Initial misinterpretation of a transesophageal echocardiographic image: Potential for alteration of a planned minimally invasive procedure

Abstract

p ORT-ACCESS (Heartport, Redwood City, CA) is a new technique which can be used to repair or replace the mitral valve through a minithoracotomy with extracorporeal circulation. 1-3 Anesthetic management for Port-Access procedures requires, in addition to routine monitoring, the insertion of a double-lumen endotracheal tube (DLT), a pulmonary artery venting catheter, and a coronary sinus catheter. 4-6 Transesophadeal echocardiography (TEE) is required for several reasons: 7,8 (1) TEE is used to examine the patient's systolic, diastolic, and valvular function 9-12 before going on cardiopulmonary bypass (CPB). This information is useful for surgical decision-making. (2) A pulmonary artery vent and a coronary sinus catheter are positioned under fluoroscopic and TEE guidance. (3) Proper placement of the venous cannula of the extracorporeal circuit in the superior/inferior caval vein is confirmed with TEE. (4) The correct position of the Endoaortic Clamp (Heartport), an aortic balloon catheter to occlude the aorta and deliver cardioplegic solution in the aortic root, is confirmed with TEE. (5) Finally, after CPB, the adequacy of mitral valve repair or replacement (MVR) is evaluated using TEE. 13 The case reported below demonstrates the need for the anesthesiologist to be very knowledgeable about TEE, because misinterpretations can lead to inappropriate surgical procedures.