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CARDIOVASCULAR ANESTHESIOLOGY

The Use of Transesophageal Echocardiography for Differential Diagnosis of Poor Venous Return During Cardiopulmonary Bypass

From the Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York.

Address correspondence to Ellen D. Iannoli, MD, 601 Elmwood Ave., Box 604, Rochester, NY 14642. Address e-mail to Ellen_iannoli{at}urmc.rochester.edu.

Transesophageal echocardiography (TEE) is now widely accepted as being useful in the management of patients undergoing cardiac surgery. There are also reports of using TEE to assist with placement of cannula for cardiopulmonary bypass (CPB) (1–3). However, there are few reports of the use of TEE for troubleshooting problems during CPB. We present a case in which intraoperative TEE assisted in the diagnosis of poor venous return during CPB.

A 64-year-old man presented for redo-sternotomy and heart transplantation. CPB was instituted after cannulation of the ascending aorta and the left femoral vein. At the time of femoral venous cannula placement, TEE was used to confirm positioning of the tip of the venous cannula at the junction of the inferior vena cava (IVC) and right atrium. After initiation of CPB, venous return flow was noted to be low and his cardiac index was <2 L · min^–1 · m^–2. Low venous return to the CPB circuit may be related to low blood volume, air in the venous return line, inappropriate cannula placement, or obstruction of the cannula. Vacuum was applied to the circuit without improvement in venous return. At this time TEE examination revealed intermittent obstruction of the venous cannula inflow by a large, redundant Eustachian valve (Figs. 1 and 2 and please see video loop available at www.anesthesia-analgesia.org). After withdrawal of the venous cannula by a few centimeters, venous return promptly improved and the cardiac index increased to 2.3 L · min^–1 · m^–2.

View larger version (44K): [in this window] [in a new window]   Figure 1. Transesophageal echocardiography bicaval image demonstrating the venous cannula at the junction of the right atrium and inferior vena cava. The Eustachian valve is also noted.

View larger version (44K): [in this window] [in a new window]   Figure 2. Similar transesophageal echocardiography image as for Figure 1 demonstrating obstruction of the venous cannula by the Eustachian valve (arrow) after initiation of cardiopulmonary bypass.

ACKNOWLEDGMENTS

The author thanks Dr. Peter Bailey for assistance in preparing the manuscript.

Footnotes

Accepted for publication March 12, 2007.

No reprints will be available from the author.

REFERENCES

1. Applebaum RM, Cutler WM, Bhardwaj N, Colvin SB, Galloway AC, Ribakove GH, Grossi EA, Schwartz DS, Anderson RV, Tunick PA, Kronzon I. Utility of transesophageal echocardiography during port-access minimally invasive cardiac surgery. Am J Cardiol 1998;82:183–8.[Web of Science][Medline]
2. Kirkeby-Garstad I, Tromsdal A, Sellevold OF, Bjorngaard M, Bjella LK, Berg EM, Karevold A, Haaverstad R, Wahba A, Tjomsland O, Astudillo R, Krogstad A, Stenseth R. Guiding surgical cannulation of the inferior vena cava with transesophageal echocardiography. Anesth Analg 2003;96:1288–93.[Abstract/Free Full Text]
3. Zlotnick AY, Gilfeather MS, Adams DH, Cohn LH, Couper GS. Innominate vein cannulation for venous drainage in minimally invasive aortic valve replacement. Ann Thorac Surg 1999;67:864–5.[Abstract/Free Full Text]

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This Article Full Text (PDF) Echo Loop Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Iannoli, E. D. Search for Related Content PubMed PubMed Citation Articles by Iannoli, E. D. Related Collections Cardiovascular Monitoring (Cardiac) Echo Rounds Video Clip