Editorial Comment: Intraoperative Transesophageal Echocardiography to Evaluate Acute Cessation of Venous Inflow During Cardiopulmonary Bypass
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n this issue of A&A Case Reports, Fierro et al.1 describe what appears to be embolized peripheral thrombus to the right atrium from a leg vein during cardiopulmonary bypass (CPB) in an elderly female undergoing aortic valve replacement and coronary artery bypass graft (CABG), detected by intraoperative transesophageal echocardiogra phy (TEE). This case highlights the potential value of rou tine use of TEE including prebypass examination during cardiac surgery, as well as the need for the cardiac anesthe siologist to appreciate the value of TEE during CPB. This is an area not well described except in isolated case reports. The recently updated ASE/SCA Guidelines for Performing a Comprehensive Transesophageal Echocar diographic Examination2 treats the period during CPB as somewhat of a “black box,” categorizing it as the period between which comprehensive anatomic examination is per formed to assess the efficacy of surgical intervention relative to the prebypass baseline. In many practices, the TEE image is frozen as soon as CPB commences. This is an appropriate maneuver when the probe is not being used, given concerns regarding possible thermal injury to the esophagus, but should not stop the clinician from performing the functions I describe below. The experienced cardiac anesthesiologist should appreciate the value that TEE adds to assessing the proper conduct of CPB on many fronts including: (a) veri fying the position and outcome of insertion of aortic and venous cannulae (particularly of value in excluding aortic dissection from the arterial cannula or placement of the venous cannulae into a hepatic vein instead of the inferior vena cava); (b) verifying the position of specialized cannu lae such as the retrograde coronary sinus catheter (usually inserted before instituting CPB, except during mitral valve surgery when it is usually placed during CPB) and the left ventricular vent (always placed during CPB to prevent sys temic air embolism); (c) recognizing ventricular distention due to problems with anterograde administration of cardio plegia (usually from varying degrees of aortic insufficiency that may not always appear significant before placement of the aortic clamp but can worsen because of distortion of the anatomy of the aortic valve by the clamp); (d) assessment of air in the right or left heart and its adequate removal after removal of the aortic cross-clamp, and as noted in this spe cific case report; and (e) the presence of thrombus or other solid material in a heart chamber or in a cannula. The increasing use of real-time 3D imaging is facilitating this general process, particularly regarding cannula visual ization. For those not yet so fortunate, there are numerous reviews and cases showing what they can expect when their current equipment is upgraded.3,4
Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000082
98 cases-anesthesia-analgesia.org
In my experience imaging during CPB can be con siderably more difficult than before or after, given that the size of various chambers is usually diminished. However, the simple recognition of a normal chamber size (denoting distention) is easy to detect, as occurred in this case. Over the years, I have become increasingly interactive with the surgeons regarding the diagnostic role of TEE, and while most of what is done confirms proper surgical tech nique, the rare unexpected event in which the surgeon and perfusionist are stymied but where TEE shows precisely what is wrong usually “seals the deal” for membership on the surgical team. All cardiac anesthesiologists should push themselves to excel in on-bypass imaging, despite the lack of formal guidelines. Although there are clear cost issues related to whether TEE should be used in all CABG, valve, or thoracic aortic cases, I suspect that the growing recog nition of the value of routine TEE to assess the conduct of CPB will eventually result in upgrading guideline recom mendations to all on-pump CABG cases (as already occurs in many hospitals around the world in the absence of con traindications to its use). A final related note on this case is the changing epidemi ology of perioperative venous thromboembolism resulting (in my opinion) from the widespread use of intraopera tive TEE. In my training, it was generally considered that intraoperative pulmonary embolism would be very low on the differential diagnosis of acute hemodynamic insta bility. Although Mangano5 back in 1980 presented a case report of purported intraoperative pulmonary embolism in a patient undergoing aortic aneurysm resection, diag nosed solely based on hemodynamic changes (consistent with acute right heart failure) from a pulmonary artery catheter (long before the first use of intraoperative TEE), there now are many case reports of intraoperative throm boembolism either noted while a TEE probe was already in place or imaged once a probe had been inserted.6–11 However, with regard to diagnosis of actual pulmonary thromboembolism, only right-sided large saddle emboli are ever likely to be imaged with TEE. Detection of throm boembolism by capture into the venous cannula appears to be a unique way to make this diagnosis, as these authors so well describe. E Martin J. London, MD Department of Anesthesia and Perioperative Care VA Medical Center and University of California, San Francisco San Francisco, California [email protected] REFERENCES 1. Fierro MA, Sheikh T, Mukherji J. Intraoperative transesopha geal echocardiography to evaluate acute cessation of venous inflow during cardiopulmonary bypass. A & A Case Reports 2014;3:95–7 October 15, 2014 • Volume 3 • Number 8
2. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH; American Society of Echocardiography; Society of Cardiovascular Anesthesiologists. Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: recommen dations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2014;118:21–68 3. Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP, Kamp O, Kasprzak JD, Lancellotti P, Marwick TH, McCulloch ML, Monaghan MJ, Nihoyannopoulos P, Pandian NG, Pellikka PA, Pepi M, Roberson DA, Shernan SK, Shirali GS, Sugeng L, Ten Cate FJ, Vannan MA, Zamorano JL, Zoghbi WA; American Society of Echocardiography; European Association of Echocardiography. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr 2012;25:3–46 4. Vegas A, Meineri M. Core review: three-dimensional trans esophageal echocardiography is a major advance for intraop erative clinical management of patients undergoing cardiac surgery: a core review. Anesth Analg 2010;110:1548–73
October 15, 2014 • Volume 3 • Number 8
5. Mangano DT. Immediate hemodynamic and pulmonary changes following pulmonary thromboembolism. Anesthesiology 1980; 52:173–5 6. Singh A, Fleming N. Right heart embolism and acute right atrial dilation during total knee arthroplasty. Anesth Analg 2007;105:1224–7 7. Bisignani G, Bisignani M, Pasquale GS, Greco F. Intraoperative embolism and hip arthroplasty: intraoperative transesopha geal echocardiographic study. J Cardiovasc Med (Hagerstown) 2008;9:277–81 8. Jha NK, Rezk AI, Omran AS, Hussain A, Najm HK. Acute pul monary thromboembolism during mitral valve repair. Heart Lung Circ 2008;17:159–61 9. Brakke TR, Agrawal A, Harden KS, Shillcutt SK, Montzingo CR. Free-floating intracardiac mass after cardiopulmonary bypass for aortic valve replacement. Anesth Analg 2011;113:1337–9 10. Lee CL, Ong J, Chang BS, Chen TY, Lai HY. Accidental pulmo nary emboli noted by TEE during aortic valve replacement: a case report. J Clin Anesth 2011;23:231–3 11. Scohy TV, Lüthen C, McGhie J, Oei F. Three-dimensional transesophageal echocardiography: diagnosing intraoperative pulmonary artery thrombus. Interact Cardiovasc Thorac Surg 2011;12:840–1
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n this issue of A&A Case Reports, Fierro et al.1 describe what appears to be embolized peripheral thrombus to the right atrium from a leg vein during cardiopulmonary bypass (CPB) in an elderly female undergoing aortic valve replacement and coronary artery bypass graft (CABG), detected by intraoperative transesophageal echocardiogra phy (TEE). This case highlights the potential value of rou tine use of TEE including prebypass examination during cardiac surgery, as well as the need for the cardiac anesthe siologist to appreciate the value of TEE during CPB. This is an area not well described except in isolated case reports. The recently updated ASE/SCA Guidelines for Performing a Comprehensive Transesophageal Echocar diographic Examination2 treats the period during CPB as somewhat of a “black box,” categorizing it as the period between which comprehensive anatomic examination is per formed to assess the efficacy of surgical intervention relative to the prebypass baseline. In many practices, the TEE image is frozen as soon as CPB commences. This is an appropriate maneuver when the probe is not being used, given concerns regarding possible thermal injury to the esophagus, but should not stop the clinician from performing the functions I describe below. The experienced cardiac anesthesiologist should appreciate the value that TEE adds to assessing the proper conduct of CPB on many fronts including: (a) veri fying the position and outcome of insertion of aortic and venous cannulae (particularly of value in excluding aortic dissection from the arterial cannula or placement of the venous cannulae into a hepatic vein instead of the inferior vena cava); (b) verifying the position of specialized cannu lae such as the retrograde coronary sinus catheter (usually inserted before instituting CPB, except during mitral valve surgery when it is usually placed during CPB) and the left ventricular vent (always placed during CPB to prevent sys temic air embolism); (c) recognizing ventricular distention due to problems with anterograde administration of cardio plegia (usually from varying degrees of aortic insufficiency that may not always appear significant before placement of the aortic clamp but can worsen because of distortion of the anatomy of the aortic valve by the clamp); (d) assessment of air in the right or left heart and its adequate removal after removal of the aortic cross-clamp, and as noted in this spe cific case report; and (e) the presence of thrombus or other solid material in a heart chamber or in a cannula. The increasing use of real-time 3D imaging is facilitating this general process, particularly regarding cannula visual ization. For those not yet so fortunate, there are numerous reviews and cases showing what they can expect when their current equipment is upgraded.3,4
Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000082
98 cases-anesthesia-analgesia.org
In my experience imaging during CPB can be con siderably more difficult than before or after, given that the size of various chambers is usually diminished. However, the simple recognition of a normal chamber size (denoting distention) is easy to detect, as occurred in this case. Over the years, I have become increasingly interactive with the surgeons regarding the diagnostic role of TEE, and while most of what is done confirms proper surgical tech nique, the rare unexpected event in which the surgeon and perfusionist are stymied but where TEE shows precisely what is wrong usually “seals the deal” for membership on the surgical team. All cardiac anesthesiologists should push themselves to excel in on-bypass imaging, despite the lack of formal guidelines. Although there are clear cost issues related to whether TEE should be used in all CABG, valve, or thoracic aortic cases, I suspect that the growing recog nition of the value of routine TEE to assess the conduct of CPB will eventually result in upgrading guideline recom mendations to all on-pump CABG cases (as already occurs in many hospitals around the world in the absence of con traindications to its use). A final related note on this case is the changing epidemi ology of perioperative venous thromboembolism resulting (in my opinion) from the widespread use of intraopera tive TEE. In my training, it was generally considered that intraoperative pulmonary embolism would be very low on the differential diagnosis of acute hemodynamic insta bility. Although Mangano5 back in 1980 presented a case report of purported intraoperative pulmonary embolism in a patient undergoing aortic aneurysm resection, diag nosed solely based on hemodynamic changes (consistent with acute right heart failure) from a pulmonary artery catheter (long before the first use of intraoperative TEE), there now are many case reports of intraoperative throm boembolism either noted while a TEE probe was already in place or imaged once a probe had been inserted.6–11 However, with regard to diagnosis of actual pulmonary thromboembolism, only right-sided large saddle emboli are ever likely to be imaged with TEE. Detection of throm boembolism by capture into the venous cannula appears to be a unique way to make this diagnosis, as these authors so well describe. E Martin J. London, MD Department of Anesthesia and Perioperative Care VA Medical Center and University of California, San Francisco San Francisco, California [email protected] REFERENCES 1. Fierro MA, Sheikh T, Mukherji J. Intraoperative transesopha geal echocardiography to evaluate acute cessation of venous inflow during cardiopulmonary bypass. A & A Case Reports 2014;3:95–7 October 15, 2014 • Volume 3 • Number 8
2. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH; American Society of Echocardiography; Society of Cardiovascular Anesthesiologists. Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: recommen dations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2014;118:21–68 3. Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP, Kamp O, Kasprzak JD, Lancellotti P, Marwick TH, McCulloch ML, Monaghan MJ, Nihoyannopoulos P, Pandian NG, Pellikka PA, Pepi M, Roberson DA, Shernan SK, Shirali GS, Sugeng L, Ten Cate FJ, Vannan MA, Zamorano JL, Zoghbi WA; American Society of Echocardiography; European Association of Echocardiography. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr 2012;25:3–46 4. Vegas A, Meineri M. Core review: three-dimensional trans esophageal echocardiography is a major advance for intraop erative clinical management of patients undergoing cardiac surgery: a core review. Anesth Analg 2010;110:1548–73
October 15, 2014 • Volume 3 • Number 8
5. Mangano DT. Immediate hemodynamic and pulmonary changes following pulmonary thromboembolism. Anesthesiology 1980; 52:173–5 6. Singh A, Fleming N. Right heart embolism and acute right atrial dilation during total knee arthroplasty. Anesth Analg 2007;105:1224–7 7. Bisignani G, Bisignani M, Pasquale GS, Greco F. Intraoperative embolism and hip arthroplasty: intraoperative transesopha geal echocardiographic study. J Cardiovasc Med (Hagerstown) 2008;9:277–81 8. Jha NK, Rezk AI, Omran AS, Hussain A, Najm HK. Acute pul monary thromboembolism during mitral valve repair. Heart Lung Circ 2008;17:159–61 9. Brakke TR, Agrawal A, Harden KS, Shillcutt SK, Montzingo CR. Free-floating intracardiac mass after cardiopulmonary bypass for aortic valve replacement. Anesth Analg 2011;113:1337–9 10. Lee CL, Ong J, Chang BS, Chen TY, Lai HY. Accidental pulmo nary emboli noted by TEE during aortic valve replacement: a case report. J Clin Anesth 2011;23:231–3 11. Scohy TV, Lüthen C, McGhie J, Oei F. Three-dimensional transesophageal echocardiography: diagnosing intraoperative pulmonary artery thrombus. Interact Cardiovasc Thorac Surg 2011;12:840–1
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