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Case 4—2010Successful Use of Transesophageal Echocardiography After Esophagogastrectomy
CASE CONFERENCE Linda Shore-Lesserson, MD Mark A. Chaney, MD Section Editors
Case 4 —2010 Successful Use of Transesophageal Echocardiography After Esophagogastrectomy Andrew D. Pitkin, MBBS, MRCP, FRCA,* Mark L. Blas, MD,* Charles T. Klodell, MD,† Audrey Oware, MD,‡ and John G.T. Augoustides, MD§
T
RANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) commonly is used in the intraoperative management of patients undergoing cardiac surgery. Despite the increasing evidence that it generates new clinical findings in up to 40% of cases1,2 and that surgical management is thereby altered in up to 25% of patients undergoing cardiac surgery,3,4 its routine use in all cardiac surgical patients is not universal in the United States.5 Like most interventions, TEE is not risk free, and a variety of complications associated with its use have been reported, including esophageal mucosal tears and perforations, compression of airways and major vascular structures,6 cardiac arrhythmias,7 and injuries to other abdominal viscera.8 Of these, esophageal injury has been the predominant type of complication noted in large observational studies of adverse sequelae of intraoperative TEE,6,9 and, therefore, pre-existing esophageal pathology commonly is cited as a contraindication to its use. There are reports of successful use of TEE in other forms of esophageal pathology, such as Zenker diverticulum,10 but to date there are no reports of its use in patients with a previous esophagogastrectomy, and, therefore, the risks of injury to the reconstructed esophagus and the quality of imaging obtainable are unknown. Two patients with previous esophageal resection in whom high-quality intraoperative TEE images were obtained and who did not sustain any clinically evident injury to their reconstructed esophagus as a result are presented.
From the *Department of Anesthesiology, University of Florida, Gainesville, FL; †Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL; ‡Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL; and §Cardiothoracic Section, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA. Address reprint requests to Andrew D. Pitkin, MBBS, MRCP, FRCA, Department of Anesthesiology, University of Florida, 1600 SW Archer Road, PO Box 100254, Gainesville, FL 32610-0254. E-mail: apitkin@ anest.ufl.edu Published by Elsevier Inc. 1053-0770/2404-0024$36.00/0 doi:10.1053/j.jvca.2010.03.022 Key words: transesophageal echocardiography, esophagogastrectomy, complications, monitoring 700
CASE REPORTS*
Case 1 A 75-year-old man with moderate aortic stenosis, severe mitral regurgitation, and atrial fibrillation was scheduled for aortic valve replacement, mitral valve repair, and Maze procedure. Preoperative transthoracic echocardiography (TTE) had shown severe mitral regurgitation with a highly eccentric anteriorly directed jet, but had not been of sufficient quality to diagnose the specific valve leaflet pathology. He had undergone an esophagogastrectomy for stage-I adenocarcinoma of the distal esophagus 3 years previously, consisting of gastric mobilization via laparotomy followed by esophageal and proximal gastric resection with anastomosis of the distal gastric segment to the upper thoracic esophageal remnant via right thoracotomy (Ivor-Lewis procedure). He did not receive any adjuvant radiotherapy or chemotherapy. He specifically denied symptoms of dysphagia, odynophagia, and regurgitation of food. The preoperative discussion with the patient covered the possible risks of intraoperative TEE in his case as well as the probable benefit in helping to achieve an effective mitral valve repair. After the uneventful induction of general anesthesia and the insertion of usual invasive monitoring catheters, a standard adult transesophageal echocardiographic probe (Omniplane III Model 21378A; Philips, Bothell, WA) was passed carefully without resistance into the esophagus. Excellent images of the mitral valve were obtained from the midthoracic (equivalent to the standard midesophageal) position, which clearly showed the mechanism of mitral regurgitation (a ruptured chordae tendineae causing a flail segment at the P1/P2 junction), and also was able specifically to exclude the presence of thrombus within the left atrial appendage. The aortic valve leaflets were observed to be calcified with very restricted motion. Given that adequate assessment of the aortic valve had been obtained from preoperative TTE and excellent views of the mitral valve and other cardiac structures had been obtained from the midthoracic position, it was decided to avoid advancing the TEE probe farther to minimize any potential further risk of injury to the reconstructed esophagus from attempting to obtain subdiaphragmatic “transgastric” views. The TEE findings were confirmed by direct inspection of the mitral valve during repair by posterior leaflet resection and annuloplasty. The aortic valve
*A.D. Pitkin, M.L. Blas, and C.T. Klodell
Journal of Cardiothoracic and Vascular Anesthesia, Vol 24, No 4 (August), 2010: pp 700-705
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was replaced by a 25-mm bioprosthesis, and a Maze procedure also was performed. After separation from cardiopulmonary bypass, good imaging was obtained of the repaired mitral valve, which at that point had trace mitral regurgitation. The aortic prosthesis was seen to be functioning normally. The patient had no symptoms suggestive of esophageal injury either during his inpatient convalescence or during a clinic visit 3 weeks after surgery. Case 2 A 70-year-old man was scheduled for pericardial resection as treatment for constrictive pericarditis. Ten years previously he had presented with progressive dysphagia caused by distal esophageal adenocarcinoma, which had been treated by esophagogastrectomy with adjuvant radiotherapy and chemotherapy. As with the first presented case, the surgical resection of his esophagus consisted of an Ivor-Lewis procedure, with anastomosis of the upper thoracic esophageal remnant to the distal gastric segment. Since this surgery, he had experienced no difficulties of any kind with swallowing food. After the uneventful induction of general anesthesia and the placement of invasive monitoring catheters, an adult TEE probe (Omniplane III Model 21378A) was passed into the esophagus with no resistance encountered. Satisfactory imaging of the heart and great vessels was obtained from midthoracic (“midesophageal”) windows, and it was, therefore, decided not to obtain subdiaphragmatic (“transgastric”) views. Surgical resection of the diseased pericardium proceeded uneventfully without requiring cardiopulmonary bypass and with an immediate improvement in hemodynamics. The patient was extubated uneventfully in the operating room at the end of the case, and after the procedure he had no symptoms suggestive of esophageal injury. DISCUSSION
These cases are the first reports of the use of TEE in patients who previously have had an esophagogastrectomy for esophageal malignancy and in whom no injury to the reconstructed esophagus occurred as a result. In both cases, it was possible to obtain sufficiently high-quality images from the midthoracic (“midesophageal”) imaging positions, and additional advancement of the probe below the diaphragm to obtain “transgastric” images was avoided to minimize the amount of probe manipulation in the reconstructed esophagus and the possibility of injury to the duodenum, which in these patients is the part of the alimentary tract lying immediately below the diaphragm. Both patients had a category I/II indication for intraoperative TEE examination as defined by the 1996 American Society of Anesthesiologists (ASA)/Society of Cardiovascular Anesthesiologists (SCA) Practice Guidelines for Perioperative Transesophageal Echocardiography.11 In the first patient, cardiac catheterization and transthoracic imaging had not identified the precise mechanism for the mitral regurgitation, and, therefore, TEE was an important guide to the intraoperative surgical repair. In addition, intraoperative TEE was highly desirable to assess the quality of the mitral repair before decannulation so that revision of the repair could be performed easily if necessary. Epicardial imaging is an alternative to TEE when the
latter is impossible or contraindicated. In the first case, it is unlikely that as much information could have been obtained with epicardial scanning as was obtained with TEE because posterior structures such as the atrioventricular valves are farther away from the probe, and it also is difficult to visualize related structures such as the left atrial appendage and pulmonary veins with epicardial imaging.12 In the second case, the surgical removal of adherent pericardium from the epicardial surface itself clearly precluded the effective use of epicardial imaging. The relevance of these cases lies in their illustration of the risk/benefit analysis that should be applied in any patient in whom TEE is considered and the finding that the quality of the images obtained through the reconstructed esophagus was as high as those obtained through the native esophageal wall. Intraoperative TEE is widely, although not universally, used in adult5 and pediatric13 cardiac surgery. It provides a wealth of information not otherwise available, including the assessment of global ventricular performance and regional wall motion abnormalities, information regarding valve structure and function, confirmation of surgical cannula positioning, identification of intracardiac shunts, and assessment of the thoracic aorta.14 Considerable evidence has been accumulated that TEE alters surgical and medical management of the patient in a significant proportion of cases, with some advocating its routine use.3 De Simone et al15 showed that TEE altered surgical management in 16.7% of 48 patients undergoing aortic, mitral, or tricuspid valve surgery. Bergquist et al16 analyzed intraoperative decision-making in 75 adult cardiac revascularization procedures; 17% of decisions were influenced primarily by information obtained from TEE. In a prospective cohort study of 5,016 adults, Mishra et al17 reported that unexpected findings helped or modified the surgical plan in 11.7% of 1,356 valve procedures and 27.1% of 3,660 myocardial revascularization procedures. A prospective observational survey of 203 mixed adult cardiac surgical procedures showed unsuspected findings in 12.8%, which changed the surgical management in 10.8%.18 In a retrospective study of over a 1,000 patients, McKinlay et al19 showed that TEE assessment of ventricular wall motion was a predictor of inotropic support requirement for separation from cardiopulmonary bypass. Gurbuz et al20 reported that TEE directed an alteration in surgical strategy in 194 (26%) of 744 cases of off-pump coronary artery bypass graft surgery. In a prospective observational study of 283 patients undergoing a variety of cardiac surgical procedures, Minhaj et al3 found that there were new findings on intraoperative TEE in 31% of patients and altered surgical management in 25% of cases, including 1 case in which surgery was cancelled. A larger retrospective analysis of 12,566 cardiac surgical patients showed that pre– cardiopulmonary bypass TEE influenced surgical decisions in 7.7% of cases and post– cardiopulmonary bypass TEE altered surgical decisions in 2.2% of cases, especially in combined valve and revascularization procedures. In 9% of these cases studied, TEE had some influence on clinical decision-making.4 Similar utility has been shown in pediatric cardiac surgery in which TEE has been reported to influence surgical management in 12.7% of cases and medical management in 19.4%.21 Furthermore, the benefit of TEE extends into the postoperative period. The use of TEE in the intensive care
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unit after cardiac surgery has been shown to provide more accurate diagnosis of hemodynamic instability than conventional hemodynamic data alone.22,23 Mechanical injury to the reconstructed esophagus was the principal concern in the 2 cases reported here, and complications related to the upper gastrointestinal tract are predominant in studies of complications of TEE use during cardiac surgery. Rousou et al24 conducted a retrospective chart review of 838 cardiac surgical patients and found that, after controlling for other risk factors, patients in whom TEE had been used were 7.8 times more likely to experience dysphagia. Kallmeyer et al6 studied complications of intraoperative TEE use in 7,200 cardiac surgical patients in a single center. The most common gastrointestinal sequela was odynophagia (0.1%), whereas hemorrhage (0.03%) and esophageal perforation (0.01%) were the most severe.6 Overall, morbidity was 0.2% with no mortality.6 Lennon et al25 noted a somewhat higher incidence of major gastrointestinal complications attributable to TEE (1.2% of 859 consecutive cardiac surgical cases, with two-thirds of these presenting later than 24 hours). There were no cases reported of esophageal perforation in their study. Huang et al9 reported TEE-related complications in 25 (0.4%) of 6,255 cardiac surgical patients, mostly consisting of oropharyngeal mucosal bleeding but also including 2 cases of upper gastrointestinal bleeding and 1 esophageal perforation. Perhaps the most illustrative study to date is the analysis of complications from TEE use in a large cardiac surgical database by Piercy et al,26 who estimated a rate of major complications (esophageal or gastric mucosal tears, esophageal perforations) of 9.2 per 10,000 cases. The large number of cases in their database allowed for subgroup analysis, which showed a significantly higher risk for females than males and for patients over 70 years old compared with younger patients. Compared with men aged 70 years or less, women over 70 were 22 times more likely to suffer a major gastrointestinal injury from intraoperative TEE.26 Although previous esophageal surgery often is cited as a contraindication to TEE, it is unknown whether patients with a healed esophageal anastomosis are at an increased risk of esophageal perforation by passage of the probe. Upper gastrointestinal endoscopy often is performed in such patients, with an endoscope of a similar diameter to a TEE probe, but has the obvious advantage of visualization of any abnormality within the esophageal lumen. Mortality associated with esophageal perforation is quoted as between 5% and 30%27 and is influenced by a number of factors, including time to diagnosis, degree of mediastinal soiling, and presence of sepsis. Management traditionally has been surgical, but similar results with nonoperative management have been reported.28,29 In the 2 present cases, the lack of symptoms related to swallowing such as dysphagia or regurgitation specifically was sought and confirmed in the preoperative interview. The existence of any such symptoms should, in the absence of further evaluation, be considered a contraindication to TEE in any patient. Other possible measures to reduce the risk of trauma to the reconstructed esophagus include preoperative upper gastrointestinal endoscopy or contrast imaging, the use of a pediatric TEE probe, and keeping probe manipulations to a minimum. In conclusion, these 2 cases indicate that it is possible to use intraoperative TEE without adverse incident in patients who
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have undergone previous esophageal resection. The authors suggest that in patients whose cardiac pathology indicates substantial benefits from intraoperative TEE imaging (eg, valve repair/replacement), previous esophagogastrectomy should not be regarded as an absolute contraindication to the use of TEE and its use in such patients may be considered after a careful analysis of risks and benefits. COMMENTARY 1†
TEE has proved to be of great utility in cardiothoracic surgery. Intraoperative TEE examinations may lead to the discovery of previously unknown pathology or residual defects after a surgical procedure, which may result in the alteration of surgical procedures. In a retrospective study of 12,566 patients, Eltzschig et al4 found that intraoperative TEE findings influenced surgical decision making in over 9% of patients. TEE studies also may provide additional information or superior quality images of certain intracardiac structures because of the location of the TEE probe as compared with TTE. However, a TEE examination is not without associated risks including oral trauma, pharyngeal trauma, esophageal trauma, or gastric tears; esophageal or gastric bleeding; swallowing dysfunction; and thermal injury.6,25,26,30,31 In patients with underlying esophageal pathology, the risks of a TEE examination, with regards to esophageal injury, are likely increased.3 Likewise, in patients who have had prior esophageal or gastric surgery, such as in the 2 patients presented in the above reports, the risk of performing an intraoperative TEE examination may be higher. Potential contraindications to TEE include a history of swallowing dysfunction, esophageal abnormalities, and/or previous esophageal gastric surgery.30 Even though the risks of a TEE examination are relatively low, with an incidence of TEE-related complications around 0.1% to 1.2 %,6,25,26 it is important to stratify the risk:benefit ratio on a patient-by-patient basis in order to determine whether an intraoperative TEE examination should be performed. In patients with pre-existing esophageal pathology, the advantages and disadvantages of the TEE examination must carefully be weighed when deciding whether or not to use the monitor during cardiothoracic surgery. Patients with recent surgical suture lines or known esophageal interruption are likely placed at an increased risk for complications because of esophageal trauma during a TEE examination. In regards to these two cases, both patients had undergone esophagogastrectomy several years before cardiac surgery, 1 patient 3 years earlier and 1 patient 10 years earlier. Thus, their risk was potentially lower because their esophagus did not have recent surgical suture lines. If it is decided that since patient outcome likely will be improved or surgical management may be altered by intraoperative TEE and the risks of performing the examination are relatively low, the patient may benefit from having an intraoperative TEE examination. This examination may be useful when inadequate TTE images have been obtained preoperatively (because of body habitus or from structures interfering with images, such as chest tubes). Further imaging with TEE
†A. Oware
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may be useful in further evaluating valvular or intracardiac pathology. A thorough preoperative history must be obtained, with a focus on any symptoms such as dysphagia or severe, unremitting gastroesophageal reflux symptoms. In the 2 cases presented, this preoperative history was obtained with the patients denying such symptoms. A preoperative esophagogastroduodenoscopy may be undertaken to directly evaluate the patient’s esophagus and suture lines for the presence of adequate surgical healing and the absence of any additional abnormal pathology. In addition, it is important in the preoperative discussion with the patient to thoroughly discuss the benefits and also potential risks associated with performing an intraoperative TEE examination in a patient with pre-existing esophageal pathology. In patients who have undergone an esophagogastrectomy and in whom risk stratification deems that the benefits of the TEE evaluation outweighs the risk, care must be undertaken to reduce the risk of injury to the patient (as with all patients undergoing TEE). Intraoperatively, during the TEE examination, the probe should be advanced gently during insertion, with care taken not to force the probe against resistance. Excessive transducer output energy should be avoided or if high energy is required as with 3-dimensional imaging, the time period of such energy usage should be minimal. The image should be frozen or the probe should be disconnected when not in use, such as during cardiopulmonary bypass. In addition, when the probe is not being used for imaging, it should be left in a neutral position and should not be locked. This will help to avoid excessive force on the esophageal mucosa. When performing the TEE examination, caution should be taken to avoid potential complications associated with probe insertion and manipulation. Such complications include but are not limited to esophageal bleeding, tearing, perforation, and dysphasia. These adverse sequelae may result from mechanical pressure applied against the esophagus from the probe or from thermal effects applied over the course of several hours during cardiothoracic surgery.31 It is important that the TEE examination is performed by properly trained practitioners to avoid complications that may result from excessive force used to advance the TEE probe against resistance encountered during placement or manipulation. In these 2 presented cases, the TEE probe was not advanced beyond the esophagus to obtain transgastric images because adequate midesophageal images were obtained. This practice may have decreased the risk of esophageal damage by avoiding manipulation of the probe in the area of the esophagogastrectomy surgical suture line. Clinicians always should consider the need for transgastric imaging in these patients, again using risk stratification to determine whether it is advisable or necessary to advance the probe beyond the esophagus in order to perform a transgastric examination if adequate images already have been obtained. Also, the imaging should be limited to only the necessary views, and an experienced echocardiographer should be manipulating the probe. In summary, the 2 case reports show the considerations that must be undertaken in patients who present for cardiothoracic surgery who have undergone a previous esophagogastrectomy. The decision to perform an intraoperative TEE examination
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should take into account the risks and benefits of performing an intraoperative examination in patients with esophageal pathology. A thorough history must be obtained from the patient regarding symptoms of esophageal dysfunction, such as dysphagia or severe gastroesophageal reflux symptoms. A TEE examination may be considered when there is difficulty obtaining adequate preoperative TTE images and further quality information may be obtained from the TEE examination that may impact surgical management. As in all patients, care must be taken in these patients during the TEE examination to avoid damage from excessive pressure applied during probe manipulation, and the examination should be performed by experienced practitioners. The examination should only be limited to the necessary views, and advancing the probe to obtain transgastric views should be avoided when adequate views of cardiac structures already have been obtained. COMMENTARY 2‡
Although rare, upper gastrointestinal injury associated with perioperative TEE is serious because it may be life-threatening.31 Consequently, TEE typically is avoided in an abnormal upper gastrointestinal tract to minimize this complication. Although multiple large observational case series have reliably documented the incidence and spectrum of upper gastrointestinal injuries associated with perioperative TEE, they comprise procedures that were performed in patients with no known severe upper gastrointestinal abnormality.4,6,9,24-26 Consequently, these large TEE series have limited applicability to adult cardiac surgical patients who simultaneously have pathology of the upper gastrointestinal tract and a strong indication for TEE. This Case Conference is important because it addresses this clinically important issue, namely how to proceed in patients who would benefit clinically from intraoperative TEE but who have a higher risk because of coexisting upper gastrointestinal anatomic abnormality. The authors present 2 patients in whom focused TEE imaging was applied successfully and safely in the setting of prior esophagogastrectomy for carcinoma of the distal esophagus. The authors selected focused TEE imaging rather than epicardial imaging because of case specifics that eroded the clinical utility of epicardial imaging including posterior structures of interest in the first case and pericardial disease requiring resection in the second case.12,32 Although epicardial imaging was not used in these patients, it is important to remember that it is always complementary to TEE. As an example, in the first patient, complementary epicardial imaging of the mitral valve, left atrial appendage, and aortic valve could only have added clinical value, especially because the decision to avoid transgastric imaging prohibited a standard comprehensive TEE examination as recommended in Society guidelines.33 As a further extension of this example, the aortic valve replacement in the first patient could have been interrogated in multiple planes after cardiopulmonary bypass with both midthoracic TEE imaging and full epicardial imaging. This complementary nature of both imaging techniques would have been even more important if the mitral intervention had not been repair but replacement with a mechanical valve be-
‡J.G.T. Augoustides
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cause then midthoracic TEE imaging of the aortic valve prosthesis would likely have been inadequate because of acoustic shadowing from the mitral prosthesis.34 Just as epiaortic imaging typically is regarded as complementary to TEE in the assessment of aortic atheroma, so is it important to regard epicardial imaging as complementary to TEE; they are not mutually exclusive. The authors are to be congratulated for their meticulous approach to the conduct of the focused TEE. Their precise understanding of the prior esophagogastric procedure, their confirmation of the absence of important esophageal symptoms, their thorough informed consent covering the risks and benefits, their careful control of the TEE probe at the midthoracic level for goal-directed imaging, and their avoidance of imaging in the reconstructed esophagogastric junction or beyond. This meticulous conduct of the intraoperative TEE examination is imperative in these high-risk scenarios to maximize safety and freedom from life-threatening esophageal perforation. The approach to TEE exhibited in these cases provides yet more evidence that TEE without transgastric views is clinically feasible, safe, and valuable in the setting of an abnormal distal esophagus and stomach. This focused intraoperative TEE approach already has entered into clinical practice for patients with gastroesophageal varices who also may undergo liver transplantation.35-38 In a small observational series (14 patients, 1997-2007), the safety and clinical efficacy of TEE without transgastric imaging was shown. Despite the presence of known gastroesophageal varices, there were no gastroesophageal complications, including bleeding. Despite the limited imaging, every TEE study provided all the clinical information required for patient management.35 The applicability, efficacy, and safety of TEE in liver transplantation have been shown in a single-center series.37 The increased use of intraoperative
TEE during liver transplantation has been extensive throughout the United States although the majority of operators use limited imaging.38 Although expert opinion has regarded TEE as contraindicated in the setting of lower esophageal pathology, this report, along with the experience in adult liver disease, provide evidence to challenge this assumption.35-38 Based on the limited published evidence, it appears reasonable to consider perioperative TEE despite distal esophageal pathology when there is a strong clinical indication and alternative cardiac imaging methods are limited. In selected cases, additional interventions such as endoscopy and/or esophageal dilation may be required to facilitate the safety required for perioperative TEE in an abnormal esophagus.39,40 Besides the distal esophagus, the oropharynx also is liable to trauma during TEE probe insertion. Multiple case reports support the utility of laryngoscopy to ease the difficult passage of a TEE probe.41-43 A recent randomized trial (80 patients) showed the oropharyngeal protection provided by rigid laryngoscopy during the placement of a TEE probe.44 In this study, rigid laryngoscopy significantly decreased the incidence of mucosal injury (5% v 55%) and odynophagia (2.5% v 32.5%).44 This trial provided evidence that even in routine practice, without known risk factors, oropharyngeal function and anatomy can be protected further by routine laryngoscopy to guide TEE probe placement under direct vision. In summary, this report highlights the critical importance of upper gastrointestinal safety during the conduct of TEE. In the setting of distal esophageal and/or gastric pathology, TEE without transgastric imaging is a reasonable clinical choice. Upper gastrointestinal endoscopy has a role in selected cases. Recent evidence supports the concept of a low threshold for laryngoscopy during TEE probe insertion in the anesthetized patient.
REFERENCES 1. Thys DM: Echocardiography and anesthesiology successes and challenges. Anesthesiology 95:1313-1314, 2001 2. Jneid H, Bolli R: Inotrope use at separation from cardiopulmonary bypass and the role of prebypass TEE. J Cardiothorac Vasc Anesth 18:401-403, 2004 3. Minhaj M, Patel K, Muzic D, et al: The effect of routine intraoperative transesophageal echocardiography on surgical management. J Cardiothorac Vasc Anesth 21:800-804, 2007 4. Eltzschig HK, Rosenberger P, Loffler M, et al: Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery. Ann Thorac Surg 85:845852, 2008 5. Morewood GH, Gallagher ME, Gaughan JP, et al: Current practice patterns for adult perioperative transesophageal echocardiography in the United States. Anesthesiology 95:1507-1512, 2001 6. Kallmeyer IJ, Collard CD, Fox JA, et al: The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients. Anesth Analg 92:1126-1130, 2001 7. Casta A, Brown DW, Yuki K: Induction of supraventricular tachycardia during transesophageal echocardiography: An unusual complication. J Cardiothorac Vasc Anesth 22:592-593, 2008 8. Chow MS, Taylor MA, Hanson CW 3rd: Splenic laceration associated with transesophageal echocardiography. J Cardiothorac Vasc Anesth 12:314-316, 1998
9. Huang CH, Lu CW, Lin TY, et al: Complications of intraoperative transesophageal echocardiography in adult cardiac surgical patients—Experience of two institutions in Taiwan. J Formos Med Assoc 106:92-95, 2007 10. Ramjohn J, Paulus DA: Use of transesophageal echocardiography in a patient with Zenker’s diverticulum. J Cardiothorac Vasc Anesth 20:385-386, 2006 11. Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 84: 986-1006, 1996 12. Eltzschig HK, Kallmeyer IJ, Mihaljevic T, et al: A practical approach to a comprehensive epicardial and epiaortic echocardiographic examination. J Cardiothorac Vasc Anesth 17:422-429, 2003 13. Stevenson JG: Utilization of intraoperative transesophageal echocardiography during repair of congenital cardiac defects: A survey of North American centers. Clin Cardiol 26:132-134, 2003 14. Iglesias I, Bainbridge D, Murkin J: Intraoperative echocardiography: Support for decision making in cardiac surgery. Semin Cardiothorac Vasc Anesth 8:25-35, 2004 15. De Simone R, Lange R, Saggau W, et al: Intraoperative transesophageal echocardiography for the evaluation of mitral, aortic and tricuspid valve repair. A tool to optimize surgical outcome. Eur J Cardiothorac Surg 6:665-673, 1992
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16. Bergquist BD, Bellows WH, Leung JM: Transesophageal echocardiography in myocardial revascularization: II. Influence on intraoperative decision making. Anesth Analg 82:1139-1145, 1996 17. Mishra M, Chauhan R, Sharma KK, et al: Real-time intraoperative transesophageal echocardiography—How useful? Experience of 5,016 cases. J Cardiothorac Vasc Anesth 12:625-632, 1998 18. Michel-Cherqui M, Ceddaha A, Liu N, et al: Assessment of systematic use of intraoperative transesophageal echocardiography during cardiac surgery in adults: A prospective study of 203 patients. J Cardiothorac Vasc Anesth 14:45-50, 2000 19. McKinlay KH, Schinderle DB, Swaminathan M, et al: Predictors of inotrope use during separation from cardiopulmonary bypass. J Cardiothorac Vasc Anesth 18:404-408, 2004 20. Gurbuz AT, Hecht ML, Arslan AH: Intraoperative transesophageal echocardiography modifies strategy in off-pump coronary artery bypass grafting. Ann Thorac Surg 83:1035-1040, 2007 21. Bettex DA, Schmidlin D, Bernath MA, et al: Intraoperative transesophageal echocardiography in pediatric congenital cardiac surgery: A two-center observational study. Anesth Analg 97:1275-1282, 2003 22. Wake PJ, Ali M, Carroll J, et al: Clinical and echocardiographic diagnoses disagree in patients with unexplained hemodynamic instability after cardiac surgery. Can J Anaesth 48:778-783, 2001 23. Costachescu T, Denault A, Guimond JG, et al: The hemodynamically unstable patient in the intensive care unit: Hemodynamic vs. transesophageal echocardiographic monitoring. Crit Care Med 30: 1214-1223, 2002 24. Rousou JA, Tighe DA, Garb JL, et al: Risk of dysphagia after transesophageal echocardiography during cardiac operations. Ann Thorac Surg 69:486-489, 2000 25. Lennon MJ, Gibbs NM, Weightman WM, et al: Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients. J Cardiothorac Vasc Anesth 19:141-145, 2005 26. Piercy M, McNicol L, Dinh DT, et al: Major complications related to the use of transesophageal echocardiography in cardiac surgery. J Cardiothorac Vasc Anesth 23:62-65, 2009 27. Kiernan PD, Sheridan MJ, Elster E, et al: Thoracic esophageal perforations. South Med J 96:158-163, 2003 28. Vogel SB, Rout WR, Martin TD, et al: Esophageal perforation in adults: Aggressive, conservative treatment lowers morbidity and mortality. Ann Surg 241:1016-1021, 2005 29. Abbas G, Schuchert MJ, Pettiford BL, et al: Contemporaneous management of esophageal perforation. Surgery 146:749-755, 2009 30. Marymont J, Murphy G: Intraoperative monitoring with transesophageal echocardiography: Indications, risks, and training. Anesth Clin 25:737-753, 2006 31. Augoustides JGT, Hosalkar HH, Milas BL, et al: Upper gastrointestinal injuries related to perioperative transesophageal echocardi-
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ography: Index case, literature review, classification proposal, and call for a registry. J Cardiothor Vasc Anesth 20:379-384, 2006 32. Reeves ST, Glas KE, Eltzschig H, et al; Council for Intraoperative chocardiography of the American Society of Echocardiography; Society of Cardiovascular Anesthesiologists: Guidelines for performing a comprehensive epicardial echocardiography examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 105:22-28, 2007 33. Shanewise JS, Cheung AT, Aronson S, 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 34. Latson LA: Transcatheter closure of paraprosthetic valve leaks after surgical mitral and aortic valve replacements. Expert Rev Cardiovasc Ther 7:507-514, 2009 35. Spier BJ, Larue S, Teelin TC, et al: Review of complications in a series of patients with known gastroesophageal varices undergoing transesophageal echocardiography. J Am Soc Echocardiogr 22:396400, 2009 36. Spencer KT: Transesophageal echocardiography in patients with esophageal varices. J Am Soc Echocardiogr 22:401-403, 2009 37. Suriani RJ, Cutrone A, Feierman D, et al: Intraoperative transesophageal echocardiography during liver transplantation. J Cardiothorac Vasc Anesth 6:699-707, 1996 38. Wax DB, Torres A, Scher C, et al: Transesophageal echocardiography utilization in high-volume liver transplantation centers in the United States. J Cardiothorac Vasc Anesth 6:811-813, 2008 39. Spence BC, Hartman GS, Gosselin BJ: Intraoperative esophageal dilation for TEE probe placement in a patient with an undiagnosed esophageal stricture. J Cardiothorac Vasc Anesth 19:209-211, 2005 40. Shernan SK: When is intraoperative transesophageal echocardiography indicated? J Cardiothorac Vasc Anesth 19:139-140, 2005 41. Hirabayashi Y: Glidescope-assisted insertion of a transesophageal echocardiogrpahy probe. J Cardiothorac Vasc Anesth 21:628, 2007 42. Hirabayashi Y, Okada O, Seo N: Airtraq laryngoscope for the insertion of a transesophageal echocardiography probe. J Cardiothorac Vasc Anesth 22:331-332, 2008 43. Tagawa T, Sakuraba S, Okuda M: Pentax-AWS-assisted insertion of a transesophageal echocardiography probe. J Clin Anesth 21: 73-74, 2009 44. Na S, Kim CS, Kim JY, et al: Rigid laryngoscope-assisted insertion of transesophageal echocardiography probe reduces oropharyngeal mucosal injury in anesthetized patients. Anesthesiology 110: 38-40, 2009
Case 4 —2010 Successful Use of Transesophageal Echocardiography After Esophagogastrectomy Andrew D. Pitkin, MBBS, MRCP, FRCA,* Mark L. Blas, MD,* Charles T. Klodell, MD,† Audrey Oware, MD,‡ and John G.T. Augoustides, MD§
T
RANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) commonly is used in the intraoperative management of patients undergoing cardiac surgery. Despite the increasing evidence that it generates new clinical findings in up to 40% of cases1,2 and that surgical management is thereby altered in up to 25% of patients undergoing cardiac surgery,3,4 its routine use in all cardiac surgical patients is not universal in the United States.5 Like most interventions, TEE is not risk free, and a variety of complications associated with its use have been reported, including esophageal mucosal tears and perforations, compression of airways and major vascular structures,6 cardiac arrhythmias,7 and injuries to other abdominal viscera.8 Of these, esophageal injury has been the predominant type of complication noted in large observational studies of adverse sequelae of intraoperative TEE,6,9 and, therefore, pre-existing esophageal pathology commonly is cited as a contraindication to its use. There are reports of successful use of TEE in other forms of esophageal pathology, such as Zenker diverticulum,10 but to date there are no reports of its use in patients with a previous esophagogastrectomy, and, therefore, the risks of injury to the reconstructed esophagus and the quality of imaging obtainable are unknown. Two patients with previous esophageal resection in whom high-quality intraoperative TEE images were obtained and who did not sustain any clinically evident injury to their reconstructed esophagus as a result are presented.
From the *Department of Anesthesiology, University of Florida, Gainesville, FL; †Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL; ‡Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL; and §Cardiothoracic Section, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA. Address reprint requests to Andrew D. Pitkin, MBBS, MRCP, FRCA, Department of Anesthesiology, University of Florida, 1600 SW Archer Road, PO Box 100254, Gainesville, FL 32610-0254. E-mail: apitkin@ anest.ufl.edu Published by Elsevier Inc. 1053-0770/2404-0024$36.00/0 doi:10.1053/j.jvca.2010.03.022 Key words: transesophageal echocardiography, esophagogastrectomy, complications, monitoring 700
CASE REPORTS*
Case 1 A 75-year-old man with moderate aortic stenosis, severe mitral regurgitation, and atrial fibrillation was scheduled for aortic valve replacement, mitral valve repair, and Maze procedure. Preoperative transthoracic echocardiography (TTE) had shown severe mitral regurgitation with a highly eccentric anteriorly directed jet, but had not been of sufficient quality to diagnose the specific valve leaflet pathology. He had undergone an esophagogastrectomy for stage-I adenocarcinoma of the distal esophagus 3 years previously, consisting of gastric mobilization via laparotomy followed by esophageal and proximal gastric resection with anastomosis of the distal gastric segment to the upper thoracic esophageal remnant via right thoracotomy (Ivor-Lewis procedure). He did not receive any adjuvant radiotherapy or chemotherapy. He specifically denied symptoms of dysphagia, odynophagia, and regurgitation of food. The preoperative discussion with the patient covered the possible risks of intraoperative TEE in his case as well as the probable benefit in helping to achieve an effective mitral valve repair. After the uneventful induction of general anesthesia and the insertion of usual invasive monitoring catheters, a standard adult transesophageal echocardiographic probe (Omniplane III Model 21378A; Philips, Bothell, WA) was passed carefully without resistance into the esophagus. Excellent images of the mitral valve were obtained from the midthoracic (equivalent to the standard midesophageal) position, which clearly showed the mechanism of mitral regurgitation (a ruptured chordae tendineae causing a flail segment at the P1/P2 junction), and also was able specifically to exclude the presence of thrombus within the left atrial appendage. The aortic valve leaflets were observed to be calcified with very restricted motion. Given that adequate assessment of the aortic valve had been obtained from preoperative TTE and excellent views of the mitral valve and other cardiac structures had been obtained from the midthoracic position, it was decided to avoid advancing the TEE probe farther to minimize any potential further risk of injury to the reconstructed esophagus from attempting to obtain subdiaphragmatic “transgastric” views. The TEE findings were confirmed by direct inspection of the mitral valve during repair by posterior leaflet resection and annuloplasty. The aortic valve
*A.D. Pitkin, M.L. Blas, and C.T. Klodell
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was replaced by a 25-mm bioprosthesis, and a Maze procedure also was performed. After separation from cardiopulmonary bypass, good imaging was obtained of the repaired mitral valve, which at that point had trace mitral regurgitation. The aortic prosthesis was seen to be functioning normally. The patient had no symptoms suggestive of esophageal injury either during his inpatient convalescence or during a clinic visit 3 weeks after surgery. Case 2 A 70-year-old man was scheduled for pericardial resection as treatment for constrictive pericarditis. Ten years previously he had presented with progressive dysphagia caused by distal esophageal adenocarcinoma, which had been treated by esophagogastrectomy with adjuvant radiotherapy and chemotherapy. As with the first presented case, the surgical resection of his esophagus consisted of an Ivor-Lewis procedure, with anastomosis of the upper thoracic esophageal remnant to the distal gastric segment. Since this surgery, he had experienced no difficulties of any kind with swallowing food. After the uneventful induction of general anesthesia and the placement of invasive monitoring catheters, an adult TEE probe (Omniplane III Model 21378A) was passed into the esophagus with no resistance encountered. Satisfactory imaging of the heart and great vessels was obtained from midthoracic (“midesophageal”) windows, and it was, therefore, decided not to obtain subdiaphragmatic (“transgastric”) views. Surgical resection of the diseased pericardium proceeded uneventfully without requiring cardiopulmonary bypass and with an immediate improvement in hemodynamics. The patient was extubated uneventfully in the operating room at the end of the case, and after the procedure he had no symptoms suggestive of esophageal injury. DISCUSSION
These cases are the first reports of the use of TEE in patients who previously have had an esophagogastrectomy for esophageal malignancy and in whom no injury to the reconstructed esophagus occurred as a result. In both cases, it was possible to obtain sufficiently high-quality images from the midthoracic (“midesophageal”) imaging positions, and additional advancement of the probe below the diaphragm to obtain “transgastric” images was avoided to minimize the amount of probe manipulation in the reconstructed esophagus and the possibility of injury to the duodenum, which in these patients is the part of the alimentary tract lying immediately below the diaphragm. Both patients had a category I/II indication for intraoperative TEE examination as defined by the 1996 American Society of Anesthesiologists (ASA)/Society of Cardiovascular Anesthesiologists (SCA) Practice Guidelines for Perioperative Transesophageal Echocardiography.11 In the first patient, cardiac catheterization and transthoracic imaging had not identified the precise mechanism for the mitral regurgitation, and, therefore, TEE was an important guide to the intraoperative surgical repair. In addition, intraoperative TEE was highly desirable to assess the quality of the mitral repair before decannulation so that revision of the repair could be performed easily if necessary. Epicardial imaging is an alternative to TEE when the
latter is impossible or contraindicated. In the first case, it is unlikely that as much information could have been obtained with epicardial scanning as was obtained with TEE because posterior structures such as the atrioventricular valves are farther away from the probe, and it also is difficult to visualize related structures such as the left atrial appendage and pulmonary veins with epicardial imaging.12 In the second case, the surgical removal of adherent pericardium from the epicardial surface itself clearly precluded the effective use of epicardial imaging. The relevance of these cases lies in their illustration of the risk/benefit analysis that should be applied in any patient in whom TEE is considered and the finding that the quality of the images obtained through the reconstructed esophagus was as high as those obtained through the native esophageal wall. Intraoperative TEE is widely, although not universally, used in adult5 and pediatric13 cardiac surgery. It provides a wealth of information not otherwise available, including the assessment of global ventricular performance and regional wall motion abnormalities, information regarding valve structure and function, confirmation of surgical cannula positioning, identification of intracardiac shunts, and assessment of the thoracic aorta.14 Considerable evidence has been accumulated that TEE alters surgical and medical management of the patient in a significant proportion of cases, with some advocating its routine use.3 De Simone et al15 showed that TEE altered surgical management in 16.7% of 48 patients undergoing aortic, mitral, or tricuspid valve surgery. Bergquist et al16 analyzed intraoperative decision-making in 75 adult cardiac revascularization procedures; 17% of decisions were influenced primarily by information obtained from TEE. In a prospective cohort study of 5,016 adults, Mishra et al17 reported that unexpected findings helped or modified the surgical plan in 11.7% of 1,356 valve procedures and 27.1% of 3,660 myocardial revascularization procedures. A prospective observational survey of 203 mixed adult cardiac surgical procedures showed unsuspected findings in 12.8%, which changed the surgical management in 10.8%.18 In a retrospective study of over a 1,000 patients, McKinlay et al19 showed that TEE assessment of ventricular wall motion was a predictor of inotropic support requirement for separation from cardiopulmonary bypass. Gurbuz et al20 reported that TEE directed an alteration in surgical strategy in 194 (26%) of 744 cases of off-pump coronary artery bypass graft surgery. In a prospective observational study of 283 patients undergoing a variety of cardiac surgical procedures, Minhaj et al3 found that there were new findings on intraoperative TEE in 31% of patients and altered surgical management in 25% of cases, including 1 case in which surgery was cancelled. A larger retrospective analysis of 12,566 cardiac surgical patients showed that pre– cardiopulmonary bypass TEE influenced surgical decisions in 7.7% of cases and post– cardiopulmonary bypass TEE altered surgical decisions in 2.2% of cases, especially in combined valve and revascularization procedures. In 9% of these cases studied, TEE had some influence on clinical decision-making.4 Similar utility has been shown in pediatric cardiac surgery in which TEE has been reported to influence surgical management in 12.7% of cases and medical management in 19.4%.21 Furthermore, the benefit of TEE extends into the postoperative period. The use of TEE in the intensive care
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unit after cardiac surgery has been shown to provide more accurate diagnosis of hemodynamic instability than conventional hemodynamic data alone.22,23 Mechanical injury to the reconstructed esophagus was the principal concern in the 2 cases reported here, and complications related to the upper gastrointestinal tract are predominant in studies of complications of TEE use during cardiac surgery. Rousou et al24 conducted a retrospective chart review of 838 cardiac surgical patients and found that, after controlling for other risk factors, patients in whom TEE had been used were 7.8 times more likely to experience dysphagia. Kallmeyer et al6 studied complications of intraoperative TEE use in 7,200 cardiac surgical patients in a single center. The most common gastrointestinal sequela was odynophagia (0.1%), whereas hemorrhage (0.03%) and esophageal perforation (0.01%) were the most severe.6 Overall, morbidity was 0.2% with no mortality.6 Lennon et al25 noted a somewhat higher incidence of major gastrointestinal complications attributable to TEE (1.2% of 859 consecutive cardiac surgical cases, with two-thirds of these presenting later than 24 hours). There were no cases reported of esophageal perforation in their study. Huang et al9 reported TEE-related complications in 25 (0.4%) of 6,255 cardiac surgical patients, mostly consisting of oropharyngeal mucosal bleeding but also including 2 cases of upper gastrointestinal bleeding and 1 esophageal perforation. Perhaps the most illustrative study to date is the analysis of complications from TEE use in a large cardiac surgical database by Piercy et al,26 who estimated a rate of major complications (esophageal or gastric mucosal tears, esophageal perforations) of 9.2 per 10,000 cases. The large number of cases in their database allowed for subgroup analysis, which showed a significantly higher risk for females than males and for patients over 70 years old compared with younger patients. Compared with men aged 70 years or less, women over 70 were 22 times more likely to suffer a major gastrointestinal injury from intraoperative TEE.26 Although previous esophageal surgery often is cited as a contraindication to TEE, it is unknown whether patients with a healed esophageal anastomosis are at an increased risk of esophageal perforation by passage of the probe. Upper gastrointestinal endoscopy often is performed in such patients, with an endoscope of a similar diameter to a TEE probe, but has the obvious advantage of visualization of any abnormality within the esophageal lumen. Mortality associated with esophageal perforation is quoted as between 5% and 30%27 and is influenced by a number of factors, including time to diagnosis, degree of mediastinal soiling, and presence of sepsis. Management traditionally has been surgical, but similar results with nonoperative management have been reported.28,29 In the 2 present cases, the lack of symptoms related to swallowing such as dysphagia or regurgitation specifically was sought and confirmed in the preoperative interview. The existence of any such symptoms should, in the absence of further evaluation, be considered a contraindication to TEE in any patient. Other possible measures to reduce the risk of trauma to the reconstructed esophagus include preoperative upper gastrointestinal endoscopy or contrast imaging, the use of a pediatric TEE probe, and keeping probe manipulations to a minimum. In conclusion, these 2 cases indicate that it is possible to use intraoperative TEE without adverse incident in patients who
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have undergone previous esophageal resection. The authors suggest that in patients whose cardiac pathology indicates substantial benefits from intraoperative TEE imaging (eg, valve repair/replacement), previous esophagogastrectomy should not be regarded as an absolute contraindication to the use of TEE and its use in such patients may be considered after a careful analysis of risks and benefits. COMMENTARY 1†
TEE has proved to be of great utility in cardiothoracic surgery. Intraoperative TEE examinations may lead to the discovery of previously unknown pathology or residual defects after a surgical procedure, which may result in the alteration of surgical procedures. In a retrospective study of 12,566 patients, Eltzschig et al4 found that intraoperative TEE findings influenced surgical decision making in over 9% of patients. TEE studies also may provide additional information or superior quality images of certain intracardiac structures because of the location of the TEE probe as compared with TTE. However, a TEE examination is not without associated risks including oral trauma, pharyngeal trauma, esophageal trauma, or gastric tears; esophageal or gastric bleeding; swallowing dysfunction; and thermal injury.6,25,26,30,31 In patients with underlying esophageal pathology, the risks of a TEE examination, with regards to esophageal injury, are likely increased.3 Likewise, in patients who have had prior esophageal or gastric surgery, such as in the 2 patients presented in the above reports, the risk of performing an intraoperative TEE examination may be higher. Potential contraindications to TEE include a history of swallowing dysfunction, esophageal abnormalities, and/or previous esophageal gastric surgery.30 Even though the risks of a TEE examination are relatively low, with an incidence of TEE-related complications around 0.1% to 1.2 %,6,25,26 it is important to stratify the risk:benefit ratio on a patient-by-patient basis in order to determine whether an intraoperative TEE examination should be performed. In patients with pre-existing esophageal pathology, the advantages and disadvantages of the TEE examination must carefully be weighed when deciding whether or not to use the monitor during cardiothoracic surgery. Patients with recent surgical suture lines or known esophageal interruption are likely placed at an increased risk for complications because of esophageal trauma during a TEE examination. In regards to these two cases, both patients had undergone esophagogastrectomy several years before cardiac surgery, 1 patient 3 years earlier and 1 patient 10 years earlier. Thus, their risk was potentially lower because their esophagus did not have recent surgical suture lines. If it is decided that since patient outcome likely will be improved or surgical management may be altered by intraoperative TEE and the risks of performing the examination are relatively low, the patient may benefit from having an intraoperative TEE examination. This examination may be useful when inadequate TTE images have been obtained preoperatively (because of body habitus or from structures interfering with images, such as chest tubes). Further imaging with TEE
†A. Oware
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may be useful in further evaluating valvular or intracardiac pathology. A thorough preoperative history must be obtained, with a focus on any symptoms such as dysphagia or severe, unremitting gastroesophageal reflux symptoms. In the 2 cases presented, this preoperative history was obtained with the patients denying such symptoms. A preoperative esophagogastroduodenoscopy may be undertaken to directly evaluate the patient’s esophagus and suture lines for the presence of adequate surgical healing and the absence of any additional abnormal pathology. In addition, it is important in the preoperative discussion with the patient to thoroughly discuss the benefits and also potential risks associated with performing an intraoperative TEE examination in a patient with pre-existing esophageal pathology. In patients who have undergone an esophagogastrectomy and in whom risk stratification deems that the benefits of the TEE evaluation outweighs the risk, care must be undertaken to reduce the risk of injury to the patient (as with all patients undergoing TEE). Intraoperatively, during the TEE examination, the probe should be advanced gently during insertion, with care taken not to force the probe against resistance. Excessive transducer output energy should be avoided or if high energy is required as with 3-dimensional imaging, the time period of such energy usage should be minimal. The image should be frozen or the probe should be disconnected when not in use, such as during cardiopulmonary bypass. In addition, when the probe is not being used for imaging, it should be left in a neutral position and should not be locked. This will help to avoid excessive force on the esophageal mucosa. When performing the TEE examination, caution should be taken to avoid potential complications associated with probe insertion and manipulation. Such complications include but are not limited to esophageal bleeding, tearing, perforation, and dysphasia. These adverse sequelae may result from mechanical pressure applied against the esophagus from the probe or from thermal effects applied over the course of several hours during cardiothoracic surgery.31 It is important that the TEE examination is performed by properly trained practitioners to avoid complications that may result from excessive force used to advance the TEE probe against resistance encountered during placement or manipulation. In these 2 presented cases, the TEE probe was not advanced beyond the esophagus to obtain transgastric images because adequate midesophageal images were obtained. This practice may have decreased the risk of esophageal damage by avoiding manipulation of the probe in the area of the esophagogastrectomy surgical suture line. Clinicians always should consider the need for transgastric imaging in these patients, again using risk stratification to determine whether it is advisable or necessary to advance the probe beyond the esophagus in order to perform a transgastric examination if adequate images already have been obtained. Also, the imaging should be limited to only the necessary views, and an experienced echocardiographer should be manipulating the probe. In summary, the 2 case reports show the considerations that must be undertaken in patients who present for cardiothoracic surgery who have undergone a previous esophagogastrectomy. The decision to perform an intraoperative TEE examination
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should take into account the risks and benefits of performing an intraoperative examination in patients with esophageal pathology. A thorough history must be obtained from the patient regarding symptoms of esophageal dysfunction, such as dysphagia or severe gastroesophageal reflux symptoms. A TEE examination may be considered when there is difficulty obtaining adequate preoperative TTE images and further quality information may be obtained from the TEE examination that may impact surgical management. As in all patients, care must be taken in these patients during the TEE examination to avoid damage from excessive pressure applied during probe manipulation, and the examination should be performed by experienced practitioners. The examination should only be limited to the necessary views, and advancing the probe to obtain transgastric views should be avoided when adequate views of cardiac structures already have been obtained. COMMENTARY 2‡
Although rare, upper gastrointestinal injury associated with perioperative TEE is serious because it may be life-threatening.31 Consequently, TEE typically is avoided in an abnormal upper gastrointestinal tract to minimize this complication. Although multiple large observational case series have reliably documented the incidence and spectrum of upper gastrointestinal injuries associated with perioperative TEE, they comprise procedures that were performed in patients with no known severe upper gastrointestinal abnormality.4,6,9,24-26 Consequently, these large TEE series have limited applicability to adult cardiac surgical patients who simultaneously have pathology of the upper gastrointestinal tract and a strong indication for TEE. This Case Conference is important because it addresses this clinically important issue, namely how to proceed in patients who would benefit clinically from intraoperative TEE but who have a higher risk because of coexisting upper gastrointestinal anatomic abnormality. The authors present 2 patients in whom focused TEE imaging was applied successfully and safely in the setting of prior esophagogastrectomy for carcinoma of the distal esophagus. The authors selected focused TEE imaging rather than epicardial imaging because of case specifics that eroded the clinical utility of epicardial imaging including posterior structures of interest in the first case and pericardial disease requiring resection in the second case.12,32 Although epicardial imaging was not used in these patients, it is important to remember that it is always complementary to TEE. As an example, in the first patient, complementary epicardial imaging of the mitral valve, left atrial appendage, and aortic valve could only have added clinical value, especially because the decision to avoid transgastric imaging prohibited a standard comprehensive TEE examination as recommended in Society guidelines.33 As a further extension of this example, the aortic valve replacement in the first patient could have been interrogated in multiple planes after cardiopulmonary bypass with both midthoracic TEE imaging and full epicardial imaging. This complementary nature of both imaging techniques would have been even more important if the mitral intervention had not been repair but replacement with a mechanical valve be-
‡J.G.T. Augoustides
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cause then midthoracic TEE imaging of the aortic valve prosthesis would likely have been inadequate because of acoustic shadowing from the mitral prosthesis.34 Just as epiaortic imaging typically is regarded as complementary to TEE in the assessment of aortic atheroma, so is it important to regard epicardial imaging as complementary to TEE; they are not mutually exclusive. The authors are to be congratulated for their meticulous approach to the conduct of the focused TEE. Their precise understanding of the prior esophagogastric procedure, their confirmation of the absence of important esophageal symptoms, their thorough informed consent covering the risks and benefits, their careful control of the TEE probe at the midthoracic level for goal-directed imaging, and their avoidance of imaging in the reconstructed esophagogastric junction or beyond. This meticulous conduct of the intraoperative TEE examination is imperative in these high-risk scenarios to maximize safety and freedom from life-threatening esophageal perforation. The approach to TEE exhibited in these cases provides yet more evidence that TEE without transgastric views is clinically feasible, safe, and valuable in the setting of an abnormal distal esophagus and stomach. This focused intraoperative TEE approach already has entered into clinical practice for patients with gastroesophageal varices who also may undergo liver transplantation.35-38 In a small observational series (14 patients, 1997-2007), the safety and clinical efficacy of TEE without transgastric imaging was shown. Despite the presence of known gastroesophageal varices, there were no gastroesophageal complications, including bleeding. Despite the limited imaging, every TEE study provided all the clinical information required for patient management.35 The applicability, efficacy, and safety of TEE in liver transplantation have been shown in a single-center series.37 The increased use of intraoperative
TEE during liver transplantation has been extensive throughout the United States although the majority of operators use limited imaging.38 Although expert opinion has regarded TEE as contraindicated in the setting of lower esophageal pathology, this report, along with the experience in adult liver disease, provide evidence to challenge this assumption.35-38 Based on the limited published evidence, it appears reasonable to consider perioperative TEE despite distal esophageal pathology when there is a strong clinical indication and alternative cardiac imaging methods are limited. In selected cases, additional interventions such as endoscopy and/or esophageal dilation may be required to facilitate the safety required for perioperative TEE in an abnormal esophagus.39,40 Besides the distal esophagus, the oropharynx also is liable to trauma during TEE probe insertion. Multiple case reports support the utility of laryngoscopy to ease the difficult passage of a TEE probe.41-43 A recent randomized trial (80 patients) showed the oropharyngeal protection provided by rigid laryngoscopy during the placement of a TEE probe.44 In this study, rigid laryngoscopy significantly decreased the incidence of mucosal injury (5% v 55%) and odynophagia (2.5% v 32.5%).44 This trial provided evidence that even in routine practice, without known risk factors, oropharyngeal function and anatomy can be protected further by routine laryngoscopy to guide TEE probe placement under direct vision. In summary, this report highlights the critical importance of upper gastrointestinal safety during the conduct of TEE. In the setting of distal esophageal and/or gastric pathology, TEE without transgastric imaging is a reasonable clinical choice. Upper gastrointestinal endoscopy has a role in selected cases. Recent evidence supports the concept of a low threshold for laryngoscopy during TEE probe insertion in the anesthetized patient.
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