Splenic injury after intraoperative transesophageal echocardiography

Transgastric Abdominal Ultrasonography in Anesthesia and Critical Care: Review and Proposed Approach

The use of transesophageal echocardiography (TEE) in the operating room and intensive care unit can provide invaluable information on cardiac as well as abdominal organ structures and function. This approach may be particularly useful when the transabdominal ultrasound examination is not possible during intraoperative procedures or for anatomical reasons. This review explores the role of transgastric abdominal ultrasonography (TGAUS) in perioperative medicine. We describe several reported applications using 10 views that can be used in the diagnosis of relevant abdominal conditions associated with organ dysfunction and hemodynamic instability in the operating room and the intensive care unit.

Conservative management for iatrogenic gastric perforation by transesophageal echocardiography

Background

Though several cases of upper gastrointestinal tract injury caused by transesophageal echocardiography (TEE) have been reported, gastric perforation is very rare. Herein, we report the case of TEE-associated gastric perforation that was successfully treated conservatively.

Case presentation

An 82-year-old man underwent mitral valve repair. Postoperative esophagogastroduodenoscopy and computed tomography revealed gastric perforation. Surgical treatment was initially considered, but conservative management was selected to avoid increasing operative stress, to minimize the need for total gastrectomy (including the lower esophagus), and to minimize the risk of a potential intraperitoneal infection spreading to the thoracic cavity.

Conclusion

Conservative management of gastric perforation can be successful even when the perforation is recognized later than 12 h following the event, provided that there are no abdominal symptoms and no signs of peritoneal effusion or sepsis. Our experience suggests that conservative management is a feasible option for treating TEE-associated gastric perforation in appropriately selected cases.

Urgent splenectomy in the course of prosthetic valve endocarditis

We present a case of a 51-year-old male patient hospitalized due to acute coronary syndrome requiring stent implantation to the left main stem. Double antiplatelet therapy was commenced. After 2-3 days, the patient presented with high fever, dyspnea on exertion, pain in the chest, myalgia, and general weakness. Transthoracic (TTE) and transesophageal (TEE) echocardiography revealed abnormal, turbulent flow across the aortic prosthesis, which was probably caused by the presence of a pathological smooth and mobile structure (10 × 9 × 5 mm) in front of the aortic annulus. Blood cultures were positive and staphylococcal prosthetic valve endocarditis (PVE) was diagnosed. Despite antibiotic treatment, the patient's condition deteriorated, and he was referred for prosthesis reimplantation. After being transferred to the Cardiac Surgery Clinic, he presented with nausea, vomiting, and abdominal pain. The results of imaging examinations suggested spleen hematoma. The patient underwent an urgent splenectomy. Histopathological examination revealed a spleen infarction consequent to an embolic event and subscapular hematoma. On the 10^th day after the laparotomy, cardiac surgery was performed. No large vegetations were found on the aortic prosthesis. The mechanical valve, implanted 20 years earlier, was functioning properly; it was intact and well healed. Several fragments of a thrombus and fibrous tissue, resembling a pannus and covered with minor calcifications, were removed from the ventricular surface of the discs. A decision was reached to leave the aortic prosthesis in situ. The valvular material culture revealed the presence of Streptococcus anginosus, and the antibiotic scheme was modified. The postoperative period was uneventful.

Transthoracic echocardiographic features of cardiac pheochromocytoma: a single-institution experience

BACKGROUND

Cardiac pheochromocytoma is extremely rare. Previous papers usually are reports of a single case. Transthoracic echocardiography (TTE) offers a useful option, but the features of cardiac pheochromocytoma on TTE have not been favorably reported. In this study, the findings of cardiac pheochromocytoma on TTE in nine cases were presented.

METHODS

TTE images (especially two-dimensional ultrasound) of nine patients with cardiac pheochromocytomas were analyzed retrospectively and compared with the findings from surgery.

RESULTS

Among the nine patients with cardiac pheochromocytomas identified in Peking Union Medical College Hospital (PUMCH) clinical and echocardiographic database, TTE identified one cardiac tumor in seven cases (77.8%), two cardiac tumors in one case (11.1%), and a false-negative result in another (11.1%). Cardiac pheochromocytomas were usually located on the base of the heart, near the origin of great arteries. The tumors were usually round or ovoid, ranging from 1.4 cm to 7.7 cm in diameter, with homogeneous and moderate echoes and low activity. They could press or invade surrounding cardiac structures and influence hemodynamics. In this study the majority of cardiac pheochromocytoma seemed marginated and appeared to be encapsulated on TTE. Apical four-chamber view and parasternal short-axis view of the aortic valve were most effective in identifying cardiac pheochromocytomas. The findings on TTE were similar to those from surgical procedures.

CONCLUSION

Cardiac pheochromocytomas presented characteristic TTE appearances in aspect of location, size, texture, and shape of tumors. Understanding of these characteristics on TTE can help correctly recognize this extremely rare disease.

Safety of transesophageal echocardiography

Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.

Transesophageal echocardiography (TEE)-induced Mallory-Weiss laceration in a patient who underwent aortic and mitral valve replacement -A case report-

Transesophageal echocardiography (TEE) is a relatively noninvasive and highly valuable diagnostic modality to monitor cardiac surgery. TEE is utilized to estimate the results of the surgical correction or the cardiac function on a real time basis. Accordingly, the frequency of TEE usage is increasing. Previous studies have shown low risk of TEE-associated complications; nonetheless, major gastrointestinal trauma can occur on a rare occasion. We herein present a case of Mallory-Weiss laceration after an intraoperative TEE examination.

Complications of Intraoperative Transesophageal Echocardiography in Adult Cardiac Surgical Patients—Experience of Two Institutions in Taiwan

There is some safety concern about transesophageal echocardiography (TEE) when it is used routinely during cardiac operations. The purpose of this investigation was to study the incidence of intraoperative TEE-associated complications in adult cardiac surgical patients. The study population comprised 6255 consecutive adult cardiac surgical patients with intraoperative TEE examinations. TEE-associated complications occurred in 25 patients (0.4%). Most of these complications consisted of oropharyngeal mucosal bleeding (15/25, 60%). Esophageal perforation occurred in one patient. Two patients experienced upper gastrointestinal bleeding. Seven patients experienced dental injuries, and TEE probe insertion failed in 10 patients. We conclude that intraoperative TEE-associated complications in cardiac operations is very low; the complication rate we found was comparable to previously reported values.