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Transesophageal Echocardiographic Bull’s Eye
DIAGNOSTIC DILEMMAS Ronald A. Kahn, MD Jack S. Shanewise, MD Section Editors
Transesophageal Echocardiographic Bull’s Eye Hovig V. Chitilian, MD, Theodore A. Alston, MD, PhD, and Edwin G. Avery, MD
A
68-YEAR-OLD woman was scheduled for surgery for diverticulosis, but her preoperative electrocardiogram prompted a stress test that was markedly positive for ischemia.
From the Cardiac Anesthesia Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Address reprint requests to Edwin G. Avery, MD, Department of Anesthesia and Critical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. E-mail: [email protected] © 2006 Elsevier Inc. All rights reserved. 1053-0770/06/2006-0028$32.00/0 doi:10.1053/j.jvca.2005.09.007 Key words: transesophageal ultrasonography
Fig 1.
894
Catheterization revealed occlusion of her left anterior descending and circumflex coronary arteries. Her ascending aorta was dilated (3.7 cm), there was mild aortic regurgitation, and there was a question of an apical left ventricular thrombus. Accordingly, intraoperative transesophageal echocardiographic examination was performed during surgery for coronary artery revascularization. The apex appeared free of thrombus and was not aneurysmal. The aortic regurgitation was confirmed to be mild, and her aortic dilation was as expected. However, upon attempting to image the descending aorta by means of transesophageal echocardiography, a pulsatile echogenic mass within a ring was encountered (Fig 1). What is the bull’s eye structure?
Bull’s eye. The iris was pulsatile.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 20, No 6 (December), 2006: pp 894-895
TEE BULL’S EYE
895
DIAGNOSIS: SPINAL CORD
At a quick glance, the dura and cord could be taken to be an abnormal aorta, but aortic surgery was not required. The spinal cord is not routinely imaged during transesophageal echocardiography for cardiothoracic surgery. However, the cord can often be scanned when it is deliberately sought.1-3 Vertebral bodies mask the cord, but intervertebral disks conduct ultrasound beams well. Cord segments can often be imaged through 4 to 6 spaces.1 Ultrasonographic visualization of the spinal column might
help to assess the structural integrity of the spinal cord and associated structures or to identify a hematoma. Normal pulsation of the cord is readily evident. Because aortic clamping or grafting can cause spinal ischemia and because spinal pulsation is sonographically apparent, transesophageal and/or surface sonography might prove of value in monitoring spinal cord perfusion during aortic surgery.4,5 Transesophageal echocardiography might assist in intraoperative localization of herniated disks during spine surgery. Furthermore, TEE might prove an aid to placement of thoracic epidural catheters.6,7
REFERENCES 1. Funck M, Schneider B, Igloffstein J, et al: Transesophageal ultrasonography of the spinal canal. Dtsch Med Wochenschr 114:529533, 1989 2. Mugge A, Konitzer M, Gaab M, et al: Ultrasound imaging of the spinal cord via the esophagus in conscious patients: initial experience. J Clin Ultrasound 19:187-190, 1991 3. Godet G, Couture P, Ionanidis G, et al: Another application of two-dimensional transesophageal echocardiography: Spinal cord imaging. A preliminary report. J Cardiothorac Vasc Anesth 8:14-18, 1994 4. Shenaq SA, Svensson LG: Paraplegia following aortic surgery. J Cardiothorac Vasc Anesth 7:81-94, 1993
5. Chiesa R, Melissano G, Marrocco-Trischitta MM, et al: Spinal cord ischemia after elective stent-graft repair of the thoracic aorta. J Vasc Surg 42:11-17, 2005 6. Galiano K, Obwegeser AA, Bodner G, et al: Ultrasound guidance for facet joint injections in the lumbar spine: A computed tomography-controlled feasibility study. Anesth Analg 101:579583, 2005 7. Galiano K, Obwegeser AA, Bodner G, et al: Ultrasound-guided periradicular injections in the middle to lower cervical spine: An imaging study of a new approach. Reg Anesth Pain Med 30:391-396, 2005
Transesophageal Echocardiographic Bull’s Eye Hovig V. Chitilian, MD, Theodore A. Alston, MD, PhD, and Edwin G. Avery, MD
A
68-YEAR-OLD woman was scheduled for surgery for diverticulosis, but her preoperative electrocardiogram prompted a stress test that was markedly positive for ischemia.
From the Cardiac Anesthesia Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Address reprint requests to Edwin G. Avery, MD, Department of Anesthesia and Critical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. E-mail: [email protected] © 2006 Elsevier Inc. All rights reserved. 1053-0770/06/2006-0028$32.00/0 doi:10.1053/j.jvca.2005.09.007 Key words: transesophageal ultrasonography
Fig 1.
894
Catheterization revealed occlusion of her left anterior descending and circumflex coronary arteries. Her ascending aorta was dilated (3.7 cm), there was mild aortic regurgitation, and there was a question of an apical left ventricular thrombus. Accordingly, intraoperative transesophageal echocardiographic examination was performed during surgery for coronary artery revascularization. The apex appeared free of thrombus and was not aneurysmal. The aortic regurgitation was confirmed to be mild, and her aortic dilation was as expected. However, upon attempting to image the descending aorta by means of transesophageal echocardiography, a pulsatile echogenic mass within a ring was encountered (Fig 1). What is the bull’s eye structure?
Bull’s eye. The iris was pulsatile.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 20, No 6 (December), 2006: pp 894-895
TEE BULL’S EYE
895
DIAGNOSIS: SPINAL CORD
At a quick glance, the dura and cord could be taken to be an abnormal aorta, but aortic surgery was not required. The spinal cord is not routinely imaged during transesophageal echocardiography for cardiothoracic surgery. However, the cord can often be scanned when it is deliberately sought.1-3 Vertebral bodies mask the cord, but intervertebral disks conduct ultrasound beams well. Cord segments can often be imaged through 4 to 6 spaces.1 Ultrasonographic visualization of the spinal column might
help to assess the structural integrity of the spinal cord and associated structures or to identify a hematoma. Normal pulsation of the cord is readily evident. Because aortic clamping or grafting can cause spinal ischemia and because spinal pulsation is sonographically apparent, transesophageal and/or surface sonography might prove of value in monitoring spinal cord perfusion during aortic surgery.4,5 Transesophageal echocardiography might assist in intraoperative localization of herniated disks during spine surgery. Furthermore, TEE might prove an aid to placement of thoracic epidural catheters.6,7
REFERENCES 1. Funck M, Schneider B, Igloffstein J, et al: Transesophageal ultrasonography of the spinal canal. Dtsch Med Wochenschr 114:529533, 1989 2. Mugge A, Konitzer M, Gaab M, et al: Ultrasound imaging of the spinal cord via the esophagus in conscious patients: initial experience. J Clin Ultrasound 19:187-190, 1991 3. Godet G, Couture P, Ionanidis G, et al: Another application of two-dimensional transesophageal echocardiography: Spinal cord imaging. A preliminary report. J Cardiothorac Vasc Anesth 8:14-18, 1994 4. Shenaq SA, Svensson LG: Paraplegia following aortic surgery. J Cardiothorac Vasc Anesth 7:81-94, 1993
5. Chiesa R, Melissano G, Marrocco-Trischitta MM, et al: Spinal cord ischemia after elective stent-graft repair of the thoracic aorta. J Vasc Surg 42:11-17, 2005 6. Galiano K, Obwegeser AA, Bodner G, et al: Ultrasound guidance for facet joint injections in the lumbar spine: A computed tomography-controlled feasibility study. Anesth Analg 101:579583, 2005 7. Galiano K, Obwegeser AA, Bodner G, et al: Ultrasound-guided periradicular injections in the middle to lower cervical spine: An imaging study of a new approach. Reg Anesth Pain Med 30:391-396, 2005