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Intraoperative Transesophageal Echocardiography for Thoracic Surgery

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Principles and Practice of Anesthesia for Thoracic Surgery

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Abstract

The use of TEE outside of the cardiac operating room has significantly increased over the last few years. Thoracic surgery is naturally becoming an exciting field for the application of this powerful technology for more than one reason. In fact, in many institutions cardiac anesthetists, most of whom are TEE trained, provide their services to thoracic surgery. Moreover, the physiology of cardiopulmonary interaction, the growing number of combined cardiothoracic operations, and the increasing complexity of patients’ pathologies create the need for the complete intraoperative monitoring of cardiac function.

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  1. Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, ON, Canada

    Massimiliano Meineri

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  1. Massimiliano Meineri
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Correspondence to Massimiliano Meineri .

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  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Electronic Supplementary Material

Case discussion. Mid-esophageal four-chamber view, zoom on mitral valve, with color Doppler (M4V 4247 kb)

Case discussion. Mid-esophageal aortic valve long axis view: color Doppler of the LVOT and mitral valve (M4V 3092 kb)

Clinical Case Discussion

Clinical Case Discussion

Case: A 54-year-old female presents for double lung transplantation. The patient has a history of end-stage lung disease secondary to bronchiolitis obliterans. Preoperative echocardiogram showed normal RV and LV function, normal valves, and RVSP of 34 mmHg. MUGA confirmed good LV function and excluded myocardial ischemia. After a smooth induction of anesthesia, a TEE probe is inserted. The ME 4C view is displayed. Color Doppler analysis is performed on the MV (Video. 30.1).

  • Is there anything abnormal with the MV?

    • The base of the posterior mitral valve leaflet is calcified, a mass attached to its atrial aspect (arrow).

  • What could be the differential diagnosis of this pathology?

    • Thrombus, infective vegetation, or tumor.

  • What should be done to better assess the MV?

    • Obtain multiple views of the mitral valve with and without color Doppler.

  • What may be the surgical implications of this finding?

    • Use cardiopulmonary bypass to surgically explore the mitral valve and eventually perform valve surgery. Gentle manipulation of the heart should prevent dislodging of the mass attached to the mitral valve. A double lung transplant is performed without CPB. No surgery is performed on the MV nor is it surgically inspected.

  • What should be the focus of immediate post-CPB TEE exam?

    • Assess mitral valve for regurgitation and mass on the posterior leaflet.

After weaning from CPB, the patient is hypotensive regardless of high doses of inotropes.

TEE shows the abnormal flow in the LVOT and severe MR (Video 30.2).

  • What is happening?

    • This is a case of dynamic LVOT obstruction and systolic motion of the anterior mitral valve leaflet with severe mitral regurgitation. The hyperdynamic, hypertrophic left ventricle generates a high pressure gradient across the LVOT and for a Bernoulli effect sucks in the anterior leaflet of the mitral valve.

  • What is the treatment?

    • Volume load, avoid inotropes, and administer short-acting beta-blockers and vasopressor.

    • The postoperative course is complicated by decreased level of consciousness. Seven days postoperatively a CT scan of the brain showed multiple strokes. We cannot exclude that embolization of material from the MV mass may have contributed to the clinical picture.

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Meineri, M. (2019). Intraoperative Transesophageal Echocardiography for Thoracic Surgery. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_30

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_30

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-00858-1

  • Online ISBN: 978-3-030-00859-8

  • eBook Packages: MedicineMedicine (R0)

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