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From the *Department of Anesthesiology, Massachusetts General Hospital and VA Boston Healthcare Service, Harvard Medical School, West Roxbury, Massachusetts; Departments of Cardiology and Anesthesiology, Boston University Medical Center; Boston University School of Medicine, Boston, Massachusetts.
Address correspondence and reprint requests to Kay B. Leissner, MD, PhD, Anesthesiology Service, VA Boston Healthcare Service, West Roxbury Division 1400 VFW Parkway, West Roxbury, MA 02132. Address e-mail to kbleissner{at}yahoo.com.
An 83-yr-old women presented to the hospital with chest pain. Cardiac catheterization revealed three-vessel disease and a large inferoseptal left ventricular aneurysm (LVA). Her medical history was significant for myocardial infarction (MI) 3 months earlier and hypertension. Transthoracic echocardiography demonstrated abnormal systolic color Doppler flow at the base of the LVA, suggestive of a ventricular septal defect (VSD). Cardiac magnetic resonance imaging did not show a VSD or abnormal vascular structures. The patient was scheduled for left ventricular (LV) aneurysmectomy and coronary artery bypass grafting.
Intraoperative transesophageal echocardiography (TEE) was performed. LV ejection fraction was estimated at 40%. The midesophageal (ME) four-chamber view and transgastric basal short axis views revealed a large (4 x 5 cm) basal inferoseptal LVA extending toward the right ventricle, right atrium (RA), and left atrium (Fig. 1). A modified ME bicaval view obtained at 84° demonstrated the LVA distorting the usual RA anatomy and color Doppler identified abnormal flow from the coronary sinus (CS) toward the RA (Fig. 2 bottom) (please see video loop available at www.anesthesia-analgesia.org). The ME CS view confirmed the color flow originating from the CS without evidence of a VSD or LVA rupture (Fig. 2 top) (video loop available at www.anesthesia-analgesia.org). The CS was not enlarged. Pulsed wave Doppler interrogation was used as previously described by Kronzon et al. (1) along the CS. It demonstrated a flow velocity (v) at the upper limit of normal of 0.9 m/s, corresponding to a calculated peak pressure gradient (
P) of 3.2 mm Hg using the modified Bernoulli equation: P = 4v2.
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Cannulation of the CS for retrograde cardioplegia was unsuccessful despite multiple attempts by the attending surgeon, as the large LVA was bulging in front of the CS orifice. Thus, the heart was arrested using cold antegrade blood cardioplegia. The LVA was then plicated and a two-vessel coronary artery bypass grafting performed.
Postbypass TEE showed an unchanged ejection fraction and a small bulging of the inferoseptal LV wall. The CS was imaged in the ME CS and bicaval views with normal 2D appearance and color Doppler signal. The patient had an uneventful postoperative course.
A true LVA is an outpouching, during systole and diastole, in the LV contour (which contains myocardial elements in its wall) It has a reported incidence of 3.5%–38% (2) and typically develops in an area of prior MI. The opening of the deformity is typically wide and it appears echocardiographically smoothly demarcated from the LV. A false or pseudoaneurysm is a rupture of the myocardium that is contained by pericardial adhesions and is sharply demarcated from the LV with a narrow orifice. True LVAs typically occur in the LV anterior wall, whereas inferoseptal LVAs are uncommon, with an incidence of <3% (2). TEE can diagnose complications of LVA, such as rupture, cardiac tamponade, and thrombus formation.
The CS is typically 3-cm long and 1-cm wide and lies posteriorly in the atrioventricular groove. It empties 95% of coronary venous blood into the RA in close proximity to the tricuspid valve (3). The CS can be viewed in long axis by advancing and retroflexing the probe from the ME four-chamber view to achieve the ME CS view (Table 1). A short axis view can be visualized in the ME two-chamber view. The CS and a thebesian valve can also be seen in the ME bicaval view as the CS enters the RA in an obtuse angle. Turning the probe leftward with retro- and leftward flexion from the ME bicaval view may be helpful. TEE visualization of the CS during retrograde cardioplegia cannulation can verify proper positioning (4) (Figs. 3–5, normal CS views available at www.anesthesia-analgesia.org).
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Cannulation of the CS may be difficult for several reasons, including a small CS, other anatomical variations, a thebesian valve, CS occlusion, or hemodynamic instability while manipulating the heart. Acute CS occlusion is rare, typically caused by thrombus and leads to significant CS dilation and MI (5).
In this case TEE confirmed the diagnosis of an uncommon extension of a LVA, which made surgical CS cannulation for retrograde cardioplegia impossible and identified an abnormal color Doppler flow as an obstruction of the CS by the LVA.
Footnotes
Accepted for publication March 12, 2007.
This article has supplementary material on the Web site: www.anesthesia-analgesia.org.
REFERENCES
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