc. A. short axis<elsevierMultimedia ident="2020111206181346324"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-10TG-MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No flexionRotate posterior by turning the probe to the left. Position the A in the middle of the screen and decrease the depth to 5<span class="elsevierStyleHsp" style=""></span>cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desc ALeft thoraxAzygos hemiazygosEvaluate aorta pathology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desc A long axis<elsevierMultimedia ident="2020111206181346325"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90-100TG-MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Same position as above, but with probe angle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desc ALeft thoraxEvaluate left pleural effusions and aorta pathology. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">UO, A arch long axis<elsevierMultimedia ident="2020111206181346326"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-10UO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the MO descending aorta view (0)Withdraw the probe until the aorta changes to an oval shapeTurn the probe slightly to the right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A. archInnominate v.MediastinumEvaluate A. arch \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">UO A. arch short axis<elsevierMultimedia ident="2020111206181346327"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70-90TG-MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the UO view of the aortic arch, rotate the angle to 60-90Bring the pulmonary valve and pulmonary artery into view \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A archInnominate v.Pulmonary a.Pulmonary valveMediastinum \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422959.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Transgastric planes.</p>" ] ] 18 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0095" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">AAA: ascending aortic artery; AI: aortic insufficiency; AV: aortic valve; EV: eustachian valve; IAS: interatrial septum; IV: interventricular; IVC: inferior vena cava; LA: left atrium; LAA: left atrial appendage; LSPV: left superior pulmonary vein; LV: left ventricle; LVEF: left ventricular ejection fraction; LVOT: left ventricular outflow tract; MO: mid-oesophageal; MV: mitral valve; PA: pulmonary artery; PASP: pulmonary artery systolic pressure; PV: pulmonary valve: PVs: pulmonary veins; RA: right atrium; RVOT: right ventricular outflow tract; RSPV: right superior pulmonary vein; RV: right ventricle; STJ: sinotubular junction; SVC: superior vena cava; TC: terminal crest; TG: transgastric; TV: tricuspid valve; UO: upper oesophageal; VSD: ventricular septal defect.</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Tables 2, 3 and 4: adapted with permission: <span class="elsevierStyleInterRef" id="intr0005" href="http://pie.med.utoronto.ca/TEE/index.htm">http://pie.med.utoronto.ca/TEE/index.htm</span>.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Views \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Angle level \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Manoeuvre \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Structures \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desc A short axis<elsevierMultimedia ident="2020111206181346328"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-10TG-MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No flexionRotate posterior by turning the probe to the left.Centre the A in the screen and decrease the depth to 5<span class="elsevierStyleHsp" style=""></span>cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desc ALeft thoraxAzygos hemiazygosEvaluate aorta pathology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desc A long axis<elsevierMultimedia ident="2020111206181346329"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90-100TG-MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Same position as above, but angle the probe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desc ALeft thoraxEvaluate left pleural effusions and aorta pathology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">UO A. arch Long axis<elsevierMultimedia ident="2020111206181346330"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-10UO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the MO descending aorta view (0)Withdraw the probe until the aorta changes to an oval shapeTurn the probe slightly to the right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A. archInnominate v.MediastinumEvaluate A. arch \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">UO A. arch short axis<elsevierMultimedia ident="2020111206181346331"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70-90TG-MO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From the UO view of the aortic arch, rotate the angle to 60-90.Bring the pulmonary valve and pulmonary artery into view \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A. archInnominate v.Pulmonary a.Pulmonary valveMediastinum \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422964.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Large vessel views.</p>" ] ] 19 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0100" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type III \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preserved leaflet mobility and/or dilated annulae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excessive leaflet motion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Restricted leaflet motion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">E.g.: Endocarditis, mitral leaflet perforation, annular dilation in dilated LA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">E.g.: Barlow's disease, fibroelastic deficiency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 A: Fusion and calcification of the subvalvular apparatus. E.g.: Rheumatic disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 B: Restricted leaflet motion due to symmetric ventricular dilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 C: Restricted leaflet motion with focal tethering \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422957.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">Mechanism of mitral insufficiency.</p>" ] ] 20 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0105" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Stunned myocardium after prolonged aortic clamping time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Suboptimal RV and/or LV myocardial protection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Incomplete coronary revascularization \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Mechanical involvement of coronary grafts \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Air embolism \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422961.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Aetiological diagnosis of ventricular dysfunction after CPB.</p>" ] ] 21 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0110" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Coronary spasm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Air embolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Stenotic coronary anastomoses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Mechanical obstruction of grafts \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Mechanical obstruction of the circumflex artery in mitral surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Occlusion of coronary vessels due to mobilization of embolic material \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422963.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">Aetiological differential diagnosis of the appearance of new segmental contractility disorders after CPB.</p>" ] ] 22 => array:8 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0115" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">LVOT: left ventricular outflow tract; MI: mitral insufficiency; SAM: systolic anterior movement.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Residual mitral insufficiency \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mitral stenosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SAM with dynamic LVOT and MI obstruction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventricular dysfunction due to occlusion or distortion of the circumflex artery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pseudoaneurysm in the area of mitral annulus decalcification and peri-annulus leaks. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aortic regurgitation secondary to distortion of the mitroaortic annulus \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422956.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">Post-mitral repair complications.</p>" ] ] 23 => array:8 [ "identificador" => "tbl0045" "etiqueta" => "Table 9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0120" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Criterion \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evaluation \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mitral leaflet coaptation length \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥ 2 mm recommended length \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leaflet coaptation depth \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">< 1 mm recommended depth \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flail gap, if flail exists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><10 mm recommended spacing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flail width \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">< 15 mm recommended width \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Valve orifice area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 4 cm<span class="elsevierStyleSup">2</span> recommended orifice \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leaflet thickness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤5 mm recommended thickness \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Major annulus calcification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Must not be present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Significant cleft or perforation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Must not be present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Significant restriction of the posterior leaflet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Must not be present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No primary or secondary chordae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Must not be present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leaflet calcification clip implantation area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Must not be present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Several significant regurgitation jets \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Must not be present \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2422960.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">Recommended echocardiographic criteria for percutaneous mitral valve repair with mitraclip.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a></p>" ] ] 24 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 14432 ] ] 25 => array:5 [ "identificador" => "202011120618134631" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 928 "Ancho" => 2500 "Tamanyo" => 191958 ] ] ] 26 => array:5 [ "identificador" => "202011120618134632" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx2.jpeg" "Alto" => 997 "Ancho" => 2500 "Tamanyo" => 177705 ] ] ] 27 => array:5 [ "identificador" => "202011120618134633" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx3.jpeg" "Alto" => 1042 "Ancho" => 2500 "Tamanyo" => 204373 ] ] ] 28 => array:5 [ "identificador" => "202011120618134634" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx4.jpeg" "Alto" => 1038 "Ancho" => 2500 "Tamanyo" => 198652 ] ] ] 29 => array:5 [ "identificador" => "202011120618134635" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx5.jpeg" "Alto" => 1096 "Ancho" => 2500 "Tamanyo" => 200073 ] ] ] 30 => array:5 [ "identificador" => "202011120618134636" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx6.jpeg" "Alto" => 1110 "Ancho" => 2500 "Tamanyo" => 188505 ] ] ] 31 => array:5 [ "identificador" => "202011120618134637" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx7.jpeg" "Alto" => 1114 "Ancho" => 2500 "Tamanyo" => 182098 ] ] ] 32 => array:5 [ "identificador" => "202011120618134638" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx8.jpeg" "Alto" => 1096 "Ancho" => 2500 "Tamanyo" => 157057 ] ] ] 33 => array:5 [ "identificador" => "202011120618134639" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx9.jpeg" "Alto" => 1287 "Ancho" => 2500 "Tamanyo" => 233541 ] ] ] 34 => array:5 [ "identificador" => "2020111206181346310" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx10.jpeg" "Alto" => 1052 "Ancho" => 2500 "Tamanyo" => 187431 ] ] ] 35 => array:5 [ "identificador" => "2020111206181346311" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx11.jpeg" "Alto" => 1036 "Ancho" => 2500 "Tamanyo" => 199991 ] ] ] 36 => array:5 [ "identificador" => "2020111206181346312" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx12.jpeg" "Alto" => 1100 "Ancho" => 2500 "Tamanyo" => 194161 ] ] ] 37 => array:5 [ "identificador" => "2020111206181346313" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx13.jpeg" "Alto" => 927 "Ancho" => 2500 "Tamanyo" => 160999 ] ] ] 38 => array:5 [ "identificador" => "2020111206181346314" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx14.jpeg" "Alto" => 970 "Ancho" => 2500 "Tamanyo" => 196260 ] ] ] 39 => array:5 [ "identificador" => "2020111206181346315" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx15.jpeg" "Alto" => 1107 "Ancho" => 2500 "Tamanyo" => 171940 ] ] ] 40 => array:5 [ "identificador" => "2020111206181346316" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx16.jpeg" "Alto" => 1114 "Ancho" => 2500 "Tamanyo" => 172303 ] ] ] 41 => array:5 [ "identificador" => "2020111206181346317" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx17.jpeg" "Alto" => 995 "Ancho" => 2500 "Tamanyo" => 209901 ] ] ] 42 => array:5 [ "identificador" => "2020111206181346318" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx18.jpeg" "Alto" => 932 "Ancho" => 2500 "Tamanyo" => 207060 ] ] ] 43 => array:5 [ "identificador" => "2020111206181346319" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx19.jpeg" "Alto" => 912 "Ancho" => 2500 "Tamanyo" => 205881 ] ] ] 44 => array:5 [ "identificador" => "2020111206181346320" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx20.jpeg" "Alto" => 990 "Ancho" => 2500 "Tamanyo" => 182887 ] ] ] 45 => array:5 [ "identificador" => "2020111206181346321" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx21.jpeg" "Alto" => 996 "Ancho" => 2500 "Tamanyo" => 181482 ] ] ] 46 => array:5 [ "identificador" => "2020111206181346322" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx22.jpeg" "Alto" => 1031 "Ancho" => 2500 "Tamanyo" => 184511 ] ] ] 47 => array:5 [ "identificador" => "2020111206181346323" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx23.jpeg" "Alto" => 1113 "Ancho" => 2500 "Tamanyo" => 213068 ] ] ] 48 => array:5 [ "identificador" => "2020111206181346324" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx24.jpeg" "Alto" => 1112 "Ancho" => 2500 "Tamanyo" => 146496 ] ] ] 49 => array:5 [ "identificador" => "2020111206181346325" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx25.jpeg" "Alto" => 1098 "Ancho" => 2500 "Tamanyo" => 165466 ] ] ] 50 => array:5 [ "identificador" => "2020111206181346326" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx26.jpeg" "Alto" => 1101 "Ancho" => 2500 "Tamanyo" => 150047 ] ] ] 51 => array:5 [ "identificador" => "2020111206181346327" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx27.jpeg" "Alto" => 1099 "Ancho" => 2500 "Tamanyo" => 184346 ] ] ] 52 => array:5 [ "identificador" => "2020111206181346328" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx28.jpeg" "Alto" => 1115 "Ancho" => 2500 "Tamanyo" => 150344 ] ] ] 53 => array:5 [ "identificador" => "2020111206181346329" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx29.jpeg" "Alto" => 1103 "Ancho" => 2500 "Tamanyo" => 166728 ] ] ] 54 => array:5 [ "identificador" => "2020111206181346330" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx30.jpeg" "Alto" => 1103 "Ancho" => 2500 "Tamanyo" => 152360 ] ] ] 55 => array:5 [ "identificador" => "2020111206181346331" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx31.jpeg" "Alto" => 1106 "Ancho" => 2500 "Tamanyo" => 183287 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:82 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Basic perioperative transesophageal echocardiography examination: a consen-sus statement of the American society of echocardiography and the society ofcardiovascular anesthesiologists" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0b013e3182a00616" "Revista" => array:6 [ …6] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Practiceguidelines for perioperative transesophageal echocardiography" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e3181c51e90" "Revista" => array:6 [ …6] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelinesfor performing a comprehensive transesophageal echocardiographic exami-nation: Recommendations from the american society of echocardiographyand the society of cardiovascular anesthesiologists" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2013.07.009" "Revista" => array:6 [ …6] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impactof intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2007.11.015" "Revista" => array:6 [ …6] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Theimportance of intraoperative transesophageal echocardiography in the sur-gical decision in cardiac surgery" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An investigation into the cau-ses of unexpected intra-operative transoesophageal echocardiography findings" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2044.2011.07022.x" "Revista" => array:6 [ …6] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cambio de la acti-tud terapéutica debido a la ecocardiografía transesofágica en cirugía cardíaca" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative transesophageal echocardiography: 5-Year prospective review of impact on surgical management" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4065/75.3.241" "Revista" => array:6 [ …6] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Theimpact of intra-operative transoesophageal echocardiography on cardiac surgi-cal practice" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2044.2009.05991.x" "Revista" => array:6 [ …6] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Analysis of the 2019ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS appropriate use criteriafor multimodal imaging in the assessment of structural heart disease" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "American Society of Echocardiography/Society of Cardiovascular Anesthesiolo-gists Recommendations and Guidelines for Continuous Quality Improvement inPerioperative Echocardiography" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2006.08.039" "Revista" => array:6 [ …6] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ecocardiografía transesofágica intraoperatoria:¿para qué?, ¿cómo?, ¿con quién?" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0300-8932(00)75236-5" "Revista" => array:6 [ …6] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perspectives on the fellowship training in cardiac thoracic, and vascularanesthesia and critical care in Europe from Program Directors and EducationalLeads Around Europe" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2019.09.029" "Revista" => array:6 [ …6] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Erdoes G., Vuylsteke A., Schreiber J., Alston R.P., Howell S.J., Wouters P.F., et al. Euro-pean Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic andVascular Anesthesia Fellowship Curriculum: First edition." ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for transoesophageal echocardiography: Update 2010" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for transoesophageal echocardiography: EACVI update2014" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ehjci/jeu015" "Revista" => array:6 [ …6] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of intra-operative transesophageal echocardiography in cardiac surgery: retrospectiveanalysis of a series of 850 examinations" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complica-tions related to peri-operative transoesophageal echocardiography – a one-yearprospective national audit by the Association of Cardiothoracic Anaesthesia andCritical Care" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/anae.14734" "Revista" => array:6 [ …6] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelinesfor performing a comprehensive transesophageal echocardiographic examina-tion: recommendations from the american society of echocardiography and thesociety of cardiovascular anesthesiologists" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000000016" "Revista" => array:6 [ …6] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for cardiac chamber quantification by echocardiographyin adults: an update from the American Society of Echocardiography andthe European Association of Cardiovascular Imaging" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2014.10.003" "Revista" => array:6 [ …6] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for the evaluation of left ventricular diastolic function byechocardiography: an update from the American Society of Echocardiographyand the European Association of Cardiovascular Imaging" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2016.01.011" "Revista" => array:6 [ …6] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of diastolic function by echocardiography:Important progression, but issues to be resolved" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diastolic dysfunction is common and predicts outcome after cardiac surgery" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ …3] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Marked reduction in right ventricular longitudinal contraction after car-diopulmonary bypass in patients with preserved right ventricular output" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Right ven-tricular function is reduced during cardiac surgery independent of proceduralcharacteristics, reoperative status, or pericardiotomy" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2017.08.039" "Revista" => array:3 [ …3] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic regurgitation in coronaryartery bypass grafting: implications for cardioplegia administration" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Protruding aor-tic atheromas predict stroke in elderly patients undergoing cardiopulmonarybypass: experience with intraoperative transesophageal echocardiography" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An intra-operative assessment of the ascending aorta: A comparison of digital palpationtransesophageal echocardiography, and epiaortic ultrasonography" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for performing a comprehensive epicardial echocardiography exa-mination: recommendations of the American Society of Echocardiographyand the Society of Cardiovascular Anesthesiologists" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2007.01.011" "Revista" => array:6 [ …6] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of general anesthesia on the severity of mitral regurgitation bytransesophageal echocardiography" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0002-9149(99)00644-x" "Revista" => array:6 [ …6] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dyna-mic quantitative echocardiographic evaluation of mitral regurgitation in theoperating department" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2005.08.019" "Revista" => array:6 [ …6] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ColorDoppler and two-dimensional echocardiographic determination of the mecha-nism of aortic regurgitation with surgical correlation" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0894-7317(96)90122-4" "Revista" => array:6 [ …6] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of transthoracic and intraoperative transesophageal color flowdoppler assessment of mitral and aortic regurgitation" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000070671" "Revista" => array:6 [ …6] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toward predictable repair of regurgitant aortic valves. A systematicmorphology-directed approach to bicommissural repair" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2008.01.073" "Revista" => array:6 [ …6] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of echocardiography in aortic valve repair" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of transesophageal echocardiography in patients with suspected aorticdissection" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2004.12.006" "Revista" => array:5 [ …5] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Minimally invasive cardiac surgery and transesophagealechocardiography" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0971-9784.129844" "Revista" => array:6 [ …6] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Papel de laecocardiografía transesofágica en la cirugía mínimamente invasiva sobrela válvula mitral" "autores" => array:1 [ …1] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1590/s0102-76382008000200014" "Revista" => array:6 [ …6] ] 1 => array:2 [ "doi" => "10.1590/s0102-76382008000200014" "WWW" => array:1 [ …1] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leftatrial appendage intraoperative echocardiography, and the anesthesiologist" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2015.04.025" "Revista" => array:6 [ …6] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0200" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve repair: echocardiography is its best friend" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0205" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Echocardiographic predictors of successful versus unsuccessful mitral valverepair in ischemic mitral regurgitation" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjcard.2006.02.056" "Revista" => array:6 [ …6] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0210" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictingsystolic anterior motion after mitral valve reconstruction: Using intraopera-tive transoesophageal echocardiography to identify those at greatest risk" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ejcts/ezt234" "Revista" => array:6 [ …6] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0215" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tricuspid annuloplasty prevents right ventricular dilatation and progression oftricuspid regurgitation in patients with tricuspid annular dilatation undergoingmitral valve repair" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2010.05.050" "Revista" => array:6 [ …6] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0220" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 44 => array:3 [ "identificador" => "bib0225" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 45 => array:3 [ "identificador" => "bib0230" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 46 => array:3 [ "identificador" => "bib0235" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 47 => array:3 [ "identificador" => "bib0240" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 48 => array:3 [ "identificador" => "bib0245" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 49 => array:3 [ "identificador" => "bib0250" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 50 => array:3 [ "identificador" => "bib0255" "etiqueta" => "51" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 51 => array:3 [ "identificador" => "bib0260" "etiqueta" => "52" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 52 => array:3 [ "identificador" => "bib0265" "etiqueta" => "53" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 53 => array:3 [ "identificador" => "bib0270" "etiqueta" => "54" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 54 => array:3 [ "identificador" => "bib0275" "etiqueta" => "55" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 55 => array:3 [ "identificador" => "bib0280" "etiqueta" => "56" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 56 => array:3 [ "identificador" => "bib0285" "etiqueta" => "57" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 57 => array:3 [ "identificador" => "bib0290" "etiqueta" => "58" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 58 => array:3 [ "identificador" => "bib0295" "etiqueta" => "59" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 59 => array:3 [ "identificador" => "bib0300" "etiqueta" => "60" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 60 => array:3 [ "identificador" => "bib0305" "etiqueta" => "61" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 61 => array:3 [ "identificador" => "bib0310" "etiqueta" => "62" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 62 => array:3 [ "identificador" => "bib0315" "etiqueta" => "63" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 63 => array:3 [ "identificador" => "bib0320" "etiqueta" => "64" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 64 => array:3 [ "identificador" => "bib0325" "etiqueta" => "65" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 65 => array:3 [ "identificador" => "bib0330" "etiqueta" => "66" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 66 => array:3 [ "identificador" => "bib0335" "etiqueta" => "67" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 67 => array:3 [ "identificador" => "bib0340" "etiqueta" => "68" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 68 => array:3 [ "identificador" => "bib0345" "etiqueta" => "69" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 69 => array:3 [ "identificador" => "bib0350" "etiqueta" => "70" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 70 => array:3 [ "identificador" => "bib0355" "etiqueta" => "71" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 71 => array:3 [ "identificador" => "bib0360" "etiqueta" => "72" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 72 => array:3 [ "identificador" => "bib0365" "etiqueta" => "73" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 73 => array:3 [ "identificador" => "bib0370" "etiqueta" => "74" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 74 => array:3 [ "identificador" => "bib0375" "etiqueta" => "75" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 75 => array:3 [ "identificador" => "bib0380" "etiqueta" => "76" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 76 => array:3 [ "identificador" => "bib0385" "etiqueta" => "77" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 77 => array:3 [ "identificador" => "bib0390" "etiqueta" => "78" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 78 => array:3 [ "identificador" => "bib0395" "etiqueta" => "79" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 79 => array:3 [ "identificador" => "bib0400" "etiqueta" => "80" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 80 => array:3 [ "identificador" => "bib0405" "etiqueta" => "81" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 81 => array:3 [ "identificador" => "bib0410" "etiqueta" => "82" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006700000008/v1_202011120617/S2341192920301347/v1_202011120617/en/main.assets" "Apartado" => array:4 [ "identificador" => "59977" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Consensus statement" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006700000008/v1_202011120617/S2341192920301347/v1_202011120617/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920301347?idApp=UINPBA00004N" ]
