 Good afternoon everybody and welcome to 20s annual Toronto Perioperative TE symposium. I want to thank organizing committee for inviting me for this symposium. I'm going to talk about common errors, lessons from three years of Perioperative TE QI review at Toronto General Hospital. The objectives of this talk is describe and illustrate common pitfalls identified during QI review of Preoperative TE studies at Toronto General Hospital, describe the extent to which studies depart in clearly significant ways from current guidelines, and describe the challenges of maintaining an ongoing QI program and potential approaches. In this guideline, I'm using couple of in this lectures. I am using couple of guidelines and we have to use this guideline always in our daily work. The most important one is this guideline that was published in 2020 by American Society of Echo and Society of Cardiac Anesthesia, the guideline for the use of TE to assist with surgical decision-making in the operating room. Because that guideline did not talk about adult congenital heart disease, we should use this guideline as well that was published 2019 about Comprehensive TE for children with congenital disease and adult congenital disease. Because we are doing like about a hundred case of adult congenital heart disease operation per year in Toronto General Hospital. So we have to take care of these patients in the war as well. And of course the latest guideline of American College of Cardiology and American Heart Association was published in 2021 about Management of Patients with Valois Heart Disease. In the program that I am doing now this last almost three years from April 2019 to October 2021, this time we had about 2,400 intraoperative TE in Toronto General Hospital. Of course, I cannot review all of them, but I review 290 of them. It means only 12 percent. From this 290, 2 of them were Valois Heart Disease. So because that's the area that we need more decision-making and we need more detailed echo. 119 of these cases, that's a surprise. It means 59 percent of all Valois Heart Disease that I reviewed, they didn't have any echo in the Toronto General Hospital. Some of them they had the echo outside, that we can have access by single external, their image. And many of them we have only report. There is no image available. So when we go to the operating room, the team of intraoptee has to start to do echo without any previous images. So it's not easy to do a complete echo in 10-15 minutes and share in decision-making. Also, surgeon himself or herself knows the patient very well. Out of 290 cases, 19 patients, 6% of them had a second poem run. And 2 of them had a third poem run in the war because of TE finding post-stop. So TE is not only important in pre-op decision-making, but is more important in post-stop decision-making about the completeness of the surgery that we did for the patient. This is a breakdown of 290 cases. As you see, the most of them are valve replacement, adult congenital disease, valve repair, and different type of surgery. It doesn't mean that, for example, the number of the valve repair that we do in 2-3 years is only 55. 55 was reviewed by me. So it was more than this. We are doing like 100 mito valve repair per year in Toronto General Hospital. What domain I have looked at in that program for these 290 cases, I used some of my old experience in accreditation in Serbia, Arabia. And I used this paper from European Institute of Cardiology about the training of Team 4TE. And especially this paper, very nice paper from Sunnybrook University in New York. And this is probably the only paper that did a very systematic way, the QI of their program. Also, the program is not a very big program. So they looked at in that paper from New York four domains. Image acquisition, completeness of their study, image interpretation, and completeness of the report. And in my assessment, I broke down this one to 2-part image interpretation pre-op, image interpretation post-op. So it will be the 5 domains that I have looked at. I give you a case example. 55-year-old man was referred to our center for mito valve repair. And as you see, the first image, it shows the flail posterior leaflet. Also gain is too much. We like to have a good ECG, but many times it's not possible in the world. And this is a severe MR, as you see, anteriorly directed. This is 3D of this pre-op study. You see there is a flail P3. So we have to show this to the surgeon before he or she started the surgery. And this is the MR that is anteriorly directed, coming from that flail part, and especially from this commissure part, medial commissure. This is a post-op study, immediate post-op. You see a flash of color here. That flash of color is anteriorly systolic. And usually when you track it, go a little bit, mid systolic will disappear. After 5, 10 minutes, this will disappear. So this will not be assumed as a residual MR. You see here there's no flash of color anymore. And the mean gradient, we always check it, because we don't like to have MS after the repair, and always use the dense part of the Doppler, not the less dense part. And there's a couple of paper that we use, we should use the dense part. And this less dense part is because of the pressure recovery effect or Doppler effect. There's lots of debate about why we have this one. But we see it many times after mitovav repair or mitovav replacement. So we use only the dense part. This is a type of the report that I generated for this special case, case number 264. And you see it with more detail here. We use the five domain. And this five domain, for each of them, I gave them a score of total 10. This special patient for image acquisition, this study took 10 out of 10, completely so it's 10 out of 10. For pre-op interpretation, 8 out of 10, post up 10 out of 10, and completely report 10 of them. So five domains, I have looked at it, and I gave to this staff a score of 48 out of 50. It's a very good score. But I will not send this score to them during the report. I will keep it myself. This is how I describe it. I go to the history of the patient at first a little bit. What was the pre-op finding? It means I will re-report that study. And I will emphasize to the part that are important, surgical procedure, what was done, because most of the time I've watched the surgery as well. So there was a magic stitch between P3 and the commissioner to solve that MR. And in post-op, there was no SAM. So what we should emphasize in the post-op study, for example, I wrote it here, and I gave an image number that if they want to go back and look at it again. And how was the final report? This is the magic stitch or corporate here. And always in my QI report, I have a part that is an educational comment, and this educational comment is related to that special study. And I always use the latest paper published about that part. That's the reason that I have to review the papers very well myself. So pre-discharge, transtrosy, how was? I look at it always, pre-discharge, echo of that patient. That's the reason that I do the review one week after that surgery to have the post-op transtrosy as well. And I do my conclusion. I will send this report, return report to the staff and the fellows, and I see it to the director of a PEG program that is Annette. And this QI report qualifies for Royal College CME as well. So most of our staff are using and I use it myself. The question that should be answered, do we expect the quality of the echo be exactly like a quality of the echo that cardiologists are doing in the echo lab? For sure, no, because we don't have enough time in the war. And the training of our team is different from cardiologists. I am cardiologist myself. And has there been any improvement of tea quality during this program, these two or three years? Yeah, I see the constant improvement. And many times I am inside the war as well, watching the tea that the staff are doing. So what time our staff do the best? What part? Probably the completeness of the study. The study are very complete, started from IVC going to the Ayurvedic arch at the end. So our very complete study, compared to the study that we as a cardiologist, we do it, we do tea mainly a goal oriented study. The part that is not very good is image acquisition. And the reason is clear because our fellow are the first operators, some of them are new, their study quality will be much, much better at the end of the fellowship. But at the beginning, sometimes it's not very good. But we have to deal with this. And the improvement should be mainly an image interpretation and completeness of the report. And we should supervise the fellows more when they generate the report. Let me show you a couple of examples that there were error, challenge, and pitfalls. The case number one was a 24 year old man with a known history of unicast with the aortic valve and had a biopsygic aortic valve replacement. You might ask me why 24 year old has a biopsygic valve? That was the wish of the patient himself. And immediate post-op tea, you see this AI. So always the question is, is this AI valvular or paravalvular? We use explain to show it, this explain, you see the swing ring here, you see the AI is coming from inside the swing ring to jets. So it's a transvalvular that is a very common finding in the magna valve. You see the 3D of this. And as you see in the predisposition, it's still I believe that AI is there or two jets as we saw it in the war. But if you follow this patient, this AI will disappear. Eight months later, you see the valve, and you see that AI is not there or very, very trace. This is a very nice paper about transvalvular or pre-transprosthetic AI in a magna valve in the war. They describe it why we have it in this paper that was about 700 patient. They believe the cause of that is this fabric between the ring and the strut. This fabric, it will leak. Most of the time, it will close after protamine, but some of them will stay and will be closed in couple of months. This is the design of this valve, Hancock is a pulsing valve, doesn't have usually commercial leak, but magna valve and Avalus valve, they have a leak, magna is more Avalus has it as well. Case number 268, you're old man, excuse me, refer to our hospital for AVR, interop T was done. This is pre-op, you see the patient has AS and mild AI, calcific AOT valve. And this patient had a magna again, AVR. Immediate post-op, you see a turbulence at the LVOT and you see some AI, more close, that's a transvalver AI. Here you see, like previous case, the AR is transvalver, but it's too much. It's not mild, it's like a moderate or moderate to severe. That's a trans-gastric view, you see the valve has a turbulence and has lots of AI. And this is the gradient across the valve, very high gradient, and you see this dense part that because of the flow of the AI, is a high as well. So this patient has a almost severe AS and moderate to severe AR. Should we accept the result? Of course no, but this result was accepted, was discussed with the surgeon and the team accepted and the patient was transferred to the ICU, was extubated at first and then re-intubated a couple of hours later, was a hypoxic and was not doing fine. On day three had another TE and this severe AI was shown much, much better than interop and patient had to come back to the ward on day three. So the cause for that AI it was not just a simple commissure AI, the cause was when the surgeon did a root enlargement during the closure of this patch, the surgeon interrupts the leaflet of the biopasic valve as well. So that was the cause of the AI and was redo again another valve and it was okay. The case 355, an old woman had bicuspid AVR due to severe AS. Immediately post up, beside the valve always look at the LV and RV function. Here RV is very good and after couple of minutes RV deteriorated quickly and this was picked very well by our fellow Rebecca and she told the surgeon RV is not doing fine. He is down severely so surgeon decided to go back and do the bypass of the right corner. Came off you see the RV improvement. So this was a very good pickup beside the check for valve always check RV and LV function. Case number 4, 71 year old man had a biopasic AVR due to bicuspid AVR severe AS, trivial AR and post up we saw this little tissue moving here and we saw this is a good AI. So we told the surgeon probably the leaflet of this new AVR is turned so and the AI is too much. So he went back and again here shows that the AI is coming from the area of the left main but still we saw that the AI is because of the turn leaflet surgeon went back couldn't find any turn leaflet took that small tissue out came off and again was the same AI he said it's not okay he went back again and check the valve and this time he found the hole above the valve there was a hole just below the left main coronary artery that was communicating between aortic root and the LV and acting like AI. So this was a eutrogenic hole he closed the hole but still at the end we had this AI here is now more clear this is trans-gasic this AI is outside the ring because there is a communication between here that is a left main below the left main to the LV and so the result was not good this patient develops this simulator and pass the replacing 59 year old woman under one biopsyc MVR in our center you see in the post-stop this is a MVR a small flow is here and the team accepted this and so this is just a small part of our leak year later the patient came back with fatigue and when they did the trans-gasic echo they saw the lateral wall and on the wall is hypo and they did in the echo lab they found this leak is much much more than before and it's a continuous it's not part of our MVR that is systolic this is continuous flow this is a very nice sweep of that flow you see the flow is from circumflex and going to the LA so this was a damage of the circumflex that was not picked up in the war so this is a year after you see again a nice sweep shows the flow continuous flow from circumflex to the LA a damage to the circumflex during my toe valve repair or replacement happens it's not common it's about less than one person and this is the only case that we had during that last three years this couple of paper about the damaging of circumflex during the my toe valve repair or replacement in summary comprehensive approach to the qi in perioperative tea can improve the quality of the studies performed by the perioperative tea team it is very important to perform a complete exam in a systemic manner for all patients whenever is possible interoperative echocardiography should be an integral and active part of the heart team for decision making clear communication and having a common language with the surgical team are crucial to overcome the challenges and possible complications that may occur in the course of the surgery ideally more studies should be reviewed by the qi program however the main challenge is the time limit as each case review takes between two to three hours in order to be significant scientifically grounded comprehensive and educational for the related staff and fellows and of course we need always the feedback from the staff cardiac anesthetist in the war that I send the case for them thank you very much