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Another Use for Transesophageal Echocardiography During Aortic Valve Bypass Surgery
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LETTERS TO THE EDITOR
Fig 2. Continuous-wave Doppler echocardiogram with sampling volume in the LVOT showing a peak velocity of approximately 5 m/s (translating to a gradient of 100 mmHg).
Dynamic LVOT obstruction after MV replacement can occur with a narrowed mitral-aortic angle, a thickened interventricular septum, systolic anterior motion of the preserved anterior mitral leaflet, and a small hypercontractile left ventricle.5 In the present case, altered mobility of the sutured leaflets of the MV from the Alfieri repair may have contributed to the dynamic obstruction in a previously narrowed LVOT. The shape of the continuouswave Doppler profile also was useful in substantiating our diagnosis of dynamic LVOT obstruction. Dynamic LVOT obstruction shows a characteristic dagger-shaped flow profile on continuous-wave Doppler echocardiogram, with velocity peaking in late systole as seen in Figure 2. Aggressive management with inotropes can significantly worsen hemodynamics in the setting of dynamic LVOT obstruction. Even though the resuscitation itself was unremarkable, we attribute our positive outcome to early recognition of the problem, prompt availability and use of TEE, aggressive fluid management, prudent titration of vasoactive medications, and good teamwork in the intensive care unit environment. Shuchita Garg, MD Avinash B. Kumar, MBBS, FCCP Department of Anesthesia University of Iowa Hospitals and Clinics, Iowa City, IA
5. Okamoto K, Kiso I, Inoue Y, et al: Left ventricular outflow obstruction after mitral valve replacement preserving native anterior leaflet. Ann Thorac Surg 82:735-737, 2006 http://dx.doi.org/10.1053/j.jvca.2012.08.006
Another Use for Transesophageal Echocardiography During Aortic Valve Bypass Surgery To the Editor: We read with interest the recent article by Odonkor et al,1 in which they gave a thorough review of aortic valve bypass (apicoaortic conduit) surgery and anesthetic management. We would like to offer additional considerations to the intraoperative anesthetic management of these patients. One of the surgical techniques involved in the placement of an aortic valve bypass without cardiopulmonary bypass is the placement of a Foley catheter, or other comparable
REFERENCES 1. Maslow A, Mahmood F, Singh A, et al: Problems with excess mitral leaflet after repair: Possible issues during repair and preservation of the posterior leaflet. J Cardiothorac Vasc Anesth 27:92–97, 2013 2. Maisano F, Schreuder JJ, Oppizzi M, et al: The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: Surgical technique. Eur J Cardiothorac Surg 17:201-205, 2000 3. St Andre´ AC, DelRossi A: Hemodynamic management of patients in the first 24 hours after cardiac surgery. Crit Care Med 33: 2082-2093, 2005 4. Karski JM: Transesophageal echocardiography in the intensive care unit. Semin Cardiothorac Vasc Anesth 10:162-166, 2006
Fig 1. Midesophageal long-axis view depicting balloon malposition (arrow) in the left ventricular outflow tract.
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LETTERS TO THE EDITOR
Fig 2. Midesophageal long-axis view showing correct balloon position (arrow) in the apex of the left ventricle.
balloon-tipped catheter, through the apex of the left ventricle to minimize blood loss and help guide apical coring.2 During this step, the balloon can be malpositioned in the left ventricular outflow tract (Fig 1) or disrupt the mitral valve apparatus. Confirmation of correct placement of the balloon-tipped catheter by transesophageal echocardiography (Fig 2) can prevent left ventricular outflow tract obstruction and minimize damage to the mitral valve and subvalvular apparatus. Justin W. Wilson, MD Julian Bick, MD Annemarie Thompson, MD Department of Cardiothoracic Anesthesiology Vanderbilt University Medical Center Nashville, TN
REFERENCES 1. Odonkor P, Stansbury LG, Gammie JS, et al: Anesthetic management of patients undergoing aortic valve bypass (apicoaortic conduit) surgery. J Cardiothorac Vasc Anesth 26:148-160, 2012 2. Vassiliades TA: Off-pump apicoaortic conduit insertion for high-risk patients with aortic stenosis. Eur J Cardiothorac Surg 23:156-158, 2003 http://dx.doi.org/10.1053/j.jvca.2012.09.003
effectively can diagnose hypovolemia, cardiac dysfunction, myocardial ischemia/infarction, and solid-phase pulmonary thromboembolism. We present the case of a 43-year-old, 182.2-lb woman undergoing laparoscopic lysis of adhesions who experienced sudden cardiovascular collapse after insufflation of CO2 through a Veress needle placed in the right upper quadrant. Her past medical history was notable for right ventricular outflow tract ventricular tachycardia for which she had undergone 3 ablation procedures 15 years prior and atrioventricular nodal re-entry tachycardia for which she had undergone an ablation procedure 12 years prior. A recent transthoracic echocardiogram showed a left ventricular ejection fraction of 55%, an estimated pulmonary artery systolic pressure of 36 mmHg, and moderate tricuspid regurgitation. The patient also had a history of superior mesenteric vein thrombus identified 16 months before presentation and had completed 6 months of anticoagulation with warfarin. Soon after insufflation of the abdomen with CO2, the patient’s heart rate decreased from 60 to 30 beats/min, with a reduction in SpO2 from 99% to 89%. Insufflation was discontinued, the Veress needle was removed, and 0.8 mg of atropine was administered intravenously. However, the patient became asystolic, the PETCO2 declined, and chest compressions were commenced. Pulseless ventricular tachycardia developed immediately thereafter, and a synchronized 200-J biphasic shock was administered. The cardiac rhythm then deteriorated into ventricular fibrillation. Epinephrine, 1 mg intravenously, was administered, and a second 200-J biphasic shock was delivered with conversion to sinus rhythm with a stable blood pressure of 104/63 mmHg, a heart rate of 105 BPM, and a end tidal carbon dioxide of 30 mmHg. Steep, transient ST elevations 42 mm were noted in all electrocardiographic leads with a return of spontaneous circulation. The differential diagnosis for the hemodynamic compromise consisted of CO2 embolism, primary arrhythmia, myocardial ischemia, and pulmonary thromboembolism. A TEE study then was used to identify gas within all 4 cardiac chambers and within the hepatic circulation, thus establishing the diagnosis of paradoxical CO2 embolism after unintentional intrahepatic Veress needle placement. A 4chamber view showed bubbles in all cardiac chambers (Fig 1 and Video 1 [supplementary videos are available online]).
Rescue Transesophageal Echocardiography for the Diagnosis and Management of Paradoxical Carbon Dioxide Embolism With Hemodynamic Compromise During Laparoscopic Surgery To the Editor: As Shillcut et al1 eloquently stated, a transesophageal echocardiogram (TEE) during cardiovascular collapse in noncardiac surgery is a valuable imaging modality that
Fig 1.
TEE showing intracardiac CO2 gas bubbles.
LETTERS TO THE EDITOR
Fig 2. Continuous-wave Doppler echocardiogram with sampling volume in the LVOT showing a peak velocity of approximately 5 m/s (translating to a gradient of 100 mmHg).
Dynamic LVOT obstruction after MV replacement can occur with a narrowed mitral-aortic angle, a thickened interventricular septum, systolic anterior motion of the preserved anterior mitral leaflet, and a small hypercontractile left ventricle.5 In the present case, altered mobility of the sutured leaflets of the MV from the Alfieri repair may have contributed to the dynamic obstruction in a previously narrowed LVOT. The shape of the continuouswave Doppler profile also was useful in substantiating our diagnosis of dynamic LVOT obstruction. Dynamic LVOT obstruction shows a characteristic dagger-shaped flow profile on continuous-wave Doppler echocardiogram, with velocity peaking in late systole as seen in Figure 2. Aggressive management with inotropes can significantly worsen hemodynamics in the setting of dynamic LVOT obstruction. Even though the resuscitation itself was unremarkable, we attribute our positive outcome to early recognition of the problem, prompt availability and use of TEE, aggressive fluid management, prudent titration of vasoactive medications, and good teamwork in the intensive care unit environment. Shuchita Garg, MD Avinash B. Kumar, MBBS, FCCP Department of Anesthesia University of Iowa Hospitals and Clinics, Iowa City, IA
5. Okamoto K, Kiso I, Inoue Y, et al: Left ventricular outflow obstruction after mitral valve replacement preserving native anterior leaflet. Ann Thorac Surg 82:735-737, 2006 http://dx.doi.org/10.1053/j.jvca.2012.08.006
Another Use for Transesophageal Echocardiography During Aortic Valve Bypass Surgery To the Editor: We read with interest the recent article by Odonkor et al,1 in which they gave a thorough review of aortic valve bypass (apicoaortic conduit) surgery and anesthetic management. We would like to offer additional considerations to the intraoperative anesthetic management of these patients. One of the surgical techniques involved in the placement of an aortic valve bypass without cardiopulmonary bypass is the placement of a Foley catheter, or other comparable
REFERENCES 1. Maslow A, Mahmood F, Singh A, et al: Problems with excess mitral leaflet after repair: Possible issues during repair and preservation of the posterior leaflet. J Cardiothorac Vasc Anesth 27:92–97, 2013 2. Maisano F, Schreuder JJ, Oppizzi M, et al: The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: Surgical technique. Eur J Cardiothorac Surg 17:201-205, 2000 3. St Andre´ AC, DelRossi A: Hemodynamic management of patients in the first 24 hours after cardiac surgery. Crit Care Med 33: 2082-2093, 2005 4. Karski JM: Transesophageal echocardiography in the intensive care unit. Semin Cardiothorac Vasc Anesth 10:162-166, 2006
Fig 1. Midesophageal long-axis view depicting balloon malposition (arrow) in the left ventricular outflow tract.
e23
LETTERS TO THE EDITOR
Fig 2. Midesophageal long-axis view showing correct balloon position (arrow) in the apex of the left ventricle.
balloon-tipped catheter, through the apex of the left ventricle to minimize blood loss and help guide apical coring.2 During this step, the balloon can be malpositioned in the left ventricular outflow tract (Fig 1) or disrupt the mitral valve apparatus. Confirmation of correct placement of the balloon-tipped catheter by transesophageal echocardiography (Fig 2) can prevent left ventricular outflow tract obstruction and minimize damage to the mitral valve and subvalvular apparatus. Justin W. Wilson, MD Julian Bick, MD Annemarie Thompson, MD Department of Cardiothoracic Anesthesiology Vanderbilt University Medical Center Nashville, TN
REFERENCES 1. Odonkor P, Stansbury LG, Gammie JS, et al: Anesthetic management of patients undergoing aortic valve bypass (apicoaortic conduit) surgery. J Cardiothorac Vasc Anesth 26:148-160, 2012 2. Vassiliades TA: Off-pump apicoaortic conduit insertion for high-risk patients with aortic stenosis. Eur J Cardiothorac Surg 23:156-158, 2003 http://dx.doi.org/10.1053/j.jvca.2012.09.003
effectively can diagnose hypovolemia, cardiac dysfunction, myocardial ischemia/infarction, and solid-phase pulmonary thromboembolism. We present the case of a 43-year-old, 182.2-lb woman undergoing laparoscopic lysis of adhesions who experienced sudden cardiovascular collapse after insufflation of CO2 through a Veress needle placed in the right upper quadrant. Her past medical history was notable for right ventricular outflow tract ventricular tachycardia for which she had undergone 3 ablation procedures 15 years prior and atrioventricular nodal re-entry tachycardia for which she had undergone an ablation procedure 12 years prior. A recent transthoracic echocardiogram showed a left ventricular ejection fraction of 55%, an estimated pulmonary artery systolic pressure of 36 mmHg, and moderate tricuspid regurgitation. The patient also had a history of superior mesenteric vein thrombus identified 16 months before presentation and had completed 6 months of anticoagulation with warfarin. Soon after insufflation of the abdomen with CO2, the patient’s heart rate decreased from 60 to 30 beats/min, with a reduction in SpO2 from 99% to 89%. Insufflation was discontinued, the Veress needle was removed, and 0.8 mg of atropine was administered intravenously. However, the patient became asystolic, the PETCO2 declined, and chest compressions were commenced. Pulseless ventricular tachycardia developed immediately thereafter, and a synchronized 200-J biphasic shock was administered. The cardiac rhythm then deteriorated into ventricular fibrillation. Epinephrine, 1 mg intravenously, was administered, and a second 200-J biphasic shock was delivered with conversion to sinus rhythm with a stable blood pressure of 104/63 mmHg, a heart rate of 105 BPM, and a end tidal carbon dioxide of 30 mmHg. Steep, transient ST elevations 42 mm were noted in all electrocardiographic leads with a return of spontaneous circulation. The differential diagnosis for the hemodynamic compromise consisted of CO2 embolism, primary arrhythmia, myocardial ischemia, and pulmonary thromboembolism. A TEE study then was used to identify gas within all 4 cardiac chambers and within the hepatic circulation, thus establishing the diagnosis of paradoxical CO2 embolism after unintentional intrahepatic Veress needle placement. A 4chamber view showed bubbles in all cardiac chambers (Fig 1 and Video 1 [supplementary videos are available online]).
Rescue Transesophageal Echocardiography for the Diagnosis and Management of Paradoxical Carbon Dioxide Embolism With Hemodynamic Compromise During Laparoscopic Surgery To the Editor: As Shillcut et al1 eloquently stated, a transesophageal echocardiogram (TEE) during cardiovascular collapse in noncardiac surgery is a valuable imaging modality that
Fig 1.
TEE showing intracardiac CO2 gas bubbles.