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LETTER TO EDITOR
Year : 2015  |  Volume : 25  |  Issue : 1  |  Page : 37-38

Intraoperative transesophageal echocardiography influences surgery


1 Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India

Date of Web Publication9-Jun-2015

Correspondence Address:
Monish S Raut
Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2211-4122.158432

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How to cite this article:
Raut MS, Maheshwari A, Shad S. Intraoperative transesophageal echocardiography influences surgery. J Cardiovasc Echography 2015;25:37-8

How to cite this URL:
Raut MS, Maheshwari A, Shad S. Intraoperative transesophageal echocardiography influences surgery. J Cardiovasc Echography [serial online] 2015 [cited 2020 Aug 14];25:37-8. Available from: http://www.jcecho.org/text.asp?2015/25/1/37/158432

Dear Sir,

A 54-year-old male patient presented with retrosternal chest pain and shortness of breath. On evaluation, he was found to have anterior wall myocardial infarction with atrial fibrillation of unknown duration. Coronary angiography revealed severe triple vessel disease. Transthoracic echocardiography showed left ventricular ejection fraction of 45% with hypokinetic anterior wall and no evidence of clot in cardiac chamber. Patient had no history of any neurological symptom. Patient was scheduled for emergency off pump coronary artery bypass grafting surgery (OPCABG) just 6 h after the angiogrpahy. After induction of anesthesia, transesophageal echocardiography (TEE) was done before surgery as a routine protocol. TEE 2 chamber view revealed freely mobile clot with high embolic potential in left atrial appendage (LAA). Clot size was 1.02 cm 2 [Figure 1], [Video Clip 1]. After consulting surgeon, it was decided to change surgical plan from off pump to on pump. After instituting cardiopulmonary bypass, LAA clot was removed followed by coronary artery bypass grafting (CABG). Patient's postoperative course was smooth without any evidence of organ ischemia. Off pump, CABG involves frequent manipulations of heart which can easily dislodge the clot into a systematic circulation and cause embolic ischemic injury.
Figure 1: Tranesophageal echocardiography 2 chamber view showing left atrial appendage clot marked with arrow

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Elayda et al. have reported the impact of intraoperative TEE on valve surgery, with changes in the operative plan based on TEE findings in 11-14% of cases. [1] Studies have emphasized utility and impact of TEE in the setting of other cardiac surgical procedures. [2] OPCABG is associated with significantly lower incidence of permanent focal neurologic events than with on pump CABG. [3]

Transesophageal echocardiography has important pivotal role in deciding surgical plan.

In the present case, though the initial plan of surgery was OPCABG, significant clot finding of TEE changed the surgical plan to on pump CABG considering risk thromboembolic event in this patient in off pump surgery.

 
  References Top

1.
Elayda MA, Hall RJ, Reul RM, Alonzo DM, Gillette N, Reul GJ Jr, et al. Aortic valve replacement in patients 80 years and older. Operative risks and long-term results. Circulation 1993;88:II11-6.  Back to cited text no. 1
    
2.
Fanshawe M, Ellis C, Habib S, Konstadt SN, Reich DL. A retrospective analysis of the costs and benefits related to alterations in cardiac surgery from routine intraoperative transesophageal echocardiography. Anesth Analg 2002;95:824-7.  Back to cited text no. 2
    
3.
Patel NC, Deodhar AP, Grayson AD, Pullan DM, Keenan DJ, Hasan R, et al. Neurological outcomes in coronary surgery: Independent effect of avoiding cardiopulmonary bypass. Ann Thorac Surg 2002;74:400-5.  Back to cited text no. 3
    


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