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LETTER TO THE EDITOR

Visualization of Pulmonary Thromboemboli Using Epicardial Ultrasound

Peter Rosenberger, MD, Stanton K. Shernan, MD^*, Simon C. Body, MB, ChB, MPH^*, and Holger K. Eltzschig, MD^*

*Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany, heltzschig{at}partners.org

In Response:

We thank Drs. Tebbs and Lennon for emphasizing the role of epicardial echocardiography as a supplement to transesophageal echocardiography (TEE) to improve the sensitivity of ultrasound visualization of thromboemboli within the pulmonary artery (PA). Epicardial echocardiography is routinely used during cardiac surgery for scanning the ascending aorta prior to cannulation or cross-clamping, as it is more sensitive than TEE for detecting aortic plaques (1). In addition, epicardial echocardiography can be used as an alternate imaging modality for patients in whom TEE is contraindicated (2), or probe insertion cannot be achieved (3). Epicardial echocardiography is particularly useful for visualizing anterior structures of the heart, due to the proximity of the transducer to the cardiac surface and availability of transducers with high ultrasound frequencies, permitting superior resolution (4,5). Finally, left pulmonary artery visualization from an esophageal probe position is often limited due to interposition of the left mainstem bronchus (6). Thus, echocardiographic examination of the pulmonary artery using an epicardial approach may provide superior echocardiographic windows and imaging quality compared to TEE.

Although we agree with Drs. Tebbs and Lennon that in comparison to TEE epicardial echocardiography may be a superior technique for visualizing thromboemboli within the proximal pulmonary artery circulation, the sensitivity and specificity of epicardial echocardiography for this indication has not been thoroughly investigated (7). Furthermore, the epicardial echocardiographic approach to visualizing the heart and great vessels requires a sternotomy or thoracotomy, and therefore has practical limitations as a preoperative diagnostic modality. Finally, TEE may still be useful for imaging extrapulmonary thromboemboli in the right heart and caval veins in patients presenting for pulmonary embolectomy (8). Nonetheless, epicardial echocardiography should still be available to the perioperative echocardiographer as an essential diagnostic technique (9)

References

1. Konstadt SN, Reich DL, Quintana C, Levy M. The ascending aorta: how much does transesophageal echocardiography see? Anesth Analg 1994;78:240–4.[Web of Science][Medline]
2. Edrich T, Felbinger TW, Rosenberger P, et al. Epicardial echocardiography intraoperative diagnostic utility to assess valve function. Anaesthesist 2003;52:1152–7.[Web of Science][Medline]
3. Frenk VE, Shernan SK, Eltzschig HK. Epicardial echocardiography: diagnostic utility for evaluating aortic valve disease during coronary surgery. J Clin Anesth 2003;15:271–4.[Web of Science][Medline]
4. Edrich T, Shernan SK, Smith B, Eltzschig HK. Usefulness of intraoperative epiaortic echocardiography to resolve discrepancy between transthoracic and transesophageal measurements of aortic valve gradient: a case report. Can J Anaesth 2003;50:293–6.[Web of Science][Medline]
5. Eltzschig HK, Kallmeyer IJ, Mihaljevic T, et al. A practical approach to a comprehensive epicardial and epiaortic echocardiographic examination. J Cardiothorac Vasc Anesth 2003;17:422–9.[Web of Science][Medline]
6. Rosenberger P, Shernan SK, Body SC, Eltzschig HK. Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism. Anesth Analg 2004;99:12–6.[Abstract/Free Full Text]
7. Zlotnick AY, Lennon PF, Goldhaber SZ, Aranki SF. Intraoperative detection of pulmonary thromboemboli with epicardial echocardiography. Chest 1999;115:1749–51.[Abstract/Free Full Text]
8. Rosenberger P, Shernan SK, Mihaljevic T, Eltzschig HK. Transesophageal echocardiography for detecting extrapulmonary thrombi during pulmonary embolectomy. Ann Thorac Surg 2004;78:862–6.[Abstract/Free Full Text]
9. Cahalan MK, Abel M, Goldman M, et al. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. Anesth Analg 2002;94:1384–8.[Free Full Text]

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