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Unexpected Intraoperative Diagnosis of Pulmonary Embolism by Transesophageal Echocardiography
Unexpected Intraoperative Diagnosis of Pulmonary Embolism by Transesophageal Echocardiography Alina Nicoara, MD,* Sherif Assaad, MD,* Arnar Geirsson, MD,† Anthony Rousou, MD,† and Farid Jadbabaie, MD‡
P
ULMONARY EMBOLISM (PE) is associated with significant perioperative morbidity and mortality. The authors present the case of a patient in whom the intraoperative diagnosis of PE by transesophageal echocardiography (TEE) altered the surgical management and most likely improved the outcome. CASE REPORT A 68-year-old man was admitted to the authors’ institution for progressive exertional chest pain and dyspnea, which had developed in the days before his admission. His past medical history was significant for stable exertional dyspnea for the past 2 years, obesity, hypertension, dyslipidemia, and impaired fasting glucose. The patient was admitted with the diagnosis of unstable angina, he had 3 sets of negative cardiac biomarkers, and an electrocardiogram was performed that did not show ischemic changes. A pharmacologic myocardial perfusion imaging test was negative for ischemia. Based on the intensity of his symptoms, the patient was referred for coronary angiography. The coronary angiography showed triple vessel disease, and the patient was referred for surgical revascularization. The patient was scheduled for on-pump coronary artery bypass graft (CABG) surgery. In the operating room after the induction of general anesthesia, a TEE probe was placed and a pulmonary artery catheter was floated in the proximal pulmonary artery (PA). Immediately after placement, unexpected pulmonary hypertension was noted with PA systolic pressure varying from 63 to 71 mmHg, whereas the systemic systolic pressures ranged from 110 to 140 mmHg. The TEE examination revealed mild enlargement of the right atrium and right ventricular chambers, bowing of the interatrial septum toward the left, flattening of the interventricular septum, and normal right ventricular systolic function. The left ventricular systolic function was normal, and there was no valvular pathology. The color-flow Doppler interrogation of the interatrial septum showed a patent foramen ovale (PFO) with right-to-left shunt documented by the injection of agitated saline bubbles. However, there was no clinical or echocardiographic explanation for the unexpected high PA pressures. Further TEE examination of the great vessels in modified midesophageal short- and long-axis views of the ascending aorta with focus on the distal right PA revealed a mass within the lumen of the right PA with small mobile components (Videos 1 and 2 and Fig 1). The injection of agitated saline confirmed a filling defect in the right PA. Epivascular examination of the pulmonary arteries showed a saddle thrombus originating from the PA bifurcation and extending into the right and left pulmonary arteries (Video 3 and Fig 2). After the initiation of cardiopulmonary bypass (CPB), pulmonary arteriotomy and embolectomy were performed, and several large fresh thrombi were removed from the main PA and the right and left pulmonary arteries extending at least into the secondorder branches (Fig 3). The patient subsequently underwent CABG and closure of the PFO. After separation from CPB, the pulmonary systolic pressures varied from 40 to 45 mmHg. Venous Doppler of the lower extremities obtained during the postoperative period revealed deep venous thrombosis in both extremities. A workup for a hypercoagulable state was negative. The patient had an uneventful postoperative course and was discharged home on oral anticoagulation and made a full recovery. DISCUSSION
This case report describes a patient with chronic exertional dyspnea and progressively worsening exertional symptoms in the days preceding his admission. The patient was found to have triple-vessel coronary artery disease, underwent an urgent
Fig 1. The midesophageal ascending aorta short-axis view. The right pulmonary artery in the long axis containing a mass (delineated by arrows) is visible in the near field.
CABG procedure, and was diagnosed with PE by intraoperative TEE. Whether PE contributed to the symptoms exhibited on admission is difficult to determine, given the fact that physical findings may be completely normal in early submassive PE.1 Although PE is a common condition in hospitalized patients, intraoperative diagnosis of PE is a rare event, with few cases reported in the literature over the past 15 years.2-9 PE is associated with significant morbidity and mortality. If untreated, PE is associated with a mortality rate of approximately 30%.10 Patients who survive an episode of acute PE are at significant risk for recurrent embolism, leading to the development of chronic pulmonary hypertension and cor pulmonale. However, prompt diagnosis followed by effective therapy may dramatically decrease the mortality rate.10 The utility of TEE in diagnosing PE is under dispute and has been thoroughly discussed by other investigators.11 The main PA, the PA bifurcation, and the right PA can be visualized in the midesophageal views of the ascending aorta. Even if the thrombus is not visualized in the proximal pulmonary arteries, secondary signs of PA obstruction such as dilated right heart chambers, flattening of the interventricular septum, leftward bowing of the interatrial septum, depressed right heart function, and right-to-left shunt through a PFO, although all nonspecific, may support a diagnosis and warrant further tests in patients with high clinical
From the Departments of *Anesthesiology, †Surgery, and ‡Cardiology, West Haven VA Medical Center, Yale University School of Medicine, West Haven, CT. Address reprint requests to Farid Jadbabaie, MD, Department of Cardiology, West Haven VA Medical Center, 950 Campbell Avenue, West Haven, CT 06516. E-mail: [email protected] Published by Elsevier Inc. 1053-0770/2404-0018$36.00/0 doi:10.1053/j.jvca.2009.05.015 Key words: pulmonary embolism, transesophageal echocardiography, epivascular
Journal of Cardiothoracic and Vascular Anesthesia, Vol 24, No 4 (August), 2010: pp 639-640
639
640
NICOARA ET AL
suspicion of PE. The present patient did not exhibit all the secondary signs of PA obstruction probably because of the fact that he presented with early submassive pulmonary embolism. In the authors’ opinion, the case presented here raises a few important issues. PE is a common and lethal condition, and a diagnosis should be sought actively whenever warranted by the clinical picture. The unexpected elevation of PA pressures in the present patient led to active pursuit of an etiology for pulmonary hypertension. The diagnosis of PE changed the surgical management and most likely improved the outcome. A thorough and comprehensive intraoperative TEE examination, as recommended by the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists guidelines,12 raised the suspicion of a mobile mass that eventually resulted in the diagnosis of PE. Although the TEE examination identified the presence of a mass in the right PA, it was the use of an epivascular probe that confirmed the presence of the saddle embolus extending into the Fig 3. Thrombi removed from the main pulmonary artery as well as from the right and left pulmonary arteries extending into the second-order branches. (Color version of figure is available online.)
Fig 2. An epivascular image of the right pulmonary artery. The arrows delineate the mass.
right and left pulmonary arteries. The higher frequencies at which the epivascular probes operate allow for a better 2D resolution at the cost of a shallower penetration. The employment of the epivascular probe in the surgical field allows for direct visualization of the anatomic structures including those inaccessible by TEE such as the left PA because of the interposition of the left main bronchus. It has been recommended that epivascular imaging can be “realistically justified based on an intuitively favorable risk-benefit ratio.”13 As described before in the literature, in situations of high clinical suspicion, epivascular echocardiography can be a powerful tool in confirming the diagnosis and guiding surgical approach.2,14
REFERENCES 1. Stein PD, et al: Clinical characteristics of patients with acute pulmonary embolism: Data from PIOPED II. Am J Med 120:871-879, 2007 2. Allyn JW, et al: The use of epicardial echocardiography as an adjunct to transesophageal echocardiography for the detection of pulmonary embolism. Anesth Analg 102:729-730, 2006 3. Jha NK, et al: Acute pulmonary thromboembolism during mitral valve repair. Heart Lung Circ 17:159-161, 2008 4. Langeron O, et al: Massive intraoperative pulmonary embolism: Diagnosis with transesophageal two-dimensional echocardiography. Anesth Analg 74:148-150, 1992 5. Nowak M, et al: A novel view for visualizing a left pulmonary artery thromboembolus with intraoperative transesophageal echocardiography. J Clin Anesth 20:136-138, 2008 6. Obray JB, et al: Cardiovascular collapse during elective orthopedic surgery: Massive intraoperative pulmonary thromboembolism treated with emergent cardiopulmonary bypass. J Clin Anesth 17:205-208, 2005 7. Sermeus L, et al: Pulmonary embolism confirmed by transoesophageal echocardiography. Anaesthesia 47:28-29, 1992 8. Whitby ME, Hellings MJ: Massive intraoperative pulmonary thromboembolism treated by pulmonary embolectomy. Anaesth Intensive Care 21:342-343, 1993
9. Wilson WC, et al: Massive intraoperative pulmonary embolus diagnosed by transesophageal echocardiography. Anesthesiology 81: 504-508, 1994 10. Carson JL, et al: The clinical course of pulmonary embolism. N Engl J Med 326:1240-1245, 1992 11. Rosenberger P, et al: Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism. Anesth Analg 99:12-16, 2004 12. Shanewise JS, et al: ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 89:870-884, 1999 13. Glas KE, et al: Guidelines for the performance of a comprehensive intraoperative epiaortic ultrasonographic examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons. Anesth Analg 106:1376-1384, 2008 14. Tsubo T, et al: Accurate detection of pulmonary embolism using epicardial echocardiography during right nephrectomy in a patient with renal cell carcinoma. J Cardiothorac Vasc Anesth 12:684-685, 1998
P
ULMONARY EMBOLISM (PE) is associated with significant perioperative morbidity and mortality. The authors present the case of a patient in whom the intraoperative diagnosis of PE by transesophageal echocardiography (TEE) altered the surgical management and most likely improved the outcome. CASE REPORT A 68-year-old man was admitted to the authors’ institution for progressive exertional chest pain and dyspnea, which had developed in the days before his admission. His past medical history was significant for stable exertional dyspnea for the past 2 years, obesity, hypertension, dyslipidemia, and impaired fasting glucose. The patient was admitted with the diagnosis of unstable angina, he had 3 sets of negative cardiac biomarkers, and an electrocardiogram was performed that did not show ischemic changes. A pharmacologic myocardial perfusion imaging test was negative for ischemia. Based on the intensity of his symptoms, the patient was referred for coronary angiography. The coronary angiography showed triple vessel disease, and the patient was referred for surgical revascularization. The patient was scheduled for on-pump coronary artery bypass graft (CABG) surgery. In the operating room after the induction of general anesthesia, a TEE probe was placed and a pulmonary artery catheter was floated in the proximal pulmonary artery (PA). Immediately after placement, unexpected pulmonary hypertension was noted with PA systolic pressure varying from 63 to 71 mmHg, whereas the systemic systolic pressures ranged from 110 to 140 mmHg. The TEE examination revealed mild enlargement of the right atrium and right ventricular chambers, bowing of the interatrial septum toward the left, flattening of the interventricular septum, and normal right ventricular systolic function. The left ventricular systolic function was normal, and there was no valvular pathology. The color-flow Doppler interrogation of the interatrial septum showed a patent foramen ovale (PFO) with right-to-left shunt documented by the injection of agitated saline bubbles. However, there was no clinical or echocardiographic explanation for the unexpected high PA pressures. Further TEE examination of the great vessels in modified midesophageal short- and long-axis views of the ascending aorta with focus on the distal right PA revealed a mass within the lumen of the right PA with small mobile components (Videos 1 and 2 and Fig 1). The injection of agitated saline confirmed a filling defect in the right PA. Epivascular examination of the pulmonary arteries showed a saddle thrombus originating from the PA bifurcation and extending into the right and left pulmonary arteries (Video 3 and Fig 2). After the initiation of cardiopulmonary bypass (CPB), pulmonary arteriotomy and embolectomy were performed, and several large fresh thrombi were removed from the main PA and the right and left pulmonary arteries extending at least into the secondorder branches (Fig 3). The patient subsequently underwent CABG and closure of the PFO. After separation from CPB, the pulmonary systolic pressures varied from 40 to 45 mmHg. Venous Doppler of the lower extremities obtained during the postoperative period revealed deep venous thrombosis in both extremities. A workup for a hypercoagulable state was negative. The patient had an uneventful postoperative course and was discharged home on oral anticoagulation and made a full recovery. DISCUSSION
This case report describes a patient with chronic exertional dyspnea and progressively worsening exertional symptoms in the days preceding his admission. The patient was found to have triple-vessel coronary artery disease, underwent an urgent
Fig 1. The midesophageal ascending aorta short-axis view. The right pulmonary artery in the long axis containing a mass (delineated by arrows) is visible in the near field.
CABG procedure, and was diagnosed with PE by intraoperative TEE. Whether PE contributed to the symptoms exhibited on admission is difficult to determine, given the fact that physical findings may be completely normal in early submassive PE.1 Although PE is a common condition in hospitalized patients, intraoperative diagnosis of PE is a rare event, with few cases reported in the literature over the past 15 years.2-9 PE is associated with significant morbidity and mortality. If untreated, PE is associated with a mortality rate of approximately 30%.10 Patients who survive an episode of acute PE are at significant risk for recurrent embolism, leading to the development of chronic pulmonary hypertension and cor pulmonale. However, prompt diagnosis followed by effective therapy may dramatically decrease the mortality rate.10 The utility of TEE in diagnosing PE is under dispute and has been thoroughly discussed by other investigators.11 The main PA, the PA bifurcation, and the right PA can be visualized in the midesophageal views of the ascending aorta. Even if the thrombus is not visualized in the proximal pulmonary arteries, secondary signs of PA obstruction such as dilated right heart chambers, flattening of the interventricular septum, leftward bowing of the interatrial septum, depressed right heart function, and right-to-left shunt through a PFO, although all nonspecific, may support a diagnosis and warrant further tests in patients with high clinical
From the Departments of *Anesthesiology, †Surgery, and ‡Cardiology, West Haven VA Medical Center, Yale University School of Medicine, West Haven, CT. Address reprint requests to Farid Jadbabaie, MD, Department of Cardiology, West Haven VA Medical Center, 950 Campbell Avenue, West Haven, CT 06516. E-mail: [email protected] Published by Elsevier Inc. 1053-0770/2404-0018$36.00/0 doi:10.1053/j.jvca.2009.05.015 Key words: pulmonary embolism, transesophageal echocardiography, epivascular
Journal of Cardiothoracic and Vascular Anesthesia, Vol 24, No 4 (August), 2010: pp 639-640
639
640
NICOARA ET AL
suspicion of PE. The present patient did not exhibit all the secondary signs of PA obstruction probably because of the fact that he presented with early submassive pulmonary embolism. In the authors’ opinion, the case presented here raises a few important issues. PE is a common and lethal condition, and a diagnosis should be sought actively whenever warranted by the clinical picture. The unexpected elevation of PA pressures in the present patient led to active pursuit of an etiology for pulmonary hypertension. The diagnosis of PE changed the surgical management and most likely improved the outcome. A thorough and comprehensive intraoperative TEE examination, as recommended by the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists guidelines,12 raised the suspicion of a mobile mass that eventually resulted in the diagnosis of PE. Although the TEE examination identified the presence of a mass in the right PA, it was the use of an epivascular probe that confirmed the presence of the saddle embolus extending into the Fig 3. Thrombi removed from the main pulmonary artery as well as from the right and left pulmonary arteries extending into the second-order branches. (Color version of figure is available online.)
Fig 2. An epivascular image of the right pulmonary artery. The arrows delineate the mass.
right and left pulmonary arteries. The higher frequencies at which the epivascular probes operate allow for a better 2D resolution at the cost of a shallower penetration. The employment of the epivascular probe in the surgical field allows for direct visualization of the anatomic structures including those inaccessible by TEE such as the left PA because of the interposition of the left main bronchus. It has been recommended that epivascular imaging can be “realistically justified based on an intuitively favorable risk-benefit ratio.”13 As described before in the literature, in situations of high clinical suspicion, epivascular echocardiography can be a powerful tool in confirming the diagnosis and guiding surgical approach.2,14
REFERENCES 1. Stein PD, et al: Clinical characteristics of patients with acute pulmonary embolism: Data from PIOPED II. Am J Med 120:871-879, 2007 2. Allyn JW, et al: The use of epicardial echocardiography as an adjunct to transesophageal echocardiography for the detection of pulmonary embolism. Anesth Analg 102:729-730, 2006 3. Jha NK, et al: Acute pulmonary thromboembolism during mitral valve repair. Heart Lung Circ 17:159-161, 2008 4. Langeron O, et al: Massive intraoperative pulmonary embolism: Diagnosis with transesophageal two-dimensional echocardiography. Anesth Analg 74:148-150, 1992 5. Nowak M, et al: A novel view for visualizing a left pulmonary artery thromboembolus with intraoperative transesophageal echocardiography. J Clin Anesth 20:136-138, 2008 6. Obray JB, et al: Cardiovascular collapse during elective orthopedic surgery: Massive intraoperative pulmonary thromboembolism treated with emergent cardiopulmonary bypass. J Clin Anesth 17:205-208, 2005 7. Sermeus L, et al: Pulmonary embolism confirmed by transoesophageal echocardiography. Anaesthesia 47:28-29, 1992 8. Whitby ME, Hellings MJ: Massive intraoperative pulmonary thromboembolism treated by pulmonary embolectomy. Anaesth Intensive Care 21:342-343, 1993
9. Wilson WC, et al: Massive intraoperative pulmonary embolus diagnosed by transesophageal echocardiography. Anesthesiology 81: 504-508, 1994 10. Carson JL, et al: The clinical course of pulmonary embolism. N Engl J Med 326:1240-1245, 1992 11. Rosenberger P, et al: Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism. Anesth Analg 99:12-16, 2004 12. Shanewise JS, et al: ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 89:870-884, 1999 13. Glas KE, et al: Guidelines for the performance of a comprehensive intraoperative epiaortic ultrasonographic examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons. Anesth Analg 106:1376-1384, 2008 14. Tsubo T, et al: Accurate detection of pulmonary embolism using epicardial echocardiography during right nephrectomy in a patient with renal cell carcinoma. J Cardiothorac Vasc Anesth 12:684-685, 1998