Role Of Intraoperative Transesophageal Echocardiography Research Articles

Management of Aortic Valve Bypass Surgery

The 3 leading causes of aortic stenosis (AS) in adults are calcific degeneration of a normal trileaflet aortic valve (AV), calcific degeneration of a congenital bicuspid AV, and rheumatic AS. Therapeutic options in patients with severe AS include aortic valve replacement (AVR), transcatheter aortic valve implantation (TAVI), or aortic valve bypass (AVB). An AVB involves the placement of a valved conduit between the apex of the left ventricle and the descending thoracic aorta. AVB serves as a useful alternative to treat severe AS in patients deemed high risk for conventional AVR (ie, porcelain aorta, previous cardiac surgery) or TAVI (ie, severe aorto-iliac disease, limited experience, lack of hybrid operating room). Advantages of on-pump AVB include the avoidance of aortic cannulation, cross-clamping, and cardioplegic cardiac arrest. The procedure can also be performed without cardiopulmonary bypass. In this article, the authors review the circulatory physiology, perioperative anesthetic management, the role of intraoperative transesophageal echocardiography, and surgical considerations of AVB surgery through 3 cases.

Giant right coronary artery aneurysm with unusual physiology: Role of intraoperative transesophageal echocardiography

A 65-year-old woman presented with a history of dyspnea and atypical chest pain. She was diagnosed with a non-ST-segment elevation myocardial infarction due to a giant right coronary artery aneurysm. After a failed percutaneous embolization, she was scheduled for right coronary artery aneurysm resection, posterior descending artery revascularization and mitral valve repair. During the induction of anesthesia and institution of mechanical ventilation, the patient suffered cardiovascular collapse. The transesophageal echocardiographic examination revealed tamponade physiology owing to compression of the cardiac chambers by the unruptured aneurysm, which resolved with the sternotomy. The surgery was carried out uneventfully.

Unmasking of patent ductus arteriosus on cardiopulmonary bypass: Role of intraoperative trans-esophageal echocardiography in a patient with severe pulmonary hypertension due to pulmonary vein stenosis and cor triatriatum

Unmasking of patent ductus arteriosus on cardiopulmonary bypass: Role of intraoperative trans-esophageal echocardiography in a patient with severe pulmonary hypertension due to pulmonary vein stenosis and cor triatriatum

The Role of Intraoperative Transesophageal Echocardiography in Robotic Mitral Valve Repair

Robotic mitral valve (MV) repair is a new surgical technique that uses small incisions. Previous studies have demonstrated the importance of intraoperative transesophageal echocardiography (TEE) for conventional MV surgery with the use of a median sternotomy incision. The aim of the present study was to delineate the utility of intraoperative TEE in robotic MV repair. Intraoperative TEE was performed in 22 consecutive patients undergoing robotic MV repair for severe degenerative mitral regurgitation (MR) over a period of 2 years. Before cardiopulmonary bypass (CPB), TEE was used to define the lesions of degenerative MR and the localization of the prolapsed leaflets, and to evaluate the severity of MR. During establishment of peripheral CPB, TEE was used to guide placement of the cannulae in the inferior vena cava (IVC), superior vena cava (SVC), and ascending aorta (AAO). After weaning from CPB, TEE was used to assess immediately the competency of the surgical repair. Agreement between TEE and surgical findings was excellent: 92.3% (kappa, 0.873) for the lesions of degenerative MR, and 98.5% (kappa, 0.943) for the localization of the prolapsed leaflets. Under TEE guidance, all the cannulae (100%) in the SVC, IVC, and AAO were placed correctly. TEE demonstrated all the patients (100%) had successful robotic MV repairs. Intraoperative TEE is a valuable adjunct in the assessment of robotic MV repair. (Echocardiography 2011;28:85-91).

SHA 47. Residual lesions after pediatric cardiac surgery: Role of intraoperative transesophageal echocardiography

SHA 47. Residual lesions after pediatric cardiac surgery: Role of intraoperative transesophageal echocardiography

Tricuspid valve excision using off-pump inflow occlusion technique: Role of intra-operative trans-esophageal echocardiography

A pacing system infection may lead to infective endocarditis and systemic sepsis. Tricuspid valve surgery may be required if the valve is severely damaged in the process of endocarditis. Although, cardiopulmonary bypass is the safe choice for performing right-heart procedures, it may carry risk of inducing systemic inflammatory response and multi-organ dysfunction. Some studies have advocated TV surgery without institution of CPB. We report tricuspid valve excision using the off-pump inflow occlusion technique in a 68-year-old man. We also describe role of intra-operative TEE as a monitoring tool at different stages of the surgical procedure.

Double Chamber Right Ventricle in a Patient With Supracristal Ventricular Septal Defect and Prolapsing Right Coronary Cusp: Role of Intraoperative Transesophageal Echocardiography

A supracristal ventricular septal defect (VSD), an outlet VSD situated in subaortic and subpulmonic regions, has a strong association with prolapse of the aortic valve cusp. The authors report the case of a patient operated for a supracristal VSD with prolapse of the right coronary cusp. The VSD was found to be in the subaortic position on preoperative transthoracic echocardiography, which failed to detect the presence of a double-chamber right ventricle. Intraoperative transesophageal echocardiography correctly recognized the supracristal nature of the VSD and identified the double-chamber right ventricle, subsequently altering the course of surgery.

Intraoperative transesophageal echocardiography is beneficial for hemodynamic stabilization during left ventricular assist device implantation in children

Mechanical circulatory support, with a left ventricular assist device (LVAD) is used in an increasing number of children for treatment of advanced heart failure as bridge-to-transplant. To date no data are available and no studies have defined the role of intraoperative transesophageal echocardiography (TEE) for hemodynamic stabilization during Centrimag Levitronix centrifugal pump implantation in children. Children with therapy resistant heart failure, undergoing LVAD implantation using Berlin Heart Excor pediatric cannula connected to a Levitronix Centrifumag pump, are intraoperatively monitored using an Oldelft micromultiplane TEE. Intraoperative TEE is specially used to monitor right ventricular (RV) and left ventricular (LV) function, correct position of the cannulas and response to pharmacological treatment. In five consecutive patients RV function was assessed by TEE after starting LVAD Levitronix centrifugal pump. Initial RV failure presents with RV dilation and LV collapse. After titration of vasopressor and inotropic agents, RV contractility improved and thereby the filling of the LV. In one child, despite those measures the RV showed no improvement by TEE and a Levitronix right ventricular assist device to support the RV function was implanted as well. All patients could hemodynamically be stabilized before transport to the intensive care unit. The complex interaction of the RV and LV function and correct positioning of the cannula, during LVAD implantation in children with end-stage cardiac failure is improved by simultaneous visualization of cardiac performance of both ventricles and cannula positioning by means of intraoperative multiplane TEE.

A Left Ventricular–to–Right Atrial Shunt in a Patient With a Perimembranous Ventricular Septal Defect: Role of Intraoperative Transesophageal Echocardiography

ADHESION OF TRICUSPID valve leaflets around margins of a perimembranous ventricular septal defect (VSD) gives rise to aneurysmal transformation of the membranous septum, which partially or completely occludes blood flow through the VSD. A case of a perimembranous VSD with a left ventricular–to–right atrial (LV-to-RA) shunt, which was misinterpreted as a tricuspid regurgitation (TR) jet on preoperative transthoracic echocardiography (TTE), is reported. Correct diagnosis was made by intraoperative transesophageal echocardiography (TEE).

The Role of Intraoperative Transesophageal Echocardiography in Management of Cardiac Anesthesia

術中経食道心エコー (IOTEE) は心臓大血管手術において必要不可欠な診断機器としてだけではなく, 心臓大血管手術麻酔の管理においても大変有用性の高いモニターであり, 拡張機能を含めたリアルタイムでの心機能や心室内容量の評価が可能である. 従来, 左心室容量の評価に肺動脈カテーテルが利用されていたが, その解析や治療方法の選択にばらつきが多いため, 近年, IOTEEが心臓大血管麻酔管理における血行動態モニターとして日常的に利用されるようになった. さらに, IOTEEの情報を心臓外科医と共有することで, 体外循環離脱時の薬剤の適切な選択や麻酔管理の戦略に応用することも可能である. IOTEEは比較的安全な機器ではあるが, 適切に使用することがIOTEEに関連する合併症の防止には肝要である. IOTEEの技術や知識を効率的に蓄積し, 実践できるようなトレーニングシステムを構築し, 客観的な評価を通して, 心臓外科医や集中治療医とこれらの情報を共有すれば, 循環器疾患に対する包括的な理解とともに, 心臓大血管手術患者に対する周術期管理の質をさらに向上させることができると考えられる.

Role of intraoperative transesophageal echocardiography in patients undergoing noncardiac surgery

Major perioperative cardiac complications, including cardiac death, nonfatal myocardial infarction and nonfatal cardiac arrest, can occur in patients undergoing noncardiac surgery. To reduce the risk of these complications, some authors have reported on the utility of intraoperative transesophageal echocardiography as a complementary monitoring tool in noncardiac surgery. However, although this approach is now well established in patients undergoing cardiac surgery, there are no guidelines for intraoperative transesophageal echocardiography application in noncardiac surgery, and little literature exists on patient outcome, logistics, financial impact, medico-legal implications and safety. In this review, we discuss published information about the use of intraoperative transesophageal echocardiography during noncardiac surgery with an attempt to clarify whether this approach may offer potential benefits compared with conventional intraoperative monitoring systems. In addition, perioperative risk determinants in noncardiac surgery are briefly summarized and information derived from intraoperative transesophageal echocardiography for evaluation of cardiac morphology and function is schematically presented.

A Case of Catastrophic Pulmonary Vasoconstriction After Protamine Administration in Cardiac Surgery: Role of Intraoperative Transesophageal Echocardiography

A Case of Catastrophic Pulmonary Vasoconstriction After Protamine Administration in Cardiac Surgery: Role of Intraoperative Transesophageal Echocardiography

Prediction of Early Pulmonary Artery Stenosis after Arterial Switch Operation: The Role of Intraoperative Transesophageal Echocardiography

Objectives: To investigate prospectively the prediction of the neopulmonary stenosis (neo-PS) after arterial switch operation (ASO) for transposition of the great artery (TGA) with intraoperative transesophageal echocardiography (TEE). Methods: Infants with TGA undergoing the ASO were prospectively studied over 5 years. The neo-PS was defined when the peak flow velocity was over 3 m/s at the neo main pulmonary artery (neo-MPA) after ASO by TEE (TEEPS). Catheterization was performed if estimated peak neo-PS pressure gradient was over 40 mm Hg by transthoracic echocardiography. Balloon angioplasty was tried first and surgical reoperation was reserved for those with failed angioplasty. Results: In total 49 consecutive patients were enrolled into the cohort study. TEEPS was identified in 21 patients. For patients with TEEPS, freedom from reintervention was 28% at 1 year and 23% at 2 years. For patients without TEEPS, freedom from reintervention for PS was 92% at 1 year and 78% at 2 years. The time interval from ASO to reintervention was significantly shorter in patients with TEEPS than without TEEPS. Existence of TEEPS and non-Lecompte method were main risk factor for reintervention. Conclusion: The present study demonstrated that the application of intraoperative TEE for infants undergoing ASO is very helpful in predicting the development of early postoperative neo-PS.

Role of intraoperative transesophageal echocardiography in coronary artery bypass grafting

Transesophapeal echocardiography (TEE) can be used as a diagnostic tool during cardiac surgery to direct the surgical procedure and diagnose unanticipated problems. TEE has also been one of the most important means of monitoring myocardial ischemia during coronary artery bypas grafting procedures. The cardiac anesthesiologist can apply intraoperative TEE in evaluating coronary artery anatomy and aorta atherosclerosis, assessing diastolic left ventricular function and preload, measuring intracardiac pressure and cardiac output, detecting ischaemic mitral regurgitation, intracardiac air and pericardial effusion.

Critical Role of Intraoperative Transesophageal Echocardiography for Detection of Extrapulmonary Thromboemboli during Surgical Pulmonary Embolectomy

Critical Role of Intraoperative Transesophageal Echocardiography for Detection of Extrapulmonary Thromboemboli during Surgical Pulmonary Embolectomy

Critical Role of Intraoperative Transesophageal Echocardiography for Detection of Extrapulmonary Thromboemboli during Surgical Pulmonary Embolectomy

We read with great interest the excellent case report by Espeel et al. 1that describes two patients experiencing pulmonary embolism with additional extrapulmonary thrombi requiring surgical intervention. The positive outcome of both patients corroborates the favorable experience in patients from our institution undergoing surgical pulmonary embolectomy.2We agree with the authors that intraoperative transesophageal echocardiography is a relatively safe and noninvasive diagnostic modality that allows early detection of intracardiac thrombi. However, we were surprised that the importance of transesophageal echocardiography for the guidance of surgical extraction was not emphasized in this case report. We recently demonstrated that extrapulmonary thromboemboli can be present in the right heart and the vena cava in up to 26% of all patients with massive pulmonary embolism undergoing pulmonary embolectomy.3Such extrapulmonary thromboemboli may have a significant impact on the surgical procedure, because they may influence cannulation placement and surgical technique during the operation. For example, it may become necessary to perform circulatory arrest in order to evacuate thrombi from the inferior vena cava. Moreover, extrapulmonary thromboemboli that remain unrecognized and are not surgically removed can become the source of recurrent pulmonary embolism.4Therefore, we believe that intraoperative transesophageal echocardiography is not only an excellent tool for hemodynamic monitoring5and management of acute right heart failure6during surgical pulmonary embolectomy, but should also be considered an important diagnostic tool to detect concurrent extrapulmonary thrombi and should guide their surgical extraction.*Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. prosenberger1@partners.org

Role of Intraoperative Transesophageal Echocardiography for Diagnosing and Managing Pulmonary Embolism in the Perioperative Period

Role of Intraoperative Transesophageal Echocardiography for Diagnosing and Managing Pulmonary Embolism in the Perioperative Period

Role of Intraoperative Transesophageal Echocardiography in Patients Having Coronary Artery Bypass Graft Surgery

Background Previous studies have shown that intraoperative transesophageal echocardiography provides important preoperative and postoperative information in various cardiac and noncardiac surgeries that may alter patient management and outcome. The role of intraoperative transesophageal echocardiography in patients in whom isolated coronary artery bypass graft surgery is anticipated has been reported only in small selected groups. This study was designed to prospectively evaluate the role of intraoperative transesophageal echocardiography in a large, nonselected group of patients undergoing primarily coronary artery bypass graft surgery. Methods From January 2001 to December 2003, 474 consecutive patients (76% men, 24% women) aged 30 to 89 years (mean age of 70 ± 10 years) who were undergoing coronary artery bypass graft surgery had prebypass and postbypass intraoperative transesophageal echocardiography. New findings and alterations in the surgical plan were documented prospectively. Results New prebypass findings were found in 10% of patients, and the surgical plan was altered in 3.4% of patients. New postbypass findings were found in 3.2% of patients, altering the surgical plan in 2% of patients. Conclusions This large consecutive, nonselected, prospective study reveals the significant impact of intraoperative transesophageal echocardiography in patients having coronary artery bypass graft surgery as a primary procedure. New findings (prebypass and postbypass) were found in 13% of patients overall, and the surgical plan was altered in 5.5% of patients. This study supports the use of intraoperative transesophageal echocardiography in patients undergoing primarily coronary artery bypass graft surgery.

Impact of intraoperative transesophageal echocardiography in patients undergoing valve replacement

Background The role of intraoperative transesophageal echocardiography (IOTEE) in valve replacement surgery is not well established. The aim of this study was to explore the impact of immediate postpump IOTEE in valve replacement surgery at a single tertiary medical center. Methods The departmental database was screened for valve replacement operations (mechanical or bioprosthetic valves) performed during a 55-month period that were succeeded by immediate postpump IOTEE. Data was gathered regarding the impact of IOTEE on the immediate postoperative course. Results The study group included 417 patients (44.8% male, 55.2% female, age 65.2 ± 13.9 years). Prepump IOTEE was performed in 352 patients (84.4%). A single valve was replaced in 336 patients (80.6%) and two or more valves were replaced in 81 patients (19.4%). Overall 501 valves were inserted: mitral, 237 (131 mechanical, 106 biological); aortic, 221 (89 mechanical, 132 biological); tricuspid, 43 (2 mechanical, 41 biological). Unexpected pathologic echocardiographic findings on postpump IOTEE necessitated immediate surgical correction in 15 patients (3.6%): perivalvular leak in 8 patients (4 mitral, 4 aortic), immobilized leaflet in 4 patients (3 mitral, 1 tricuspid), coronary obstruction by an aortic bioprosthesis in 2 patients, and incompetent xenograft in 1 patient. Prolonged removal of air was necessary in 45 patients (10.8%). In 47 patients (11.3%) the postpump IOTEE contributed to the evaluation of difficult weaning from the bypass pump and to its appropriate therapeutic management (volume expansion, inotropic agents, vasodilators, or mechanical assistance). Conclusions Immediate postpump IOTEE is an important diagnostic and therapeutic role in valve replacement surgery and should be widely implemented.

Successful surgical repair of a giant left main coronary artery aneurysm with arteriovenous fistula draining into a persistent left superior vena cava and coronary sinus: role of intraoperative transesophageal echocardiography

We report the case of a 74-year-old woman with a history of hypertension, hypercholesterolemia, and pacemaker who presented to the hospital with new onset New York Heart Association class IV congestive heart failure. Transthoracic echocardiography revealed a markedly dilated right ventricle with normal right ventricular systolic function. There was moderate pulmonary hypertension with an estimated pulmonary artery systolic pressure of 60 mm Hg. Her echocardiogram 1 year earlier had demonstrated normal right ventricular size and systolic function, and no pulmonary hypertension. Additional transthoracic imaging with saline contrast study through a left peripheral vein demonstrated the presence of a dilated coronary sinus with a persistent left superior vena cava. Color Doppler demonstrated turbulent flow within the coronary sinus with evidence of significant left-to-right shunting. Cardiac catheterization revealed a massively dilated left main coronary artery aneurysm with an arteriovenous fistula into the left superior vena cava and coronary sinus. The calculated Qp/Qs was 2:1. The patient underwent 2 unsuccessful attempts at percutaneous intervention to occlude the arteriovenous fistula. She then underwent successful surgical closure of the coronary arteriovenous fistula. The important role of intraoperative transesophageal echocardiography in guiding this technically challenging surgical case is discussed.