Anesth Analg 2006;102:729-730
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000197692.55834.a2
CARDIOVASCULAR ANESTHESIA
The Use of Epicardial Echocardiography as an Adjunct to Transesophageal Echocardiography for the Detection of Pulmonary Embolism
J. W. Allyn,
P. F. Lennon,
J. H. Siegle,
R. D. Quinn, and
M. N. D’Ambra
Department of Anesthesiology and Pain Management, Maine Medical Center; Department of Cardiac Services, Maine Medical Center, Portland, Maine; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
Address correspondence and reprint requests to John W. Allyn, MD, Department of Anesthesiology and Pain Management, Maine Medical Center, 22 Bramhall St., Portland, ME 04102. Address e-mail to allynj{at}spectrummg.com.
A 54-yr-old 89-kg male with endocarditis involving an existing prosthetic aortic valve presented for aortic valve and aortic root replacements. After induction of general anesthesia and tracheal intubation, his arterial blood pressure was 130/70 mm Hg, heart rate 90 bpm, and pulmonary artery (PA) pressure 72/24 mm Hg. This degree of pulmonary hypertension was not expected, although no prior right heart catheterization data were available. During the pre-cardiopulmonary bypass transesophageal echocardiography (TEE) examination a density separate from the PA catheter was noted in the proximal right PA (Fig. 1). Multiple attempts were made to image and further define this density without success. Therefore, epicardial echocardiography (EE; Philips Medical Systems Bothell, WA) was used to further delineate this density (see video clip at www.anesthesia-analgesia.org) before separation from cardiopulmonary bypass. This EE examination confirmed a discrete, mobile mass in the right PA. An incision was made in the right PA and a 45-cm thrombus was extracted (Fig. 2). The patient had a filter placed in his inferior vena cava the next day and had an otherwise uneventful recovery.
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Figure 1. This image is similar to the midesophageal long axis view, but the transesophageal echocardiography probe has been rotated and withdrawn slightly to better image the right pulmonary artery and thus more of the ascending aorta is shown beyond the right pulmonary artery in the image. The density is seen to the left of the pulmonary artery catheter in the right pulmonary artery (arrow).
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Other investigators have discussed the benefits of TEE or EE in cases of suspected pulmonary embolism (1,2). The linear array EE probe operates at a higher frequency range (6–15 MHz) than the phased array TEE transducer (4–7 MHz); these higher transmitted frequencies provide better two-dimensional resolutionat a cost of reduced penetration. More importantly, EE’s larger footprint (aperture) results in excellent axial and lateral resolution, but with a loss in temporal resolution. In contrast, TEE’s phased array transducer is designed for better temporal resolution and better penetration.
The echo density in the right PA on TEE was subtle and could have easily been missed. Detailed evaluation by TEE of the distal and main PA, as well as the distal ascending aorta, is often impeded by the interposition of the trachea. Although an abnormality was suggested by TEE, the mass was difficult to image. EE allowed detailed localization of the mass for the surgeon before an incision was made in the PA. In this case the patient’s symptoms were attributed to his aortic valve endocarditis and pulmonary thromboembolism was not entertained until after PA catheter placement. This case demonstrates the utility of EE to identify pulmonary thromboembolism.
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Footnotes
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Video images for this case can be accessed at www.anesthesia-analgesia.org. Click on Cardiovascular Anesthesia in the Contents page and then the Data Supplement link located below the title of the article.
Accepted for publication October 20, 2005.
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References
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- 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]
- 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]
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