Anesth Analg 2005;101:328-329
© 2005 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000158463.70845.BE
CARDIOVASCULAR ANESTHESIA
Solitary Liver Mass Detected by Transesophageal Echocardiography
Y. J. Oh, MD*
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J. Y. Kim, MD*, and
Y. L. Kwak, MD*
*Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University School of Medicine; and Yonsei Cardiovascular Research Institute, Yonsei University School of Medicine, Seoul, Korea
Address correspondence and reprint requests to Y. L. Kwak, MD, Yonsei University School of Medicine, 134 Shinchon-Dong, Seodaemun-Gu, Seoul 120-752, Korea. Address e-mail to ylkwak{at}yumc.yonsei.ac.kr.
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Abstract
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Transesophageal echocardiography (TEE) has become a mainstay of cardiac surgery in the diagnosis of intracardiac and vascular lesions adjacent to the esophagus. In this case, we detected a liver mass during intraoperative TEE examination in a patient undergoing elective cardiac valve surgery. Preoperatively, the patient had normal liver function tests and no symptoms of hepatocellular carcinoma. This mass was diagnosed as hepatocellular carcinoma after the surgery and treated with transarterial chemoembolization. In conclusion, this case report outlines another potential application of intraoperative TEE extending its role outside the realm of cardiac surgery.
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Introduction
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Transesophageal echocardiography (TEE), which has became a mainstay of cardiac anesthesia (1,2), is a useful adjunct in the diagnosis of intra- and extracardiac lesions (3–6). However, its use in the diagnosis of an intraabdominal lesion is limited. In this case, a solitary liver mass was detected by intraoperative TEE in a patient with valvular heart disease. The mass was diagnosed as hepatocellular carcinoma (HCC) after the surgery.
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Case Report
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A 72-yr-old female patient with mitral valve regurgitation combined with tricuspid valve regurgitation presented to the operating room for mitral valve replacement with tricuspid valve (TV) annuloplasty. She had been diagnosed with secundum type atrial septal defect 22 yr previously, and received patch repair of the atrial septal defect 6 yr previously. At the time of her previous surgery, valvular abnormalities were not evident. Symptoms of congestive heart failure such as palpitation, general weakness, and dyspnea developed within the previous 2 yr. Her medical history identified no other illness. Physical examination at admission did not reveal any gross abnormal findings except pitting edema of the extremities. The liver was not palpable below the costal margin. She had been taking digoxin, amiloride, lasix, and warfarin. Laboratory findings were not significant, including the liver profile: albumin 4.0 g/dL; total protein 6.5 g/dL; aspartate aminotransferase 21 U/L; alanine aminotransferase 4 U/L; alkaline phosphatase 112 U/L; total bilirubin 0.9 mg/dL; and 
-fetoprotein 3.16 ng/mL. Transthoracic echocardiography revealed prolapsed anterior mitral leaflet with mitral valve regurgitation of grade III/IV and incomplete coaptation of the TV leaflets with tricuspid valve regurgitation of grade IV/IV. The estimated left ventricular ejection fraction was 70%.
After the induction of anesthesia, preoperative TEE examination was done and the findings corroborated the results of transthoracic echocardiography. When TEE was manipulated to show the transgastric short axis view, an echogenic mass was detected in the liver near the junction of the posterior aspect of the right ventricle and mid-inferior aspect of the left ventricle (Fig. 1). To evaluate the mass further, TEE probe was advanced about 5 cm and rotated 60° clockwise. A round heterogeneous echogenic solitary liver mass of approximately 4 cm in diameter was detected (Fig. 2). No other mass was detected in the right side of the heart, inferior vena cava, and pulmonary vessels. The diagnosis of a possible HCC was reported to the surgeon. Because the patient's condition did not allow the treatment of HCC, the surgeon proceeded with mitral valve replacement and TV annuloplasty. The mitral valve showed myxoid degeneration.
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Figure 1. An echogenic mass (arrow) was detected in the liver near the junction of the posterior aspect of the right ventricle (RV) and mid-inferior aspect of the left ventricle (LV) in transgastric short axis view.
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Figure 2. Transesophageal echocardiographic probe was advanced about 5 cm and rotated 60° clockwise from Figure 1. A round heterogeneous echogenic solitary liver mass of approximately 4 cm in diameter was detected.
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After the surgery, a computed tomography (CT) scan of the abdomen was performed and demonstrated a low-density round mass of 3 x 4 cm in the lateral segment of the left lobe of the liver (Fig. 3A). The mass showed heterogeneous enhancement in the arterial phase of contrast CT scan, which was consistent with HCC (Fig. 3B). A month after the valvular surgery, transarterial chemoembolization of the HCC was performed.
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Figure 3. Computed tomography (CT) scan of the abdomen. A, A low-density round mass (arrow) of 3 x 4 cm in the lateral segment of the left lobe of the liver. B, Heterogeneous enhanced mass (arrow) in arterial phase of contrast CT scan, which was consistent with hepatocellular carcinoma.
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Discussion
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TEE has become an indispensable part of cardiac anesthesia as a tool to facilitate complex diagnostic decisions and guide and evaluate pharmacological and surgical intervention (1,2). Occasionally, it also can be a useful adjunct in the diagnosis of extracardiac lesions. Unfortunately, TEE examination of extracardiac lesions, especially intraabdominal lesions, is affected and limited by factors such as patient size, body habitus, and preexisting pathology. There are a few case reports concerning the usefulness of TEE in the diagnosis of intraabdominal lesions. Hofmann and Papadimos (3) found an echo free space between the liver and the diaphragm that was diagnosed as liver laceration in a trauma patient. Yamaura et al. (4) also found massive retroperitoneal hemorrhage during cardiopulmonary bypass using TEE. In both cases, hemodynamic instability, which indicated a source of bleeding, was noted.
Although TEE has been used to detect subclinical cardiac metastasis of HCC (5,6), detection of a solitary liver mass without cardiac metastasis using TEE has never been reported. This case is interesting because this incidental finding permitted the early treatment of the HCC. HCC is the sixth most common cancer of men and eleventh most common cancer of women worldwide and the survival of patients with HCC varies by stage at the time of presentation and the presence of underlying liver disease (7). Because the patient did not have any symptoms of HCC at admission, the mass would likely have gone undetected until the patient complained of abdominal pain or jaundice, and the prognosis would have been much worse.
In conclusion, this case report outlines another potential application of intraoperative TEE extending its role outside the realm of cardiac surgery.
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Footnotes
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Accepted for publication January 21, 2005.
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References
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- Poterack KA. Who uses transesophageal echocardiography in the operating room? Anesth Analg 1995;80:454–8.[Abstract]
- Mishra M, Chauhan R, Sharma KK, et al. Real-time intraoperative transesophageal echocardiography: how useful? Experience of 5,016 cases. J Cardiothorac Vasc Anesth 1998;12:625–32.[ISI][Medline]
- Hofmann JP, Papadimos TJ. Transesophageal echocardiographic diagnosis of liver laceration accompanied by hemodynamic instability. Anesth Analg 2004;98:611–3.[Abstract/Free Full Text]
- Yamaura K, Okamoto H, Maekawa T, et al. Detection of retroperitoneal hemorrhage by transesophageal echocardiography during cardiac surgery. Can J Anaesth 1999;46:169–72.[Abstract/Free Full Text]
- Tse HF, Lau CP, Lau YK, Lai CL. Transesophageal echocardiography in the detection of inferior vena cava and cardiac metastasis in hepatocellular carcinoma. Clin Cardiol 1996;19:211–3.[ISI][Medline]
- Edanaga M, Yoshida S, Nakayama M, et al. The usefulness of intraoperative TEE monitoring in a patient with renal cell carcinoma. Masui 2004;53:803–5.[Medline]
- Hussain SA, Ferry DR, El-Gazzaz G, et al. Hepatocellular carcinoma. Ann Oncol 2001;12:161–72.[Abstract/Free Full Text]
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Abstract
Introduction
