Diagnosis of an iatrogenic complication using intraoperative transoesophageal echocardiography after coronary artery bypass graft surgery

Abstract

IntroductionThe systematic use of intraoperative transesophageal echocardiography (iTEE) is a matter of debate and controversy. We describe a case showing the usefulness of iTEE for the diagnosis of a life-threating complication during an urgent Coronary Artery Bypass Graft (CABG) surgery.MethodsAn 82-year-old man was admitted in our center with a non-ST-segment elevation myocardial infarction. The coronary angiogram revealed a severe three vessel coronary disease. The patient underwent an on-pump CABG surgery through a median sternotomy approach and a total mammary technique was employed.ResultsThe left anterior descending artery was intramyocardial and its dissection was complicated with a laceration of the free wall of the right ventricle (RV). The cardiac surgeon quickly sutured the laceration and infiltrated sealant fibrin into the myocardium and finally, he sprayed the fibrin on the surface of the anatomical defect.The weaning of the Cardiopulmonary Bypass (CPB) was without incidences. However, immediately after the administration of protamine, the patient had a severe hypotension refractory to vascular filling and to high doses of vasoconstrictor agents. iTEE examination showed a echogenic mobile mass inside of the RV outflow tract. This mass progressively the mass progressively progressed towards the pulmonary valve with each RV contraction. It was decided to return to CPB for exploration of the RV cavity through the tricuspid valve and extraction of the floating mass.DiscussionIn this case, the use of iTEE during CABG surgery modified the normal course of procedure and allowed the early detection of a serious perioperative complication, avoiding a possible fatal outcome in the patient. The systematic use of intraoperative transesophageal echocardiography (iTEE) is a matter of debate and controversy. We describe a case showing the usefulness of iTEE for the diagnosis of a life-threating complication during an urgent Coronary Artery Bypass Graft (CABG) surgery. An 82-year-old man was admitted in our center with a non-ST-segment elevation myocardial infarction. The coronary angiogram revealed a severe three vessel coronary disease. The patient underwent an on-pump CABG surgery through a median sternotomy approach and a total mammary technique was employed. The left anterior descending artery was intramyocardial and its dissection was complicated with a laceration of the free wall of the right ventricle (RV). The cardiac surgeon quickly sutured the laceration and infiltrated sealant fibrin into the myocardium and finally, he sprayed the fibrin on the surface of the anatomical defect. The weaning of the Cardiopulmonary Bypass (CPB) was without incidences. However, immediately after the administration of protamine, the patient had a severe hypotension refractory to vascular filling and to high doses of vasoconstrictor agents. iTEE examination showed a echogenic mobile mass inside of the RV outflow tract. This mass progressively the mass progressively progressed towards the pulmonary valve with each RV contraction. It was decided to return to CPB for exploration of the RV cavity through the tricuspid valve and extraction of the floating mass. In this case, the use of iTEE during CABG surgery modified the normal course of procedure and allowed the early detection of a serious perioperative complication, avoiding a possible fatal outcome in the patient.