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CARDIOVASCULAR ANESTHESIOLOGY

Use of Transesophageal Echocardiography in the Evaluation and Surgical Treatment of a Patient with an Aneurysmal Interatrial Septum and an Intracardiac Thrombus Traversing a Patent Foramen Ovale

Thomas M. Burch, MD^*, Mark F. Davidson, MD^*, and Sara J. Pereira, MD

From the Departments of *Anesthesiology, and Surgery, The University of AL at Birmingham, Birmingham, Alabama.

Address correspondence and reprint requests to Thomas M. Burch, MD, Department of Anesthesiology, The University of AL at Birmingham, 1621 14th Ave. S, Birmingham, AL 35205. Address e-mail to tburch333{at}yahoo.com.

A 77-yr-old women presented to an outside hospital complaining of shortness of breath and transient diploplia. A transthoracic echocardiogram revealed an intracardiac mass and, due to the high risk of systemic embolization, she was transferred to our institution for emergency surgical removal. In the operating room, after induction of general anesthesia, transesophageal echocardiography (TEE) was performed, revealing a large serpentine mass in the right atrium extending across an aneurysmal interatrial septum into the left atrium through a patent foramen ovale (PFO). The end sections of this horseshoe-shaped mass repeatedly descended into both ventricles during diastole and then flipped back into the atria before atrioventricular valve closure and ventricular systole. (Figs. 1 and 2, Video clips 1–4; please see video loop at www.anesthesia-analgesia.org). TEE was used to guide placement of a left subclavian central line and bicaval cannulation. During placement of these devices, a bicaval view revealed that neither the central line wire nor the venous cannulae entered the right atrium and interfered with the thrombus. The proximal pulmonary arteries were examined in the midesophageal ascending aortic short axis view, and no thrombus was seen. The thrombus was removed and the PFO was closed. Postoperatively, the patient was neurologically intact and was discharged 7 days after admission. Of interest, the patient's symptom of dyspnea was due to distal pulmonary artery emboli (unseen on TEE) from deep venous thromboses. We think the pulmonary emboli increased right atrial pressure and thereby facilitated right-to-left flow and "trapping" of the large thrombus in the PFO.

View larger version (33K): [in this window] [in a new window]   Figure 1. Midesophageal four-chamber views showing a thrombus located in both atria traversing a patent foramen ovale (PFO) in a patient with an aneurysmal interatrial septum (IAS). This horseshoe-shaped mass appeared to repeatedly descend into both ventricles during diastole and then flip back into the atria before atrioventricular valve closure and ventricular systole. RA = right atrium, LA = left atrium, RV = right ventricle, LV = left ventricle.

View larger version (52K): [in this window] [in a new window]   Figure 2. Top left: modified bicaval view showing the thrombus traversing a patent foramen ovale, Top right: Arrow indicating wire entering the superior vena cava. The wire was advanced slowly until it was observed to enter the right atrium through the superior vena cava, then it was withdrawn until no longer seen in the atrium and the line was placed using the Seldinger technique. Bottom middle: intact thrombus after surgical removal. LA = left atrium, RA = right atrium.

1. Aneurysmal interatrial septums may expand PFO dimensions; creating a wider orifice for emboli to traverse.
   
2. Aneurysmal interatrial septums may baffle blood containing emboli from the inferior vena cava across the PFO.
   
3. The aneurysmal interatrial septum itself may act as a thrombogenic nidus assisting in local clot formation.1
   

Although intraoperative closure of an isolated PFO found incidentally during cardiac surgery is controversial, patients with a PFO and an aneurysmal interatrial septum should be strongly considered for intraoperative PFO closure, given the increased risk for paradoxical emboli.5–7 Outpatients found to have an aneurysmal interatrial septum and a PFO should be strongly considered for transcatheter treatment with a closure device, since these patients are at increased risk of recurrent paradoxical emboli, and because transcatheter treatment has been shown to decrease the risk of recurrent cerebral events.1,2–4

TEE aids in PFO detection in patients presenting with symptoms consistent with paradoxical embolism.8,5 Every comprehensive TEE examination should include interrogation of the interatrial septum for a PFO or atrial septal defect using color flow Doppler and, if necessary, contrast echocardiography. Color flow Doppler examination of the septum should be performed in multiple views, especially the four-chamber and bicaval views. The color flow Doppler Nyquist limit should be serially decreased to 20–40 cm/s, since flow across the septum is low velocity. If color flow Doppler is negative, and excluding a PFO is essential (for example, in a patient undergoing left ventricular assist device placement) then a contrast examination should be performed. Agitated saline contrast should be injected IV while imaging the septum. In ventilated patients, this should be performed with and without the release of 25 cm H₂O positive airway pressure. The release of positive airway pressure provokes a transient increase in right atrial pressure which presses the contrast medium against the septum. Visualization of contrast medium crossing into the left atrium within 3–5 cardiac cycles is consistent with a positive contrast study. A contrast study with release of positive airway pressure significantly improves PFO detection and should be conducted when color flow Doppler examination is negative and when excluding a septal defect is essential.2,6 In nonventilated patients, release of a valsalva maneuver will have results similar to the release of positive pressure in ventilated patients.

Footnotes

This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Accepted for publication November 13, 2007.

Supported by the Departments of Anesthesiology and Surgery.

REFERENCES

1. Wahl A, Krumsdorf U, Bernhard M, Sievert H, Ostermayer S, Billinger K, Schwerzmann M, Becker U, Seiler C, Arnold M, Mattle HP, Windecker S. Transcatheter treatment of atrial septal aneurysm associated with patent foramen ovale for prevention of recurrent paradoxical embolism in high-risk patients. J Am Coll Cardiol 2005;45:377–80[Abstract/Free Full Text]
2. Agmon Y, Khandheira BK, Meissner I, Meissner I, Gentile F, Sicks JD, O'Fallon M, Whisnant JP, Wiebers DO, Seward JB. Frequency of atrial septal aneurysms in patients with cerebral ischemic events. Circulation 1999;99:1942–4[Abstract/Free Full Text]
3. Pearson AC, Nagelhour D, Castello R, Gomez CR, Labovitz AJ. Atrial septal aneurysm and stroke: a transesophageal echocardiographic study. J Am Coll Cardiol 1991;18:1223–9[Abstract]
4. Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001;345:1740–6[Abstract/Free Full Text]
5. Sukernik MR, Mets B, Bennett-Guerro E. The incidental finding of a patent foramen ovale during cardiac surgery: should it always be repaired? A core review. Anesth Analg 2007;105: 602–10[Abstract/Free Full Text]
6. Argenziano M. PRO: the incidental finding of a patent foramen ovale during cardiac surgery: should it always be repaired? Anesth Analg 2007;105:611–12[Free Full Text]
7. Flachskampf FA. CON: the incidental finding of a patent foramen ovale during cardiac surgery: should it always be repaired? Anesth Analg 2007;105:613–14[Free Full Text]
8. Augoustides JG, Weiss SJ, Weiner J, Mancini J, Savino JS, Cheung AT. Diagnosis of patent foramen ovale with multiplane transesophageal echocardiography in adult cardiac surgical patients. J Cardiothorac Vasc Anesth 2004;18:723–30

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