A practical approach to a comprehensive epicardial and epiaortic echocardiographic examination

Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting

Porcelain aorta (PA) is an asymptomatic atherosclerotic disease, characterized by circumferential calcification throughout the whole perimeter of the aorta. It is seen in 2% to 9.3% of patients undergoing elective coronary artery bypass grafting (CABG) and makes manipulation of the ascending aorta impossible. It has been clearly shown that most emboli seen and detected during the CABG procedure occur during aortic cross-clamping and aortic side-clamping. Manipulation of porcelain or a severely atherosclerotic aorta increases the risk of perioperative stroke. The incidence of stroke after CABG is between 0.48% and 2.9%, and the risk is correlated with the extent and severity of the atherosclerotic disease. A conventional CABG procedure involves successive steps that include cannulation of the ascending aorta, application of a cross-clamp to the aorta, and partial clamping of the aorta to create the proximal anastomosis. Therefore in procedures that involve cannulation, clamping, or proximal anastomosis, and where aortic manipulation is inevitable, preassessment of the atherosclerotic aortic plaques is crucial. Although many surgeons still rely on intraoperative manual aortic palpation, this approach has very low sensitivity and underestimates the severity of the atherosclerotic illness. Imaging methods including preoperative computed tomography or intraoperative epiaortic ultrasonography enable modification of the surgical technique according to the severity of atherosclerosis. Various surgical techniques have been described to reduce the risk of atheroembolism that may lead to cerebrovascular events in patients with severely atherosclerotic ascending aorta. Anaortic or "no-touch" techniques that do not utilize aortic manipulation may significantly decrease the development of neurological complications by avoiding aortic maneuvers known to cause emboli. In cases where severe atherosclerotic disease or other factors preclude safe use of the ascending aorta, modifications in the surgical techniques, such as switching to different cannulation sites including the axillary/subclavian, femoral and innominate arteries, or using hypothermic ventricular fibrillation and in-situ pedicled arterial grafts, or performing proximal anastomoses at alternative anatomical locations will enable CABG operations to be performed safely with low morbidity and mortality rates in patients with porcelain aortas.

A systematic approach to epicardial echocardiography in pediatric cardiac surgery: An important but underutilized intraoperative tool

Intraoperative echocardiography is an integral component of the peri-operative management of pediatric heart disease. It confirms the adequacy of surgery, identifies residual lesions, and can provide useful hemodynamic data. It, therefore, helps to decide on the need for revision of repair and guides the postoperative management strategy. Intraoperative echocardiography is done with the use of either an epicardial probe or a transesophageal probe. Epicardial echocardiography is a simple, useful modality and has the ability to perform imaging in cases where transesophageal echocardiography cannot be easily performed, for example, in low birth weight babies. We attempt to describe in detail the technique of epicardial echocardiography and the various views that we have found useful for a complete postsurgical evaluation. The limitations of the technique are also discussed in detail.

Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery

Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.

Epiaortic Ultrasound for Assessment of Intraluminal Atheroma; Insights from the REGROUP Trial

OBJECTIVES

To assess the use of epiaortic ultrasound in contemporary cardiac surgery, as well as its impact on surgical cannulation strategy and cerebrovascular events.

DESIGN

Epiaortic ultrasound data was prospectively collected in the Randomized Endovein Graft Prospective (REGROUP) trial (VA Cooperative Studies Program #588, ClinicalTrials.gov, NCT01850082), which randomized 1,150 coronary artery bypass graft patients between 2014 and 2017 to endoscopic or open-vein graft harvest.

SETTING

Sixteen cardiac surgery programs within the Veterans Affairs Healthcare System with expertise at performing endoscopic vein-graft harvesting.

PARTICIPANTS

Veterans Affairs patients, greater than 18 years of age, undergoing elective or urgent coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest with at least one planned saphenous vein graft were eligible for enrollment.

INTERVENTIONS

Epiaortic ultrasound was performed by the surgeon using a high frequency (>7 MHz) ultrasound transducer. Two-dimensional images of the ascending aorta in multiple planes were acquired before aortic cannulation and cross-clamping.

MEASUREMENTS AND MAIN RESULTS

Epiaortic ultrasound was performed in 34.1% (269 of 790) of patients in REGROUP. Among these patients, simple intraluminal atheroma was observed in 21.9% (59 269), and complex intraluminal atheroma comprised 2.2% (6 of 269). The aortic cannulation or cross-clamp strategy was modified based on these findings in 7.1% of cases (19 of 269). There was no difference in stroke between patients who underwent epiaortic ultrasound and those who did not (1.9% v 1.2% p = 0.523).

CONCLUSIONS

Despite current guidelines recommending routine use of epiaortic ultrasound (IIa/B) to reduce the risk of stroke in cardiac surgery, in this contemporary trial, use remains infrequent, with significant site-to-site variability.

Epicardial Echocardiography in Pediatric and Congenital Heart Surgery

Epicardial echocardiography (e-echo) is a useful approach to intraoperative imaging for the smallest patients and in those with contraindications to transesophageal echocardiography (TEE). The e-echo has additional advantages that include improved visualization of anterior and vascular structures and three-dimensional capabilities. In this review, we describe the advantages and disadvantages of e-echo versus TEE for pediatric and congenital heart surgery with the goal of enhancing the utility and feasibility of the former among congenital heart surgeons. We also review the technique for performance of an e-echo and provide demonstrations of the images obtained for select lesions.

The use of intraoperative epiaortic ultrasonography in monitoring patients over 75 years old treated with aortic valve replacement

Introduction

Epiaortic ultrasound scanning (EAS) extended the use of ultrasound to the intraoperative diagnosis of aortic pathology. Surgical palpation of the ascending aorta underestimates the presence and severity of atherosclerotic plaques. Epiaortic ultrasound scanning has been used as an adjunct to transesophageal echocardiography (TEE) or as a primary direct diagnostic tool for imaging the ascending aorta as well as the aortic arch, which gained prominence as part of a multipronged intraoperative strategy to reduce atherosclerotic emboli.

Aim

To compare the epiaortic examination with transthoracic and transesophageal echo (transthoracic echocardiography (TTE) and TEE), X-ray, surgical intraoperative palpation, and postoperative neurological status.

Material and methods

The analyzed group consisted of 35 patients (mean age: 81.3 years) treated with aortic valve replacement (AVR), either alone (60%) or combined with coronary artery bypass grafting (CABG; 22.8%) or aortic aneurysm replacement (11.42%). In 2 patients, only CABG was performed because intraoperatively reevaluated strategy. Thierteen patients have got a history of diabetes, 10 chronic renal failure and 3 of cerebral stroke.

Results

In more than 80% of patients, positive EAS results had an influence on the choice of aortic clamping site and in 50% of patients on the site of cannulation. Female sex, peripheral vascular disease, history of previous stroke, and calcifications in the ascending aorta in TTE have significant predictive value for recognizing atherosclerotic changes in EAS and the risk of postoperative neurological complications in octogenarians treated with AVR.

Conclusions

Epiaortic ultrasound scanning imaging is superior to TTE and manual palpation in the detection and localization of ascending atherosclerosis. This technique should be introduced as a standard perioperative examination in older patients at risk of neurological complications.

Vector Flow Imaging Compared with Conventional Doppler Ultrasound and Thermodilution for Estimation of Blood Flow in the Ascending Aorta

Transverse oscillation (TO) is a real-time ultrasound vector flow method implemented on a commercial scanner. The TO setup was examined on a flowrig with constant and pulsatile flow. Subsequently, 25 patients undergoing cardiac bypass surgery were scanned intraoperatively with TO on the ascending aorta and compared to transesophageal echocardiography (TEE) and pulmonary artery catheter thermodilution (PACTD). On the flowrig, TO had a precision of 5.5%, 9.4% and 14.7%, a percentage error of 18.2%, 14.6% and 40.7%, and a mean bias of 0.4 cm/s, 36.8 ml/min and 32.4 ml/min for velocity and flow rate (constant and pulsatile) estimation. The correlation coefficients for all flowrig evaluations were 0.99 indicating systematic bias. After bias correction, the percentage error was reduced to 11.5%, 12.6% and 15.9% for velocity and flow rate (constant and pulsatile) estimation. In the in vivo setup, TO, TEE, and PACTD had a precision of 21.9%, 13.7%, and 12.0%. TO compared with TEE and PACTD had a mean bias of 12.6 cm/s and -0.08 l/min, and a percentage error of 23.4%, and 36.7%, respectively. The percentage error was reduced to 22.9% for the TEE comparison, but increased to 43.8% for the PACTD comparison, after correction for the systematic bias found in the flowrig. TO is a reliable and precise method for velocity and flow rate estimation on a flowrig. However, TO with the present setup, is not interchangeable with PACTD for cardiac volume flow estimation, but is a reliable and precise angle-independent ultrasound alternative for velocity estimation of cardiac flow.

Intraoperative Echocardiography: Support for Decision Making in Cardiac Surgery

Intraoperative echocardiography (including transesophageal echocardiography, epiaortic ultrasound and epicardial echocardiography) is commonly performed in North American hospitals during cardiac anesthesia. Several authors have reported on the positive impact of intraoperative echocardiography on patients’ outcomes. Transesophageal echocardiography is useful in identifying anatomic and functional abnormalities either before or after cardiopulmonary bypass and helps to make decisions in the care of high-risk and unstable patients. In minimally invasive and robotically assisted surgery, transesophageal echocardiography is essential in order to guide cannulation of venous and arterial vessels for cardiopulmonary bypass and in providing immediate assessment of the quality of the performed repair. Intraoperative echocardiography can also detect complications associated with the performed procedure and can be an excellent hemodynamic monitor in unstable patients. In this paper different scenarios where intraoperative echocardiography is useful are reviewed, some clinical cases are shown to illustrate, and a review of related literature is reported.

The Impact of Intraoperative Echocardiography on Clinical Outcomes Following Adult Cardiac Surgery

Over the past 30 years, intraoperative echocardiography has become an invaluable diagnostic tool and monitor of cardiac performance for the management of cardiac surgical patients. The essential information provided by intraoperative echocardiography regarding hemodynamic management, cardiac valve function, congenital heart lesions, and great vessel pathology has contributed to its widespread popularity. Numerous investigations have been conducted in an attempt to specifically demonstrate a beneficial impact of intraoperative echocardiography in cardiac surgery. However, there is a relative paucity of data derived from prospective trials in which the use of intraoperative echocardiography has been randomized among various cardiac surgical patient populations to formally ascertain, rather than simply infer, its putative impact on perioperative decision-making and clinical outcomes. Ironically, the popularity of intraoperative echocardiography has imposed ethical limitations on performing randomized trials in patient populations for whom significant benefit has been previously inferred. Nonetheless, significant evidence has been published to support its almost universal acceptance as an important perioperative diagnostic tool and monitor for cardiac surgical patients. This review focuses on the impact of intraoperative echocardiography on clinical outcomes in the more common adult cardiac surgical scenarios, including coronary artery bypass graft surgery, mitral and aortic valve surgery, and in evaluating the intrathoracic aorta.

Design, Fabrication, and Characterization of a Bifrequency Colinear Array

Ultrasound imaging with high resolution and large penetration depth has been increasingly adopted in medical diagnosis, surgery guidance, and treatment assessment. Conventional ultrasound works at a particular frequency, with a [Formula: see text] fractional bandwidth of [Formula: see text], limiting the imaging resolution or depth of field. In this paper, a bifrequency colinear array with resonant frequencies of 8 and 20 MHz was investigated to meet the requirements of resolution and penetration depth for a broad range of ultrasound imaging applications. Specifically, a 32-element bifrequency colinear array was designed and fabricated, followed by element characterization and real-time sectorial scan (S-scan) phantom imaging using a Verasonics system. The bifrequency colinear array was tested in four different modes by switching between low and high frequencies on transmit and receive. The four modes included the following: 1) transmit low, receive low; 2) transmit low, receive high; 3) transmit high, receive low; and 4) transmit high, receive high. After testing, the axial and lateral resolutions of all modes were calculated and compared. The results of this study suggest that bifrequency colinear arrays are potential aids for wideband fundamental imaging and harmonic/subharmonic imaging.

Update on Perioperative Right Heart Assessment Using Transesophageal Echocardiography

Purpose of the review. This review aims to summarize recent findings relevant for perioperative 2- and 3-dimensional imaging of the right heart with transesophageal echocardiography. Special attention is given to developments that are likely to affect future approaches for prevention and therapy of perioperative right heart failure. Recent findings. Three-dimensional transesophageal echocardiography techniques are becoming more common for the evaluation of anatomy, volumes, and functional indices. Summary. Right heart failure continues to contribute to morbidity and mortality in the context of cardiothoracic surgery. The advent and widespread clinical use of innovative tools permitting more accurate echocardiographic assessment of the right heart will open the door to renewed interest in novel therapeutic strategies.

Perioperative Echocardiography

Echocardiography has been utilized perioperatively since the 1970s and many studies have been conducted to prove its efficacy. Epicardiac echocardiography (EE) is the modality of choice when transesophageal echocardiography (TEE) is contraindicated or when aortic atherosclerosis is suspected. Perioperative TEE has shown to be an excellent tool in the operating room for assessment, diagnosis, surgical guidance, and outcome evaluation. Pediatric surgery has also shown better surgical outcomes for congenital disease states with the guidance of TEE. The cardiac Sonographer’s role in the operating room is a very important one because it involves operating the ultrasound machine and communicating image interpretations to surgeons in a timely and efficient manner. Cardiac Sonographers eager to progress in their careers can take advantage of this opportunity to enhance their clinical and educational qualifications. Technology is advancing quickly with the breakthrough of 3D and 4D TEE, where images are captured in real time, providing improved diagnoses and prognosis. This article discusses the evolution of echocardiography in the operating room and its future impact on perioperative evaluation, with attention paid to the role of cardiac Sonographers and the future clinical progression in their scope of practice.

Left ventricular assist devices: physiologic assessment using echocardiography for management and optimization

Left ventricular assist devices (LVAD) are being deployed increasingly in patients with severe left ventricular dysfunction and medically refractory congestive heart failure of any etiology. The United States Food and Drug Administration (FDA) recently approved the use of the Thoratec Heartmate II (Thoratec Corporation, Pleasanton, CA, USA) for outpatient use. Echocardiography is fundamental during each stage of patient management, pre-LVAD placement, during LVAD placement, for postoperative LVAD optimization and long-term follow-up. We present a pragmatic and systematic echocardiographic approach that serves as a guide for the management of left ventricular assist devices.

Evaluation of transmitral pressure gradients in the intraoperative echocardiographic diagnosis of mitral stenosis after mitral valve repair

Objective

Acute mitral stenosis (MS) following mitral valve (MV) repair is a rare but severe complication. We hypothesize that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair.

Methods

The medical records of 552 consecutive patients undergoing MV repair at a single institution were reviewed. Post-cardiopulmonary bypass peak and mean transmitral pressure gradients (TMPG), and pressure half time (PHT) were obtained from intraoperative transesophageal echocardiographic (TEE) examinations in each patient.

Results

Nine patients (9/552 = 1.6%) received a reoperation for primary MS, prior to hospital discharge. Interestingly, all of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not: 10.7±4.8 mmHg vs 2.9±1.6 mmHg; p<0.0001 and 22.9±7.9 mmHg vs 7.6±3.7 mmHg; p<0.0001, respectively. However, PHT varied considerably (87±37 ms; range: 20–439 ms) within the entire population, and only weakly predicted the requirement for reoperation (113±56 vs. 87±37 ms, p = 0.034). Receiver operating characteristic curves showed strong discriminating ability for mean gradients (AUC = 0.993) and peak gradients (area under the curve, AUC = 0.996), but poor performance for PHT (AUC = 0.640). A value of ≥7 mmHg for mean, and ≥17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not.

Conclusions

Intraoperative TEE diagnosis of a peak TMPG ≥17 mmHg or mean TMPG ≥7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair.

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.

Perioperative management of a patient with Chagas disease having mitral valve surgery

A patient with advanced Chagas disease presented with symptoms attributable to dilated cardiomyopathy and mitral regurgitation. Although esophageal involvement is part of the constellation of findings in Chagas, transesophageal echocardiography was safely used to guide the mitral valve surgery.

The right ventricle in cardiac surgery, a perioperative perspective: I. Anatomy, physiology, and assessment

The importance of right ventricular (RV) function in cardiovascular disease and cardiac surgery has been recognized for several years. RV dysfunction has been shown to be a significant prognostic factor in heart failure, congenital heart disease, valvular disease, and cardiac surgery. In the first of our two articles, we will review key features of RV anatomy, physiology, and assessment. In the first article, the main discussion will be centered on the echographic assessment of RV structure and function. In the second review article, pathophysiology, clinical importance, and management of RV failure in cardiac surgery will be discussed.

The influence of epiaortic ultrasonography on intraoperative surgical management in 6051 cardiac surgical patients

BACKGROUND

Intraoperative echocardiography has become a mainstay monitor of cardiac function and a popular diagnostic tool in patients undergoing cardiac procedures. Previous reports suggest that epiaortic ultrasonography (EU) is superior to transesophageal echocardiography and manual palpation in identifying ascending aortic atheroma. Its impact on surgical decision making has not been thoroughly investigated, however.

METHODS

We retrospectively analyzed the medical records of 6051 consecutive patients who underwent EU of their ascending aorta during cardiac operations between 1996 and 2006 to determine a potential impact on intraoperative surgical decision making. Aortic atheroma was graded according to standard classification. Neurologic complications were evaluated according to the Society of Thoracic Surgeon definition for stroke and transient ischemic attack (TIA).

RESULTS

The overall impact of EU on surgical decision making was 4.1% and included a change in the technique for inducing cardiac arrest in 1.8%, aortic atherectomy or replacement surgery in 0.8%, requirement for off-pump coronary artery bypass grafting (CABG) in 0.6%, avoidance of aortic cross-clamping and use of ventricular fibrillatory arrest in 0.5%, change in arterial cannulation site in 0.2%, or avoidance of aortic cannulation in 0.2%. The greatest affect of EU was observed in patients undergoing combined CABG with aortic/mitral valve procedures (6.7%). The smallest impact was seen in patients undergoing mitral valve operations (1.4%). Aortic atheroma was more frequent on the anterior aspect of the aorta (n = 171) in patients with a change in surgical plan than on the posterior aspect (n = 78). The overall stroke rate was lower in patients with intraoperative EU compared with all patients undergoing surgical procedures.

CONCLUSIONS

Epiaortic ultrasonography is a useful technique to detect ascending aortic atheroma, has a significant impact on surgical decision making in more than 4% of cardiac surgical patients, and might result in improved perioperative neurologic outcome.

A Systematic Approach to Substernal Epicardial Echocardiographic Examination

OBJECTIVE

The importance of echocardiography in the perioperative management of cardiac surgical patients is widely appreciated. A modified mediastinal drain has been developed, which allows the introduction of a standard TEE probe in a closed-ended sleeve coupled with the drain to permit epicardial echocardiographic imaging after chest closure (substernal epicardial echocardiography [SEE]). The aim of the present study was to develop a standardized and comprehensive SEE examination sequence to allow repeatable examinations with a single movement of the TEE probe inside the drain.

DESIGN

Prospective observational protocol.

SETTING

Tertiary care university hospital.

PARTICIPANTS

Ten adult patients undergoing elective cardiac surgery.

INTERVENTIONS

Twenty-three SEE examinations in 10 patients undergoing elective myocardial revascularization to develop a standard examination sequence.

MEASUREMENTS AND MAIN RESULTS

The examination sequence includes 11 views with all the structures relevant for postoperative monitoring. The entire sequence is performed with a single in-out movement of the transesophageal probe to minimize discomfort to patients and the risk of damaging the tube.

CONCLUSIONS

This new approach to the perioperative monitoring of cardiac surgical patients represents an option for patients in whom TEE is contraindicated or multiple examinations are anticipated because SEE examinations can be performed without the need for sedation in awake patients.

Epicardial Real-Time Three-Dimensional Echocardiography in Cardiac Surgery: A Preliminary Experience

PURPOSE

Intraoperative two-dimensional transesophageal echocardiography (2DTEE) is a widely accepted method to guide cardiac valve surgery. The aim of our study was to evaluate the feasibility, effectiveness, and incremental value of intraoperative epicardial real-time three-dimensional echocardiography (RT3DE).

DESCRIPTION

Thirty consecutive patients (18 aortic and 12 mitral valve diseases) underwent intraoperative 2DTEE and RT3DE before and after cardiopulmonary bypass. Five observers compared independently 2DTEE to live and full volume images and to the surgical view, to assess the incremental value of RT3DE in depicting the different anatomic structures.

EVALUATION

Epicardial RT3DE was feasible in all patients. Qualitative evaluation determined RT3DE superiority in depicting aortic cusp morphologic lesions; left ventricular outflow tract spatial relationships with mitral apparatus and aortic root; and both anterior and posterior mitral leaflet scallops, particularly posterior commissure.

CONCLUSIONS

In our study, epicardial RT3DE has been demonstrated to improve morphologic definition of anatomic valvular lesions and their relationship with cardiac adjacent structures. It may be a valid substitute when the 2DTEE approach is contraindicated, or it could have a complementary role, coupled with 2DTEE, to give additional information for surgical planning.

Perioperative Echokardiographie

Over the past decades, echocardiography has undergone a continuous evolution in technology that has promoted its clinical application and acceptance throughout perioperative medicine. These technological advances include improvements in transducer development that permit superior imaging quality and a wider selection of probes for epicardial, epiaortic, and surface echocardiography which can also be used in conjunction with multiplane transesophageal echocardiography. Moreover, the addition of Doppler technology and digital acquisition has secured the role of echocardiography as a valuable and relatively noninvasive diagnostic tool for the assessment of cardiovascular disease and hemodynamic monitoring throughout the perioperative period. Therefore, it has become increasingly important for perioperative physicians to understand the basic principles and underlying fundamental concepts pertaining to the technology and physics of echocardiography, as well as its inherent limitations. The current review outlines the modes and applications of different echocardiographic techniques used in perioperative echocardiography including M-mode, two-dimensional echocardiography, and Doppler assessment of blood flow. In addition, the limitations of these techniques and typical artifacts associated with the perioperative use of echocardiography are described.

Off-pump resection of a coronary arterial fistula using the Harmonic Scalpel

Off-pump surgery was performed in a patient with post-infarction angina complicated with aneurysmal coronary-pulmonary arterial fistula. Epicardial echocardiography localized the artery feeding the fistula in the myocardium, which had not been revealed by visual inspection, palpation, or transesophageal echocardiography. The patient underwent off-pump coronary artery bypass grafting concomitant with aneurysmectomy. The feeding arteries were dissected easily using a Harmonic Scalpel and ligated. The flow in the aneurysm disappeared immediately and aneurysmectomy was performed without bleeding.

[Preoperative evaluation and perioperative management of patients with increased cardiovascular risk]

Due to the increasing age in western countries, combined with high rates of major surgical interventions in high-risk patients, perioperative reduction of cardiovascular complications becomes increasingly more important for perioperative physicians. After identifying patients with increased perioperative risk, specific interventions need to be considered to reduce their risk for cardiovascular complications, either by perioperative medical therapy or specific treatment options (e.g. coronary intervention). Several trials have demonstrated an effect of perioperative beta-blocker-therapy in reducing cardiovascular complications among high-risk patients. Additionally, several monitoring techniques are effective in detecting cardiovascular complications. Nevertheless, it remains unclear whether they are associated with a measurable improvement of outcome. Based on the ACC/AHA-guidelines, the present review describes a stepwise approach to surgical patients to identify perioperative risks, based on specific patient related risk factors, the kind of surgery and on the specific setting (emergency versus elective surgery). In addition, strategies to reduce perioperative cardiovascular complications are discussed.

Transesophageal echocardiography for detecting extrapulmonary thrombi during pulmonary embolectomy

BACKGROUND

Pulmonary embolectomy is an evolving surgical procedure for the treatment of severe pulmonary embolism. In addition to removing pulmonary thromboemboli, the achievement of optimal results also requires identification and extraction of intrathoracic, extrapulmonary thromboemboli from the right atrium, right ventricle, and the superior or inferior vena cava. Otherwise, these thromboemboli may become the source of recurrent pulmonary embolism. Intraoperative transesophageal echocardiography is frequently used during pulmonary embolectomy as a guide for the surgeon and a monitor of cardiac performance. However, its utility for detecting concurrent intrathoracic, extrapulmonary thromboemboli has not been thoroughly investigated.

METHODS

The study population included 50 consecutive patients undergoing emergent pulmonary embolectomy. Results from preoperative diagnostic studies including transthoracic echocardiography; ventilation/perfusion scan, pulmonary angiography, and computed tomography were reviewed, along with the intraoperative echocardiographic reports for the presence of intrathoracic extrapulmonary thromboemboli. In addition, the surgical operative notes were consulted to determine the impact of intraoperative transesophageal echocardiography on surgical decision making.

RESULTS

Extrapulmonary intrathoracic thromboemboli were identified preoperatively in 8 patients (16%). Intraoperatively, thromboemboli were identified in 5 additional patients by transesophageal echocardiography, adding to a total of 13 patients with extrapulmonary thrombi (26%). Intraoperative transesophageal echocardiography provided the sole source of evidence that directed surgical management in 10% (5 of 50) of all patients undergoing pulmonary emboletcomy.

CONCLUSIONS

Intraoperative transesophageal echocardiography identified intrathoracic, extrapulmonary thomboemboli in 26% of patients undergoing pulmonary embolectomy, resulting in an alteration of surgical management in 10% of patients. These findings support the critical role of intraoperative echocardiography during pulmonary embolectomy.