Intraoperative detection of pulmonary thromboemboli with epicardial echocardiography

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.

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.

The Role of Transesophageal Echocardiography in Rapid Diagnosis and Treatment of Migratory Tumor Embolus

Transesophageal echocardiography (TEE) is sometimes used in renal cell carcinoma excision for evaluating the extension of tumor in the inferior vena cava (IVC), characterizing the tumor anatomy, monitoring the tumor during surgical mobilization, and assessing cardiac function. Although the risk for embolization is small, when embolization does occur, its consequences can be catastrophic. In this case report, we describe the crucial role of TEE in diagnosing an intraoperative migratory embolus from the IVC to the pulmonary artery and also provide both single-frame photographs and Internet-accessible videos of the event. Our case illustrates the key role that TEE played in the intraoperative management of a patient with renal cell carcinoma undergoing surgical excision of tumor. TEE aided in accurately defining the cephalad extent of the thrombus, provided continuous monitoring of the thrombus during surgical manipulation, and allowed immediate identification of its embolization and proper notification of the surgeons. This case illustrates the crucial role TEE played in the management of a migratory tumor embolus and argues for its routine use during excision of renal cell carcinomas invading the IVC.

A practical approach to a comprehensive epicardial and epiaortic echocardiographic examination

OBJECTIVE

More than a decade before the introduction of intraoperative transesophageal echocardiography (TEE), epicardial echocardiography was already in use as a diagnostic imaging modality to assist cardiac surgeons and anesthesiologists with clinical decision making. Although TEE has since become increasingly more popular, epicardial echocardiography may be the most convenient intraoperative imaging technique when TEE probe placement cannot be performed or is contraindicated. The authors developed a comprehensive examination protocol for the intraoperative interrogation of cardiac structures using an epicardial/epiaortic echocardiographic approach.

DESIGN

Retrospective analysis of patient's medical records.

SETTING

Single-center academic tertiary care hospital.

PARTICIPANTS

Patients undergoing cardiac surgery.

INTERVENTIONS

A total of 10 echocardiographic views were obtained for imaging cardiac structures, the ascending aorta, and proximal aortic arch. The described imaging planes permit the evaluation of ventricular performance, valvular function, cardiac structural abnormalities, and aortic disease.

MEASUREMENTS AND MAIN RESULTS

A comprehensive epicardial/epiaortic echocardiographic examination was performed in 20 patients undergoing cardiac surgery requiring a full sternotomy. The described imaging planes were obtained in all patients in less than 8 minutes (range, 3.5-8 minutes; mean, 5.5 minutes).

CONCLUSION

The present manuscript delineates a protocol for performing a comprehensive, intraoperative epicardial/epiaortic echocardiographic examination. Echocardiographic imaging planes of cardiac and aortic anatomy are described. This protocol may be useful for cardiac surgeons and anesthesiologists seeking to use this technique as a cardiac imaging modality that is complementary to TEE.

Epicardial echocardiography: diagnostic utility for evaluating aortic valve disease during coronary surgery

Intraoperative epicardial echocardiography is commonly used to evaluate the ascending aorta for atheromatous disease before cannulation and cross clamping. In addition, it may serve as a cardiac imaging technique in patients where placement of a transesophageal echocardiography (TEE) probe is contraindicated, probe advancement is difficult, or a TEE probe is not available. We report a patient who was taken to the OR for coronary artery bypass grafting. Intraoperative TEE was planned to evaluate aortic valve function. However, attempts to place a TEE probe were abandoned due to high resistance on probe insertion. Epicardial echocardiography revealed previously undiagnosed aortic valve disease resulting in replacement of this valve.