Routine Intraoperative Transesophageal Echocardiography Research Articles

Intraoperative intracardiac thrombus in liver transplantation: A 9-year retrospective review focusing on treatment and outcomes.

This study characterizes incidence and outcomes surrounding intracardiac thrombosis (ICT) during liver transplantation over 9 years at a single center before and after the routine use of transesophageal echocardiography (TEE). Adult liver transplantation patients from 2011 to 2020 were divided into eras based on routine TEE use. ICTs were identified by querying anesthetic records for search terms. Descriptive statistics included counts and proportions for baseline recipient, donor, intraoperative, and postoperative characteristics. Outcome data were based on date of hospital discharge and date of death. The incidence of ICT increased in the TEE era (2016-2020) compared with the pre-TEE era (2011-2015; 3.7% [25/685] vs. 1.9% [9/491]; p < 0.001). Patients with ICT had significantly higher Model for End-Stage Liver Disease-sodium (MELD-Na) scores, pretransplant hospitalization, malignancy, drug-induced liver injury, hypertension, deep vein thrombosis, reperfusion syndrome, transfused platelets and cryoprecipitate, and use of hemostatic medications. A higher proportion of patients in the ICT group underwent simultaneous liver-kidney transplantation. The patients with ICT were similar, except patients in the pre-TEE era had higher MELD-Na scores and incidences of hepatitis C virus and lower incidences of encephalopathy. In the pre-TEE era, all ICTs presented as intraoperative cardiac arrest, and the 30-day mortality in the setting of ICT was 66.7% (6/9). During the TEE era, 80% of ICTs were diagnosed incidentally or attributed to hemodynamic instability (p=0.002). The 30-day mortality rate was 36% (9/25) in the TEE era (p=0.25). ICT incidence increased in the TEE era, yet the mortality rate was lower, suggesting that routine intraoperative TEE may lead to the early detection of ICT prior to hemodynamic collapse.

Interdisciplinary approach to surgical treatment for patients with hypertrophic obstructive cardiomyopathy

Hypertrophic cardiomyopathy (HCM) – is the most common genetically determined heart disease, characterized by symmetrical or asymmetrical myocardial thickening (≥15 mm), leading to progressive heart failure and a high risk of sudden cardiac death (SCD). Diagnosis, natural course and treatment of HCM have become sources of uncertainty, misunderstanding and debate due to the increasing complexity of diagnosis in clinical practice, international differences in strategic approaches, advances in the treatment of genetic diseases and cardiac imaging. The aim. To amplify the current concept of HCM pathogenesis and mechanisms of the left ventricular outflow tract (LVOT) obstruction as well as to highlight our own results of HCM surgical correction. Materials and methods. A total of 330 HCM patients underwent surgical correction (septal myectomy) in the National M. Amosov Institute of Cardiovascular Surgery affiliated to National Academy of Medical Sciences of Ukraine. The mean age of the patients was 49.7 ± 15.0 years, median – 53; 168 (50.9 %) were male. Results. Surgical correction of HCM significantly improves the quality of life (80 % of patients were in NYHA II functional class after correction), reduces the symptoms of heart failure (93 % of patients had minimal mitral regurgitation after septal myectomy), decreases LVOT systolic pressure gradient (SPG) (the mean SPG was 18.9 ± 8.5 mmHg versus preoperative 93.6 ± 23.2 mmHg) and lowers the high-risk for SCD in the patients (the mean percentage of high-risk group was 3.78 % after correction). Routine CT planning and intraoperative transesophageal echocardiography helps to avoid severe iatrogenic complications and resect the interventricular septum as accurately as possible, completely eliminating LVOT obstruction. Conclusions. Secondary abnormal chordal attachment cutting, papillary muscle realignment and anterior mitral leaflet plication along with septal myectomy allows to fully correct all phenotype of HCM, is the safe and effective procedure as well as the definitive method of this pathology treatment minimizing the risk of disease recurrence.

Cost-effectiveness of routine transoesophageal echocardiography during cardiac surgery: a discrete-event simulation study

BackgroundThe aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used. MethodsThe impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost–effectiveness ratio of €30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness. ResultsRoutine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation. ConclusionsRoutine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events.

Emergent Management of Intracardiac Thrombosis during Liver Transplantation.

Intraoperative thromboembolism is a well-documented complication associated with orthotopic liver transplantation (OLT) but its identification and intraoperative treatment are still an emerging topic in anesthesia. Intracardiac thrombus during OLT is associated with a high mortality rate. There are only a few reports describing the successful management of thromboembolism during OLT. We describe a case where routine intraoperative transesophageal echocardiography during a live donor liver transplantation enabled early detection of an intracardiac thrombus with subsequent successful heparin treatment. Our case suggests that if an intracardiac thrombus is identified early (before hemodynamic instability occurs), the use of IV heparin may be a safe therapeutic option.

The Value of a Systematic Transesophageal Echocardiography Examination: An Isolated Finding mimicking a Pleural Effusion

ABSTRACT An interesting case report of presumed pleural fluid collection observed during routine intraoperative transesophageal echocardiography examination is presented here. Acquisition of an isolated image without giving due consideration to the technique used in obtaining that image may be misleading and result in avoidable patient intervention. How to cite this article Kunju SAM, Rapchuk IL. The Value of a Systematic Transesophageal Echocardiography Examination: An Isolated Finding mimicking a Pleural Effusion. J Perioper Echocardiogr 2016;4(2):64-66.

Routine intra-operative trans-oesophageal echocardiography yields better outcomes in surgical repair of CHD.

Trans-oesophageal echocardiographic imaging is valuable in the pre- and post-operative evaluation of children and adults with CHD; however, the frequency by which trans-oesophageal echocardiography guides the intra-operative course of patients is unknown. We retrospectively reviewed 1748 intra-operative trans-oesophageal echocardiograms performed between 1 October, 2005 and 31 December, 2010, and found 99 cases (5.7%) that required return to bypass, based in part upon the intra-operative echocardiographic findings. The diagnoses most commonly requiring further repair and subsequent imaging were mitral valve disease (20.9%), tricuspid valve disease (16.0%), atrioventricular canal defects (12.0%), and pulmonary valve disease (14.1%). The vast majority of those requiring immediate return to bypass benefited by avoiding subsequent operations and longer lengths of hospital stay. A total of 14 patients (0.8%) who received routine imaging required further surgical repair within 1 week, usually due to disease that developed over ensuing days. Patients who had second post-operative trans-oesophageal echocardiograms in the operating room rarely required re-operations, confirming the benefit of routine intra-operative imaging. This study represents a large single institutional review of intra-operative trans-oesophageal echocardiography, and confirms its applicability in the surgical repair of patients with CHD. Routine imaging accurately identifies patients requiring further intervention, does not confer additional risk of mortality or prolonged length of hospital stay, and prevents subsequent operations and associated sequelae in a substantial subset of patients. This study demonstrates the utility of echocardiography in intra-operative monitoring of surgical repair and highlights patients who are most likely to require return to bypass, as well as the co-morbidities of such manipulations.

Incidental finding of cardiac papillary fibroelastoma of the left ventricular outflow tract, associated with rheumatic mitral and tricuspid stenosis

Cardiac papillary fibroelastomas (CPFs) are one of the most common benign cardiac tumours. However, due to their location and pedunculated nature, they are associated with substantial complications secondary to systemic embolization or coronary ostial obstruction. Surgical resection should be offered to all patients when the mass is >1 cm in diameter. Valve-sparing excision produces good long-term results in most instances. We present the case of a young female scheduled for elective mitral and tricuspid valve replacement and maze procedure for chronic atrial fibrillation. A CPF was incidentally discovered during routine intraoperative transoesophageal echocardiography with an unusual location; at the left ventricular outflow tract.

Impact and Cost Effectiveness of Routine Intraoperative Transthoracic and Transesophageal Echocardiography on Surgical Decision Making in Pediatric Cardiac Surgery

ABSTRACTIntroductionCongenital heart diseases (CHD) present with wide spectrum of lesions leading to diagnostic dilemmas and it is quite possible to miss correct diagnosis during preoperative transthoracic echocardiography (TTE) in an inadequately sedated child, especially in a busy outpatient setting. It is a routine practice in our center to do baseline TTE after induction of anesthesia followed by pre and postcardiopulmonary bypass (CPB) transesophageal echocardiography (TEE) in all CHD patients thus helping us review our surgical plan.Materials and methodsAll pediatric patients &lt;18 years undergoing cardiac surgery from January 2013 to December 2013 at our tertiary care center in whom perioperative echocardiograhy was done were included. Appropriate sized TTE and TEE probes were used with the Philips iE33 echocardiography platform (Philips, Andover, MA).ResultsOut of total 352 pediatric cardiac surgical patients, perioperative echocardiography was done in 347(98.5%) patients. Baseline TTE showed new findings leading to change in surgical plan in 11 (3.1%) patients while additional new findings in baseline TEE were seen in 9 (2.6%). Post bypass TEE showed residual lesions requiring a CPB rerun in 19 (5.5%) patients. Intraoperative echocardiography was found to be cost effective with an estimated savings per patient of ₹ 3950 to 5373($61 - 83).ConclusionIntraoperative echocardiography is an important tool in armamentarium of perioperative physician which can be used to review diagnosis and help to formulate an informed surgical plan. Post-bypass transesophageal echocardiography is also useful as it identifies the residual lesions and establishes anatomical correction, which ultimately translates to lesser redo surgeries and a better postoperative outcome.How to cite this articleMishra A, Madhavan JS, Ghuman BPS, Raj R, Kumar A, Dutta V, Negi S, Tandon Y, Kumar A, Arya VK, Kumar B, Jayant A, Puri GD. Impact and Cost Effectiveness of Routine Intraoperative Transthoracic and Transesophageal Echocardiography on Surgical Decision Making in Pediatric Cardiac Surgery. J Perioper Echocardiogr 2014;2(1):3-9.

Accessory Mitral Valve—An Unexpected Intra–Operative TEE Finding Causing Left Ventricular Outflow Tract Obstruction in an Adult

There is a long-standing debate between proponents of routine intra-operative echo and those who want it restricted to selected groups of patients (such as those undergoing valve repair or correction of congenital abnormalities). We present a case where routine transesophageal echocardiography (TEE) identified completely unexpected pathology, with implications for the postoperative follow-up and for patient outcomes. A 64-year-old male, with a history of surgical repair of coarctation of the aorta in childhood, was admitted for elective valve replacement for severe aortic stenosis (AS). Previous transthoracic echocardiography had not identified any other pathology apart from AS, but routine intra-operative TEE picked up severe turbulence in the left ventricular outflow tract (LVOT). On further analysis this was due to 2 mechanisms: a localized subaortic membrane and a "cystic" mass attached to the anterior mitral leaflet, protruding into the LVOT in systole. Multiplane imaging of the mass disclosed an accessory mitral valve (MV), a rare congenital abnormality. The patient had excision of the stenosed aortic valve and of the subaortic membrane, while the accessory MV was spared, as the surgeon judged its removal might distort the mitral apparatus. Postoperative recovery was unremarkable and the patient went home with symptomatic improvement. This case illustrates the fact that even "standard" cardiac procedures can benefit from intra-operative TEE which, in our view, should be available for all patients who undergo heart surgery.

Impacto do ecocardiograma transesofágico intraoperatório na mortalidade em cirurgia de revascularização do miocárdio com circulação extracorpórea

To evaluate the rates of mortality and morbidity in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) using routine intraoperative transesophageal echocardiography (ITEE). We conducted a retrospective, observational review of medical records of 360 patients from April 2010 to April 2012. We analyzed: age, weight, height, gender, EuroSCORE, diabetes mellitus, ejection fraction and number of diseased vessels. Outcomes were compiled in intraoperative and postoperative (myocardial infarction, stroke, renal failure, hemodialysis, atrial fibrillation, length of stay in the intensive care unit). 53 patients were included, with 27 receiving monitoring; we excluded 307 individuals, as they were not operated by the same surgical team. The two groups were homogeneous for age, weight and gender. However, the ejection fraction was lower in the group submitted to ITEE (ITEE group 56.3% versus Non-ITEE group 65.9 ± 11%, p = 0.01). In patients not subjected to ITEE, mortality was higher (ITEE group 0% versus Non-ITEE group 7.6%, p = 0.01). There was no significant difference between groups as for the incidence of stroke, myocardial infarction, atrial fibrillation and acute kidney injury. The use of intraoperative transesophageal echocardiography in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass decreased perioperative mortality, warranted the use of inotropic drugs and vasodilators and contributed to a better patient outcome.

Routine Intraoperative Transesophageal Echocardiography: Impact on Intraoperative Surgical Decision Making, a Single Center Interim Analysis

ABSTRACTTransesophageal echocardiography (TEE) has become an important part of armamentarium for anesthesiologists in the management of patients undergoing cardiac surgery. Many studies have demonstrated the safety and utility of TEE in cardiac surgery. With advances in hardware and software, easy availability of resources for learning and optimal understanding of image generation and interpretation, many new findings crop up in the operating room (OR) which may have been missed in preoperative transthoracic echocardiography (TTE), leading to necessary changes in planned surgical procedure. In our retrospective analysis of 726 cases in which TEE was performed over the last 1 year, changes in decision was made in 65 (8.9%) of cases. This included 42 unanticipated findings prior to cardiopulmonary bypass and 23 new findings after CPB, requiring revision in 15 cases. With the increasing use and further impending advances of TEE, the number of cases in which surgical decision will be altered may increase in near future.How to cite this articleBadamali AK, Madhavan JS, Ghuman BPS, Subash S, Raj R, Mishra A, Mishra A, Arya VK, Kumar B, Jayant A, Shyam KST, Rana SS, Singh H, Mishra A, Kuthe S, Mahajan S, Prasad S, Mathew S, Arora I, Puri GD. Routine Intraoperative Transesophageal Echocardiography: Impact on Intraoperative Surgical Decision Making, a Single Center Interim Analysis. J Perioper Echocardiogr 2013;1(1):16-20.

The Role of Transesophageal Echocardiography During Surgery for Patients With Tetralogy of Fallot

Routine use of intraoperative transesophageal echocardiography (TEE) is a safe monitoring and diagnostic method during pediatric congenital cardiac surgery. However, the question of whether intraoperative TEE is accurate and cost effective for patients with tetralogy of Fallot (TOF) has not been raised. This study aimed to analyze the cost-benefit of routine TEE during the repair of TOF. The medical records, including TEE results, for patients who underwent correction of TOF between January 1997 and June 2007 were reviewed and retrospectively analyzed. Intraoperative TEE was performed for 340 patients (85 %). Residual problems were detected in 17.9 % (61/340), and a return to bypass was needed for 10 % (34/340) of the patients. The degree of agreement between the intraoperative TEE and early postoperative transthoracic echocardiography (TTE) was relatively high. Surgeons with less surgical experience more frequently used intraoperative TEE (p = 0.007) and performed repeat bypass surgery at a higher rate (p = 0.00). Even relatively unskilled surgeons might be able to achieve surgical outcomes similar to those of experienced surgeons using intraoperative TEE. By avoiding late surgical revision, the possible cost savings were estimated to be 1,726,000 Korean won (US$1,489) per TEE examination. Intraoperative TEE can be used as a tool for surgeons in making decisions in the operating room. In addition, intraoperative TEE decreased the frequency of reoperations and postoperative interventions. The results of this study demonstrate that routine intraoperative TEE during repair of TOF was both clinically beneficial and cost effective.

CASE 5—2012: Incidentally Detected Patent Foramen Ovale in A Patient Undergoing Aortic Valve Replacement: To Close or Not to Close?

g r ( a C r T b a n WITH THE INCREASING USE of routine intraoperative transesophageal echocardiography (TEE), cardiac anesthesiologists often discover a patent foramen ovale (PFO) in the operating room. Whether or not to repair the defect surgically is a difficult question to answer because this may involve altering surgical management (eg, converting from an off-pump technique to on-pump technique) and, thus, perhaps increasing surgical risk. Furthermore, noninvasive techniques (percutaneous closure in the catheterization suite) are available for closure as well. Lastly, depending on the physiologic effects and/or symptomatology, closure may not even be indicated clinically. This complex scenario is further complicated by the fact that the patient is unable to contemplate the risks and benefits of available options because he/she is under general anesthesia.

Evaluation of Tricuspid and Pulmonary Valves Using Epicardial and Transesophageal Echocardiography—A Comparative Study

To compare measurements obtained by transesophageal echocardiography (TEE) and epicardial echocardiography (EE) for evaluation of the tricuspid valve (TV) and pulmonary valve (PV). Prospective observational. University hospital. Patients undergoing elective coronary artery bypass grafting with or without aortic valve replacement. After routine intraoperative TEE, EE was performed to compare measurements obtained by the 2 methods. After institutional review board approval, 25 patients >18 years old were recruited. Biases with EE versus TEE for E and A waves were 11.9 cm/second (95% confidence interval [CI], 48.2 to -24.4) and 6.8 cm/second (95% CI, 28 to -15), respectively, and for E/A ratio was 0.08 (95% CI, 1.2 to -1). Pulmonary velocity bias was 57.94 cm/second (95% CI, 192.9 to -76.98), with higher values using EE. Bias for pulmonary trunk diameter was -0.31 cm (95% CI, 1.5 to -2.1). For quality of images, means were 2.4 (standard deviation [SD], 1.0) for EE and 2.3 (SD, 0.57) with TEE for TV and 2.4 (SD, 1.0) with EE and 2.5 (SD, 1.0) with TEE for PV. For the number of leaflets visualized, means were 2.2 (SD, 1.0) with EE and 2.5 (SD, 0.5) with TEE for TV and 2.5 (SD, 0.5) for EE and 1.3 (SD, 1.1) with TEE for PV. There was good agreement for Doppler measurements across TVs; however, measurements across PVs were significantly higher with EE versus TEE. TV Doppler measurements were difficult to acquire even for surgeons experienced in epiaortic scanning.

Case 4—2010Successful Use of Transesophageal Echocardiography After Esophagogastrectomy

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) commonly is used in the intraoperative management of patients undergoing cardiac surgery. Despite the increasing evidence that it generates new clinical findings in up to 40% of cases 1 Thys D.M. Echocardiography and anesthesiology successes and challenges. Anesthesiology. 2001; 95: 1313-1314 Crossref PubMed Scopus (17) Google Scholar , 2 Jneid H. Bolli R. Inotrope use at separation from cardiopulmonary bypass and the role of prebypass TEE. J Cardiothorac Vasc Anesth. 2004; 18: 401-403 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar and that surgical management is thereby altered in up to 25% of patients undergoing cardiac surgery, 3 Minhaj M. Patel K. Muzic D. et al. The effect of routine intraoperative transesophageal echocardiography on surgical management. J Cardiothorac Vasc Anesth. 2007; 21: 800-804 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar , 4 Eltzschig H.K. Rosenberger P. Loffler M. et al. Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery. Ann Thorac Surg. 2008; 85: 845-852 Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar its routine use in all cardiac surgical patients is not universal in the United States. 5 Morewood G.H. Gallagher M.E. Gaughan J.P. et al. Current practice patterns for adult perioperative transesophageal echocardiography in the United States. Anesthesiology. 2001; 95: 1507-1512 Crossref PubMed Scopus (32) Google Scholar Like most interventions, TEE is not risk free, and a variety of complications associated with its use have been reported, including esophageal mucosal tears and perforations, compression of airways and major vascular structures, 6 Kallmeyer I.J. Collard C.D. Fox J.A. et al. The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients. Anesth Analg. 2001; 92: 1126-1130 Crossref PubMed Scopus (364) Google Scholar cardiac arrhythmias, 7 Casta A. Brown D.W. Yuki K. Induction of supraventricular tachycardia during transesophageal echocardiography: An unusual complication. J Cardiothorac Vasc Anesth. 2008; 22: 592-593 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and injuries to other abdominal viscera. 8 Chow M.S. Taylor M.A. Hanson 3rd, C.W. Splenic laceration associated with transesophageal echocardiography. J Cardiothorac Vasc Anesth. 1998; 12: 314-316 Abstract Full Text PDF PubMed Scopus (21) Google Scholar Of these, esophageal injury has been the predominant type of complication noted in large observational studies of adverse sequelae of intraoperative TEE, 6 Kallmeyer I.J. Collard C.D. Fox J.A. et al. The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients. Anesth Analg. 2001; 92: 1126-1130 Crossref PubMed Scopus (364) Google Scholar , 9 Huang C.H. Lu C.W. Lin T.Y. et al. Complications of intraoperative transesophageal echocardiography in adult cardiac surgical patients—Experience of two institutions in Taiwan. J Formos Med Assoc. 2007; 106: 92-95 Abstract Full Text PDF PubMed Scopus (27) Google Scholar and, therefore, pre-existing esophageal pathology commonly is cited as a contraindication to its use. There are reports of successful use of TEE in other forms of esophageal pathology, such as Zenker diverticulum, 10 Ramjohn J. Paulus D.A. Use of transesophageal echocardiography in a patient with Zenker's diverticulum. J Cardiothorac Vasc Anesth. 2006; 20: 385-386 Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar but to date there are no reports of its use in patients with a previous esophagogastrectomy, and, therefore, the risks of injury to the reconstructed esophagus and the quality of imaging obtainable are unknown. Two patients with previous esophageal resection in whom high-quality intraoperative TEE images were obtained and who did not sustain any clinically evident injury to their reconstructed esophagus as a result are presented.

Iatrogenic type A aortic dissection during cardiac surgery

We reviewed our experience of intraoperative type A aortic dissection during cardiovascular surgery. From January 1998 to May 2009, intraoperative aortic dissection occurred in 10 of 3421 cardiac surgical patients (M:F=4:6, 62.4+/-8.0 years). Preoperative diagnoses were valvular heart disease (n=6), ischemic heart disease (n=2), combined disease (n=1) and aortic aneurysm (n=1). All underwent total circulatory arrest (TCA) with retrograde cerebral perfusion and the torn aorta was replaced (n=8) or repaired (n=2). Iatrogenic type A dissection occurred in 0.29% of patients. It was related with cannulation of ascending aorta (n=4), axillary artery (n=2), aortic root (n=2), and femoral artery (n=1) and aortotomy repair (n=1). Mortality rate was 40% (4/10). After adoption of routine intraoperative transesophageal echocardiography, mortality rate decreased from 75% (3/4) to 17% (1/6) (P=0.190). We initiated TCA before achieving deep hypothermia in three of four non-survivors. There was a trend of increased mortality when the disease extended beyond aortic arch (67%, 4/6 vs. 0%, 0/4; P=0.076). Although intraoperative aortic dissection occurred in <0.3% of our patient population, mortality was high, especially when it extended beyond the arch vessels. Better results were expected when early recognition and proper treatment under deep hypothermic circulatory arrest could be performed.

Transesophageal Echocardiography and Intraoperative Diagnosis of Persistent Left Superior Vena Cava

Isolated persistent left superior vena cava has an incidence of 0.5% in the normal population, but in patients with congenital cardiopathy its incidence ranges from 3% to 10%. The objective of this report was to present a case of intraoperative diagnosis with transesophageal echocardiography and to emphasize the importance of its routine use in surgical procedures for correction of congenital cardiopathies. This is a 16-year old male patient, ASA II, with a diagnosis of superior sinus venosus interatrial communication (IAC) with partial anomalous drainage of the pulmonary veins scheduled for the surgical correction of the cardiopathy. After induction of general anesthesia, transesophageal echocardiography (TEE) showed initially a dilation of the right cardiac chambers, a 17-mm superior sinus venosus IAC, anomalous drainage of the right superior pulmonary vein draining into the right superior vena cava (SVC), and dilation of the coronary sinus raising the possibility of persistent left superior vena cava. To confirm this suspicion, 10 mL of NS (works as a contrast in echocardiography) were injected in the venous access of the left arm, and microbubbles crossing the coronary sinus were observed immediately afterwards confirming the diagnosis of persistent left superior vena cava. Routine intraoperative transesophageal echocardiography in patients with congenital cardiopathy is a fundamental auxiliary method, not only for the surgeon, often having direct influence on the surgical technique used, but also for the anesthesiologist, who can get useful information for the hemodynamic management of the patient.

A Mysterious Echogenic Structure in the Left Atrium After Coronary Artery Bypass Graft Surgery

A 62-YEAR-OLD male patient with coronary artery disease underwent coronary artery bypass graft surgery on cardiopulmonary bypass (CPB). Before the institution of CPB, routine intraoperative transesophageal echocardiography (TEE) showed normal anatomy of the left atrium, and the left atrial appendage was normally visualized in the midesophageal 2-chamber view. However, post-CPB examination by TEE, after the removal of venous and aortic catheters, revealed an echogenic mass with acoustic shadowing in the left atrium close to the mitral valve annulus in the midesophageal 2-chamber view (Fig 1). The left atrial appendage was not visualized in this view; instead, the left upper pulmonary vein was visualized adjacent to the mass. What is the diagnosis?

The Differences Between Venous Air Embolism and Fat Embolism in Routine Intraoperative Monitoring Methods, Transesophageal Echocardiography, and Fatal Volume in Pigs

Venous air embolism (VAE) or fat embolism (FE) may occur in similar clinical settings such as after multiple injuries or total hip replacement. We designed this study to observe the differences between VAE and FE in routine intraoperative monitoring methods, transesophageal echocardiography (TEE), and fatal volume in pigs. Sixteen domestic pigs were randomly assigned to either a fat group (n = 8) or an air group (n = 8). Each animal was injected with a series of volumes of air or fat. TEE and routine intraoperative monitoring were used during the experiment. The echogenic pattern of air or fat emboli were recorded and was graded (grade 0, no emboli; grade 1, a few fine emboli; grade 2, embolic masses less than 5 mm in diameter and the right atrium opacified with echogenic materials; grade 3, fine emboli mixed with large embolic masses greater than 5 mm in diameter or serpentine emboli). Precordial auscultation was performed before and after each injection of air or fat. The fatal volumes of air and fat were recorded. No echogenic pattern grade 3 on TEE in the fat group was observed even fatal volume of fat was injected, whereas echogenic pattern grade 3 was found in all pigs in the air group when > or = 0.5 mg/kg of air was injected (0/8 vs. 8/8, p < 0.01). Paradoxical embolism and cutaneous petechiae was more common in the fat group than in the air group (8/8 vs. 1/8, 6/8 vs. 0/8, p < 0.05). "Bubble-like" sounds, "drum-like" murmurs, and "mill-wheel" murmurs were only heard in the air group but not in the fat group (8/8 vs. 0/8, p < 0.01). Fatal volume of air was much higher than that of fat (4 mL/kg +/- 0.76 mL/kg vs. 0.24 mL/kg +/- 0.05 mL/kg, p < 0.01). Large extensive echogenic masses on TEE, "bubble-like" sounds, "drum-like" murmurs, and "mill-wheel" murmurs were more likely associated with VAE. All of fat emboli were fine on TEE. Paradoxical embolism and cutaneous petechiae were more common in FE. Fatal volume of fat is lower than that of air.

Functional systolic anterior motion of the mitral valve due to accessory chordae

Accessory mitral valve tissue is an uncommon finding, usually associated with other congenital cardiac malformations and diagnosed during childhood. We present the case of a 70-year-old patient referred to our hospital for aortic valve and ascending aorta replacement. At preoperative examination, no evidence of mitral valve structural abnormalities was detected. Anaesthesia induction was complicated by sudden haemodynamic impairment. Intraoperative transoesophageal echocardiography showed two anomalous mitral chordae. The presence of abnormal mitral tissue also allowed to assess the mechanism of unexpected haemodynamic worsening: anomalous chordae caused anterior displacement of the anterior mitral leaflet, resulting in left ventricular outflow tract obstruction and mitral regurgitation. Medical therapy was instituted and the planned surgical approach was modified according to the new anatomy observed at echocardiographic examination. A valve-sparing technique was successfully applied. This case provides a good example of the diagnostic usefulness of routine intraoperative transoesophageal echocardiography, especially when facing unexpected findings. It also shows how transoesophageal echocardiography may help guide medical and surgical treatment.