Robert J. Suriani

Intraoperative Transesophageal Echocardiography During Noncardiac Surgery

OBJECTIVE To investigate the use and impact of transesophageal echocardiography (TEE) during noncardiac surgery. DESIGN Retrospective study. SETTING A university teaching hospital. PARTICIPANTS AND INTERVENTIONS The medical records and the videotapes of 123 intraoperative TEE examinations were reviewed. MEASUREMENTS AND MAIN RESULTS TEE was used for non-consultative indications in 68 patients and in consultation in 55 patients. Information that would not have been detected intraoperatively by other means included intracardiac defects, valvular and aortic pathology, the presence or absence of ventricular dysfunction or intracardiac thrombi, and embolization during surgery. Findings during the initial TEE examination and the TEE evaluation of intraoperative events resulted in a major impact on patient management in 15% of patients. The majority of patients in whom TEE had any impact (the sum of major, minor, and limited impact groups) were classified as American Society of Anesthesiologists (ASA) class 3 or 4. Patients in whom TEE had any impact were significantly older than patients in whom TEE had no impact (66.5 +/- 13.4 years v 58.1 +/- 16.2 years; p < 0.05). No patient experienced a complication related to intraoperative TEE. CONCLUSION It appears that TEE in patients undergoing noncardiac surgery is efficacious in rapidly disclosing new findings and information during periods of hemodynamic instability. It may have a significant impact on intraoperative patient management and may be beneficial in patients older than 66 years of age.

Intraoperative transesophageal echocardiography during liver transplantation

OBJECTIVE To investigate the safety, value, and impact of transesophageal echocardiography during liver transplantation. DESIGN Retrospective. SETTING University teaching hospital. PARTICIPANTS AND INTERVENTIONS The medical records of 346 patients and the videotapes of 100 intraoperative transesophageal echocardiography examinations were reviewed. MEASUREMENTS AND MAIN RESULTS Transesophageal echocardiography was indicated for intraoperative monitoring in 62 patients, 41 of whom had pertinent findings, and for diagnostic purposes in 38 patients, 14 of whom had the expected diagnosis verified. Thirty-one patients had no intraoperative findings. Information that would not have been detected intraoperatively by other means included intracardiac defects, the potential for transpulmonary air passage, valvular regurgitation, the presence or absence of ventricular dysfunction, and embolization occurring at allograft reperfusion. Unanticipated findings during the initial transesophageal echocardiography examination as well as evaluation of intraoperative events resulted in a major impact on patient management in 11% of patients. Preoperatively, 64 patients had a prothrombin time greater than 14 seconds; 56 had a platelet count less than 100,000/mm3; and 23 had esophageal varices, 7 of whom had not had variceal sclerotherapy. Two patients had a complication possibly caused by transesophageal echocardiography (sinus bradycardia and upper gastrointestinal bleeding). No patient experienced documented variceal hemorrhage, esophageal or gastric perforation, and/or oropharyngeal trauma. CONCLUSIONS It appears that transesophageal echocardiography can be performed safely in patients undergoing liver transplantation, is efficacious in rapidly disclosing new information and monitoring during periods of hemodynamic instability, and may have a significant impact on intraoperative patient management during liver transplantation.

Transesophageal Doppler echocardiographic monitoring for malperfusion during aortic dissection repair

Abstract The present case of cardiopulmonary bypass malperfusion demonstrates the usefulness of transesophageal Doppler echocardiographic monitoring during repair of acute aortic dissection.

Echo round: transesophageal imaging of a left common pulmonary vein during a minimaze procedure.

A 57-year-old woman with paroxysmal atrial fibrillation, hypertension, noninsulin-dependent diabetes, obesity, and asthma presented for bilateral thorocoscopic pulmonary vein (PV) isolation and left atrial (LA) appendage (LAA) exclusion (Minimaze procedure). Consent for publication of this case has been obtained from the patient. Her preoperative computed tomography thoracic angiogram revealed the absence of filling defects within the LA, the absence of thrombus in the LAA, and a conjoined upper and lower PV to form a single common PV on the left, which entered the LA posteriorly (Fig. 1A). The upper and lower PVs on the right appeared unremarkable in anatomic size and orientation. An initial intraoperative transesophageal echocardiography (TEE) was performed under general endotracheal anesthesia on 2-lung ventilation. The left common PV was observed just lateral to the LAA in the midesophageal 4-chamber view with retroflexion and leftward rotation of the TEE probe, and the multiplane array increased to 47° (Fig. 1B) (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A385). It entered the posterior aspect of the LA, had a diameter of 1.4 cm at a point approximately 2 cm from its origin, and expanded to an ostial diameter of 2.3 cm using the system calipers. The bifurcation was not observed along the 4 cm of its length that could be visualized. Color-flow and pulsed-wave Doppler imaging demonstrated normal antegrade bloodflow patterns into the LA. The right upper and lower PVs appeared echocardiographically normal, with ostial diameters measuring 1.5 cm and 1.4 cm, respectively. During the second phase of a bilateral Minimaze procedure with right-sided 1-lung ventilation, left-sided hemithorax insufflation, and anterior surgical retraction of the pericardium, the surgeon positioned the bipolar radiofrequency clamp around the common PV and onto its atrial cuff. He expressed concern that due to the abnormal proximity of the common PV ostia to the right PVs, an ablation burn encroaching upon or encompassing the right PVs could result in stenosis. TEE examination was thus requested with the clamp applied and before this ablation. Two-dimensional assessment demonstrated that the clamp did not impinge upon either the right upper or lower PVs. Color-flow and pulsed-wave Doppler imaging demonstrated unobstructed and nonturbulent bloodflow (Fig. 2) (Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A387). The ablation was then uneventfully completed. TEE re-evaluation at the end of the procedure demonstrated unobstructed and unchanged pulmonary venous bloodflow in the right upper and lower PVs as well as the left common PV. The patient had an unremarkable postoperative course. Normal pulmonary venous anatomy occurs in only 70%–80% of individuals, consisting of 4 PVs with individual ostia emptying into the LA. Mean PV diameter at the ostia has been reported as left superior 16.6 mm, left From the Departments of *Anesthesiology and ‡Cardiothoracic Surgery, St. Vincent’s Medical Center, Bridgeport, CT. Accepted for publication November 4, 2011. Funding: None. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Robert J. Suriani, MD, Department of Anesthesiology, St. Vincent’s Medical Center, 2800 Main Street, Bridgeport, CT 06606. Address e-mail to rsuriani@stvincents.org. Copyright