Assessment of Coronary Blood Flow by Transesophageal Echocardiography.

Abstract

A 49-YEAR-OLD MALE presented in extremis after 3 weeks of malaise. Preoperative transthoracic echocardiography showed mild mitral regurgitation, mild pulmonic valve insufficiency (PI), and severe aortic insufficiency (AI) with a large mobile target on the aortic valve. Left heart catheterization confirmed the presence of severe AI and showed the presence of left-dominant circulation and the proximal occlusion of the left circumflex coronary artery (LCx) by a pseudoaneurysm of the aortic annulus lateral to the left coronary sinus of Valsalva (Fig 1). The patient was taken to the operating room for aortic valve conduit root replacement with coronary reconstruction (Bentall procedure) and possible coronary artery bypass graft (CABG) of the LCx. The prebypass intraoperative transesophageal echocardiographic (TEE) examination confirmed the findings of the preoperative studies but also showed severe PI and wall motion abnormalities in the inferior and lateral walls, consistent with left-dominant coronary circulation and LCx ischemia (Video 1). The patient underwent a Bentall procedure with a 21-mm Medtronic Freestyle porcine root (Medtronic, Minneapolis, MN), pulmonic valve replacement with a 27-mm CarpentierEdwards Perimount Magna pericardial valve (Edwards Lifesciences, Irvine CA), and saphenous vein harvest in anticipation of possible CABG. After excision of the aortic root pseudoaneurysm, the LCx artery looked normal during surgical inspection. Therefore, the decision was made to forego grafting of the LCx. The patient was successfully weaned from cardiopulmonary bypass (CPB). After the patient was weaned from CPB, TEE showed well-positioned and well-functioning aortic and pulmonic prosthetic valves but persistence of wall motion abnormalities in the LCx territory. Should CABG of the LCx be performed at this time due to the possibility of damage to the LCx after prolonged compression?