Special Article

Minimally invasive cardiac surgery and transesophageal echocardiography  Ajay Kumar Jha, Vishwas Malik, Milind Hote1 Departments of Cardiothoracic and Vascular Anaesthesia, 1Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India

ABSTRACT

Received: 02‑06‑13 Accepted: 26‑01‑14

Improved cosmetic appearance, reduced pain and duration of post‑operative stay have intensified the popularity of minimally invasive cardiac surgery (MICS); however, the increased risk of stroke remains a concern. In conventional cardiac surgery, surgeons can visualize and feel the cardiac structures directly, which is not possible with MICS. Transesophageal echocardiography (TEE) is essential during MICS in detecting problems that require immediate correction. Comprehensive evaluation of the cardiac structures and function helps in the confirmation of not only the definitive diagnosis, but also the success of surgical treatment. Venous and aortic cannulations are not under the direct vision of the surgeon and appropriate positioning of the cannulae is not possible during MICS without the aid of TEE. Intra‑operative TEE helps in the navigation of the guide wire and correct placement of the cannulae and allows real‑time assessment of valvular pathologies, ventricular filling, ventricular function, intracardiac air, weaning from cardiopulmonary bypass and adequacy of the surgical procedure. Early detection of perioperative complications by TEE potentially enhances the post‑operative outcome of patients managed with MICS. Key words: Cardiopulmonary bypass; Minimally invasive cardiac surgery; Transesophageal echocardiography

INTRODUCTION

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There is growing enthusiasm among cardiovascular surgeons for minimally invasive cardiac surgery (MICS). Increasing trends of MICS have been prompted by increasing demand from patients, technological advancement and improvement in the technical expertise of the surgeons. Patients have now become more aware of anatomical, physiological and psychological consequences of the surgery. Minimal incision and minimal anatomic disruption of the body tissues give better cosmetic results and provide psychological comfort to the patients. Patients are always afraid of the consequences of surgery. MICS reduces the duration of convalescence and allows patients to resume activities earlier and thus may reduce the fear of surgery. Psychological comfort decreases stress level of patients and helps pre‑operative preparation before surgery. However, the advantages and disadvantages of

MICS should be explained to patients in detail pre‑operatively. Inadequate surgical exposure, inadequate surgical correction and residual anatomic defects are inherent risks of MICS.[1] Increased cardiopulmonary bypass (CPB) and aortic cross clamp (ACC) times have their own negative consequences. Inadequate cardioplegia delivery and myocardial protection may negate the benefits associated with MICS. Modi et  al., in a meta‑analysis reviewed the effects of minimally invasive mitral valve surgery on morbidity and mortality compared with conventional mitral valve surgery and demonstrated equivalent perioperative mortality, reduced need for reoperation for bleeding and a trend toward shorter hospital stay. These benefits were evident despite longer CPB and ACC times in the MICS group.[2] However, Society of Thoracic Surgeons database observed a higher incidence of stroke in less invasive mitral valve surgery with an odds ratio of two when compared with traditional sternotomy.[3] This increased

Address for correspondence: Dr. Vishwas Malik, Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, Ansari Nagar, New Delhi ‑ 110 029, India. E‑mail: [email protected]

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incidence of stroke was mainly due to inadequate deairing, fibrillating‑heart techniques and prolonged CPB and ACC times.

precludes minimal access mitral valve replacement. MICS is usually not performed in acute bacterial endocarditis or as an emergency surgery.

MICS is applicable to the broadest range of cardiac lesions and performed through a smaller incision preferably 15 mm is suggestive of the presence of left SVC. However, a normal CS diameter does not exclude 130

the possibility of left SVC. Abnormally dilated CS may also be an indicator of CS ostial narrowing or intracardiac shunts.[14] Presence of left superior caval vein (LSVC) is further confirmed by the presence of a venous loop adjacent to Coumadin ridge in ME four‑chamber view or aortic valve short‑axis view [Figure 8]. The presence of left SVC can also be confirmed by injecting agitated bubble contrast (normal saline mixed with patient’s blood) into the patient’s left‑arm vein. Appearance of the contrast in the CS before appearing in the RA confirms the presence of left SVC; however, a negative study does not exclude LSVC.[15] A persistent LSVC is present in about 0.3% of the population at necropsy and in adults undergoing pacing. Nonetheless, it may occur in up to 9% of necropsies of children with congenital heart disease.[16] Uninterrupted retrograde cardioplegia delivery requires a patent and unobstructed CS and the absence of left SVC. Occasionally, right internal jugular and subclavian vein drain into the left SVC through right innominate vein.[17] In such cases, right SVC is usually small or it can be absent as in cases of persistent left SVC. Right SVC rarely drains into the left atrium and IVC rarely drains into the RA through CS. Retrograde cardioplegia delivery For retrograde cardioplegia, a 9 F triple‑lumen catheter is placed in the CS through an 11 F internal jugular vein introducer. Three‑lumens allow balloon inflation, retrograde cardioplegia delivery and measurement of CS pressure. Percutaneous cannulation of the CS for administration of retrograde cardioplegia during MICS can be accomplished safely and efficiently using TEE.[18] TEE helps in the navigation of the catheter from SVC to CS through the RA. Midesophageal bicaval view is useful for tracing the catheter from SVC to RA. The path of the catheter from SVC to CS orifices is facilitated

Figure 8: Midesophageal four chamber view shows left superior vena cava as a venous loop

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by changing the imaging plane from 90° to 110° or more, which brings SVC and CS orifices in the same plane [Figure 9].[19] As the catheter is advanced, the path of the catheter tip is adjusted to bring it into alignment with the CS. The tip turns in response to application of torque. When the catheter tip is directed toward the IVC, clockwise torque should be applied at the point of entry and counterclockwise torque should be applied when the tip is directed toward tricuspid valve. TEE displays the movement of catheter tip in opposite direction to the applied torque in modified bicaval view while torque and catheter tip move in the same direction in four‑chamber ME view. A prominent Eustachian valve may help in guiding the catheter tip toward the CS. Presence of abnormal thebesian valve may obstruct the passage of the CS catheter. Successful placement of catheter may be further confirmed by the examination of pressure trace. Once the catheter has been advanced into the CS orifice, it can be traced deeper within the CS lumen by bringing the probe little deeper than the classical ME four‑chamber view with slight retroflexion. The mid to distal CS is visible in a two‑chamber view. Progressively distal segments are displayed by turning the probe further left from a two‑chamber view. Fluoroscopy is an ideal choice for tracing deeper into the CS. Live 3D echo‑guided CS catheter insertion is feasible, safe and provide a “virtual surgeon’s view” of the pertinent anatomy.[20] TEE guided cannulation of the CS prevents exposure of the patient and operating room personnel to unnecessary radiation from fluoroscopy and substantially decreases health care costs by reducing expenditures on accessory equipment and personnel. Endosinus balloon is inflated at 3‑5 cm from the orifice with 1‑2 ml of dilute contrast media. Measurement of CS diameter by the TEE is crucial to keep the balloon/ vessel ratio below one to avoid CS injury.[21] Retrograde cardioplegia is delivered through the other lumen of

the CS catheter. Catheter balloon is visible with TEE. Retrograde cardioplegia delivery is frequently visible with color flow Doppler at low aliasing velocities. Weaning from CPB and post CPB period Due to limited exposure, removal of intracavitary air and visual assessment of cardiac function during MICS is not possible. TEE is especially helpful in weaning from CPB. Completeness of deairing is assessed just prior to and immediately following cardioplegia cannula removal and after separation from CPB. A quick and focused TEE evaluation is done to confirm the adequacy of surgical repair, absence of residual anatomic defects and absence of air bubble during brief weaning period from the CPB. Weaning is continued if satisfactory surgical correction is ensured. TEE further helps assessment of post‑operative ventricular systolic and diastolic function, assessment of fluid requirement and inotropic adjustment. CONCLUSION The ever growing technical expertise coupled with patient’s awareness has led to the tremendous growth of MICS. It is generally performed upon a simple, uncomplicated cardiac lesion. Therefore, the safe and complications‑free conduct of MICS is a huge challenge, both for the anesthesiologist and the surgeon. Re‑establishing the diagnosis is crucial before the surgical incision. Inadequate access to the surgical site necessitates retrograde placement of venous cannula, arterial cannula and cardioplegia delivery. Intraoperative TEE provides reliable, real time feedback thus facilitates and ensures safe and smooth conduct of the surgical procedure. An appropriate placement of these cannulae is extremely difficult without TEE. Misplaced cannula is always a danger, and hampers the smooth conduct of CPB and may threaten the patient’s life. Continuous exchanges of information among caregivers are vital at every stage of surgery. TEE further ensures establishing the adequacy of surgical correction, complete de‑airing and thus helps in successful weaning from CPB. REFERENCES 1.

Figure 9: Midesophageal modified bicaval view shows coronary sinus and superior vena cava in a single plane

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ERRATUM Annals of Cardiac Anaesthesia January 2014; Vol 17; Issue 1 Title: Anesthesia management for MitraClip device implantation Page 17; Authors: Ho Vui Kian, Yeo Khung Keong, Hwang Nian Chih

Should read as Kian Ho Vui, Keong Yeo Khung, Chih Hwang Nian The error is regretted

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- Chief Editor, Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia    Vol. 17:2    Apr-Jun-2014

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Minimally invasive cardiac surgery and transesophageal echocardiography.

Improved cosmetic appearance, reduced pain and duration of post-operative stay have intensified the popularity of minimally invasive cardiac surgery (...
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