RESUMEN
In this study, we sought to define the impact of intraoperative transesophageal echocardiography (IOTEE) among patients undergoing aortic valve replacement for severe aortic stenosis. We reviewed the clinical data and preoperative, intraoperative, and postoperative echocardiograms of all adults who underwent aortic valve replacement for aortic stenosis and had IOTEE between January 1993 and December 1996. There were 383 patients (223 men, 160 women; mean age, 69 years). Fifty-four (14%) of the 383 patients had mitral valve surgery at the time of aortic valve replacement. In 6 patients, mitral valve surgery was not planned but was added because of findings on IOTEE. In 25 patients, mitral valve surgery was canceled on the basis of the IOTEE. Additional information was found by IOTEE in 25 patients before and after bypass, altering the surgical plan in 18 of these 25 patients. Overall, IOTEE altered the planned operation in 49 (13%) of the 383 patients. These data support the routine use of IOTEE among patients undergoing aortic valve replacement for aortic stenosis.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Adolescente , Anciano , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Toma de Decisiones , Ecocardiografía Transesofágica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Monitoreo Intraoperatorio , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
In the early days of transesophageal echocardiography, the "Q-tip sign" was occasionally mistaken for a left atrial mass. This area is now well recognized as a normal anatomic landmark dividing the left atrial appendage from the left upper pulmonary vein. However, in this report we describe 2 patients in whom pathology was found in this area, which should not be overlooked.
Asunto(s)
Apéndice Atrial/diagnóstico por imagen , Ecocardiografía Transesofágica , Fibroma/diagnóstico por imagen , Neoplasias Cardíacas/diagnóstico por imagen , Mixoma/diagnóstico por imagen , Venas Pulmonares/diagnóstico por imagen , Anciano , Apéndice Atrial/patología , Femenino , Fibroma/patología , Fibroma/cirugía , Neoplasias Cardíacas/patología , Neoplasias Cardíacas/cirugía , Humanos , Mixoma/patología , Mixoma/cirugía , Venas Pulmonares/patologíaRESUMEN
To evaluate the role of intraoperative transesophageal echocardiography (IOTEE) during surgical removal of cardiac masses, we studied 75 consecutive patients (34 men, aged 56 +/- 16 years, range 17 to 82 years) who underwent surgery primarily for cardiac mass removal with the adjunct of IOTEE for the years 1993 through 1998. The IOTEE provided new information before bypass in 6 patients (8%), altering the planned surgical procedure in all. A newly discovered patent foramen ovale was closed in 2 patients, a second myxoma discovered in one patient, a mitral valve repaired in one patient, inferior vena caval cannulation site clarified in one patient, and in one patient the mass was no longer present and the surgery canceled. In 10 patients (13%), new post-bypass information was found, which prompted return to bypass for valve repair in 3 patients, altered nonsurgical management in 3 patients, and did not necessitate specific measures in 4 patients. Thus, in 75 patients coming to surgery for mass removal, IOTEE affected intraoperative management in 12 (16%).
Asunto(s)
Ecocardiografía Transesofágica , Neoplasias Cardíacas/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Puente Cardiopulmonar , Femenino , Neoplasias Cardíacas/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio , Resultado del TratamientoRESUMEN
Frequently portions of the mitral valve and sub-valvular apparatus are left intact during mitral valve replacement to help preserve left ventricular function. We describe a patient with paroxysmal congestive heart failure caused by intermittent entrapment of the subvalvular apparatus in the prosthesis, preventing complete valve closure.
Asunto(s)
Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/etiología , Prótesis Valvulares Cardíacas , Complicaciones Posoperatorias/diagnóstico por imagen , Anciano , Cuerdas Tendinosas/fisiopatología , Ecocardiografía Transesofágica , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Falla de PrótesisRESUMEN
OBJECTIVE: To determine the impact of intraoperative transesophageal echocardiography (IOTEE), an important adjunct in many types of cardiac surgical cases, on the surgical decisions made perioperatively in adult patients undergoing cardiac surgery. PATIENTS AND METHODS: All adult patients who had cardiac surgery between 1993 and 1997 and who also had IOTEE were studied. New findings before and after cardiopulmonary bypass and alterations in the planned surgical procedure or management were documented prospectively. RESULTS: A total of 3245 patients (60% men, 40% women; aged 18-93 years with a mean +/- SD age of 62 +/- 15 years) were included in the study. The most common operations performed were mitral valve repair (26%) and aortic valve replacement (22%). Over the 5-year period, 41% of patients had IOTEE. New information was found before bypass in 15% of patients, directly affecting surgery in 14% of the patients. The most common new prebypass information found was patent foramen ovale resulting in closure in the majority of patients. New information was found after bypass in 6% of the patients, resulting in a change in surgery or hemodynamic management in 4% of the total. The most common postbypass finding was valvular dysfunction with repeat bypass in most patients for re-repair or replacement. No major complications occurred. CONCLUSION: In adult patients undergoing cardiac surgery, IOTEE provides important important information both before and after bypass that affects surgical and hemodynamic management.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Ecocardiografía Transesofágica , Monitoreo Intraoperatorio/métodos , Adulto , Anciano , Anciano de 80 o más Años , Ecocardiografía Transesofágica/efectos adversos , Ecocardiografía Transesofágica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Estudios ProspectivosRESUMEN
The purpose of this study was to determine the role of power Doppler imaging in assessing patency of coronary artery bypass graft (CABG) anastomosis. Twelve consecutive patients referred for CABG with the use of anastomosis of the internal thoracic artery to the left anterior descending coronary artery (LAD) were studied. A linear 6.5-MHz wide-band transducer was used during cardioplegic administration and reperfusion. Baseline power Doppler signals were obtained in the LAD in 11 patients, and post-CABG signals were obtained in 11 patients. In one patient the LAD was poorly visualized because of extensive calcification. In another patient the flow after bypass worsened and the graft was revised. Visualization of the LAD and internal thoracic artery grafts by epicardial intraoperative power Doppler imaging is feasible in almost all patients and allows rapid and simple intraoperative assessment of graft patency. In addition, myocardial perfusion is limited by heavily calcified coronaries.
Asunto(s)
Puente de Arteria Coronaria , Circulación Coronaria , Ecocardiografía Doppler , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Femenino , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Arterias Torácicas/diagnóstico por imagen , Arterias Torácicas/cirugía , Grado de Desobstrucción VascularAsunto(s)
Dolor en el Pecho/etiología , Neoplasias Cardíacas/complicaciones , Neoplasias Cardíacas/diagnóstico , Melanoma/complicaciones , Melanoma/diagnóstico , Anciano , Diagnóstico Diferencial , Atrios Cardíacos , Neoplasias Cardíacas/secundario , Humanos , Masculino , Melanoma/secundario , Esfuerzo FísicoRESUMEN
The purpose of this study was to prospectively compare the intraoperative transesophageal echocardiographic (IOTEE) findings with the operative findings in 1918 consecutive cardiac cases. Forty-eight discordant findings were found between the IOTEE and operative findings. Of the 48 discordant findings, most were related to valve pathology. Structural abnormalities that were missed by IOTEE included those of the aortic valve, 12 cases (25%), mitral valve, 13 cases (27%), and pulmonic and tricuspid valves, 5 cases (10%). Functional discrepancies occurred in 8% of cases. Overall, incidence of discrepant findings between IOTEE and operative findings was low (2.5%). This resulted in an alteration of the planned surgical procedure in a small number of cases (0.3%).
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Ecocardiografía Transesofágica , Cuidados Intraoperatorios , Ultrasonografía Intervencional , Adolescente , Adulto , Anciano , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Niño , Preescolar , Puente de Arteria Coronaria , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Planificación de Atención al Paciente , Estudios Prospectivos , Válvula Pulmonar/diagnóstico por imagen , Válvula Pulmonar/cirugía , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugíaRESUMEN
Transesophageal echocardiography (TEE) has a definitive role in the diagnosis and management of critically ill patients with cardiovascular disease and patients undergoing cardiac operations. The diagnostic role of emergency intraoperative TEE and the impact on clinical outcome have not been evaluated. We reviewed the indications, findings, and impact of emergency intraoperative TEE in 66 patients over a 4-year period. The indications for emergency TEE were unexplained hemodynamic instability (36 patients), preoperative evaluation of patients having emergency surgery (19 patients), cardiac evaluation of trauma cases (6 patients), and unexplained intraoperative hypoxemia (5 patients). New findings were disclosed in 53 (80%) patients, with an alteration of the planned surgical procedure in 15 (23%). Despite the therapeutic impact, 24 patients (36%) did not survive to hospital dismissal. We recommend that TEE be considered as the diagnostic tool of choice when surgical patients have unexplained hemodynamic instability, when time does not permit complete preoperative evaluation, when cardiovascular injury is suspected in a trauma patient, and to evaluate unexplained hypoxemia.
Asunto(s)
Enfermedades Cardiovasculares/cirugía , Ecocardiografía Transesofágica , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/diagnóstico por imagen , Urgencias Médicas , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana EdadRESUMEN
The sizing of aortic valve (AV) homografts for optimum function requires an accurate measurement of the aortic annulus. Typically, this measurement is obtained directly with sizers in the open aorta. We describe the use of intraoperative transesophageal echocardiography (IOTEE) to measure the aortic annulus and select the appropriate AV homograft before cardiopulmonary bypass and aortic cross-clamping. Thirty-two patients underwent AV homograft insertion between March 1993 and March 1996 and had IOTEE. There were 13 women and 19 men. Mean age was 58 +/- 14 years. IOTEE measurements were satisfactory in sizing in all patients, and no extraordinary surgical measures were necessary to insert the AV homografts. Early postoperative follow-up showed trivial or mild regurgitation of all homografts. Prebypass IOTEE is reliable in guiding the selection of optimal AV homografts.
Asunto(s)
Ecocardiografía Transesofágica , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Adulto , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Femenino , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Trasplante HomólogoRESUMEN
OBJECTIVES: This study assessed the reliability of transesophageal echocardiographic measurements of pericardial thickness and the potential diagnostic usefulness of this technique. BACKGROUND: Transthoracic echocardiography cannot reliably detect thickened pericardium. The superior resolution achieved with transesophageal echocardiography should allow better pericardial definition. METHODS: Pericardial thickness measured at 26 locations in 11 patients with constrictive pericarditis who underwent intraoperative transesophageal echocardiography was compared with pericardial thickness measured with electron beam computed tomography. Intraobserver and interobserver variabilities were determined. Pericardial thickness was then measured in 21 normal subjects. With these values as a guide, two observers reviewed 37 transesophageal echocardiographic studies to determine whether echocardiographic measurement of pericardial thickness could be used to distinguish diseased from normal pericardium. RESULTS: The correlation between echocardiographic and computed tomographic measurements (r > or = 0.95, SE < or = 0.06 mm, p < 0.0001) was excellent. The +/-2 SD limits of agreement were +/-1.0 mm or less for pericardial thickness < 5.5 mm and +/-2.0 mm or less for the entire range of thicknesses. Intraobserver and interobserver agreements were good. Mean normal pericardial thickness was 1.2 +/- 0.8 mm (+/-2 SD) and did not exceed 2.5 mm. Pericardial thickness > or = 3 mm on transesophageal echocardiography was 95% sensitive and 86% specific for the detection of thickened pericardium. CONCLUSIONS: Measurement of pericardial thickness with transesophageal echocardiography is reproducible and should be a valuable adjunct in assessing constrictive pericarditis.
Asunto(s)
Ecocardiografía Transesofágica , Pericarditis Constrictiva/diagnóstico por imagen , Pericardio/diagnóstico por imagen , Estudios de Casos y Controles , Estudios de Factibilidad , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Pericarditis Constrictiva/cirugía , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X/métodosRESUMEN
Twenty patients (13 men and 7 women; mean age 61 +/- 12 years) with > 30 minutes chest pain and new ST-segment elevation who were treated with reperfusion therapy underwent technetium 99m sestamibi imaging and two-dimensional echocardiography simultaneously before and within 2 hours of each test after acute reperfusion therapy. Nine patients had anterior wall myocardial infarction. Fifteen patients were initially treated with intravenous thrombolytic agents, and five patients underwent urgent percutaneous transluminal coronary angioplasty. Both myocardial perfusion defect and wall motion score index (WMSI) improved after reperfusion therapy (perfusion defect from 28% to 15%, WMSI from 1.68 to 1.45, respectively; p < 0.005). The overall correlation between WMSI and perfusion defect as a measure of myocardium at risk was significant during the acute phase (r = 0.71) and at hospital dismissal (r = 0.71). Thus myocardial perfusion defect and wall motion abnormalities correlated fairly well in patients with acute myocardial infarction during the acute phase and at predismissal study.
Asunto(s)
Angioplastia Coronaria con Balón , Circulación Coronaria , Ecocardiografía , Contracción Miocárdica , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/terapia , Tecnecio Tc 99m Sestamibi , Terapia Trombolítica , Adulto , Anciano , Electrocardiografía , Femenino , Fibrinolíticos/uso terapéutico , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Alta del Paciente , Factores de Riesgo , Activador de Tejido Plasminógeno/uso terapéutico , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
OBJECTIVE: To evaluate the clinical impact of transesophageal echocardiography on subsequent management and outcome in hemodynamically unstable patients with suspected cardiovascular pathologic conditions. DESIGN: We reviewed data on patients with hemodynamic instability (hypotension, shock, or pulmonary edema) who underwent transesophageal echocardiography between December 1987 and May 1994. MATERIAL AND METHODS: A total of 127 patients (70 male and 57 female patients with a mean age of 68 years) underwent transesophageal echocardiography at our institution as part of the diagnostic procedures used to evaluate unstable hemodynamics. RESULTS: No clinically significant complication was encountered during the procedure; transesophageal echocardiographic imaging was inadequate in three patients (2%). Of the 124 patients with adequate images, transesophageal echocardiography disclosed a severe cardiovascular abnormality responsible for the unstable hemodynamics in 65 patients (52%), and 26 patients (21%) underwent urgent pericardiocentesis or a cardiac surgical procedure, primarily based on transesophageal echocardiographic findings. CONCLUSION: Transesophageal echocardiography can be safely performed in hemodynamically unstable patients, it produces a high diagnostic yield, and it provides important information for prompt therapeutic decision making. Therefore, we recommend transesophageal echocardiography as one of the initial diagnostic procedures in critically ill patients suspected of having an underlying cardiovascular disorder.
Asunto(s)
Enfermedades Cardiovasculares/diagnóstico por imagen , Ecocardiografía Transesofágica , Hemodinámica/fisiología , Anciano , Enfermedades Cardiovasculares/fisiopatología , Enfermedad Crítica , Ecocardiografía Transesofágica/efectos adversos , Ecocardiografía Transesofágica/normas , Estudios de Factibilidad , Femenino , Humanos , Hipotensión/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Edema Pulmonar/diagnóstico por imagen , Choque/diagnóstico por imagenRESUMEN
Between 1982 and 1992, 10 patients who underwent echocardiography at the Mayo Clinic were found to have congenital absence of the pericardium. Clinical, electrocardiographic, chest roentgenographic, echocardiographic, computed tomographic, and magnetic resonance imaging features were reviewed in this patient group. The characteristic features of this entity are reviewed. The echocardiographic features in order of frequency are (1) unusual echocardiographic windows, seen in all 10 patients, (2) cardiac hypermobility in nine patients, (3) abnormal ventricular septal motion in eight patients, and (4) abnormal swinging motion of the heart in seven patients.
Asunto(s)
Cardiopatías Congénitas/diagnóstico por imagen , Pericardio/anomalías , Adolescente , Adulto , Niño , Preescolar , Ecocardiografía/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pericardio/diagnóstico por imagen , Estudios RetrospectivosRESUMEN
BACKGROUND: Transient bacteremia may lead to endocarditis in patients with significant valvular lesions. METHODS AND RESULTS: Because transesophageal echocardiography selects a patient population with a high prevalence of valvular lesions, we prospectively evaluated the risk of transient bacteremia associated with transesophageal echocardiography in 49 patients. Blood cultures were obtained immediately before transesophageal echocardiography and at 5, 10, and 20 minutes after the start of the procedure. For each culture, 30 ml venous blood was obtained and 10 ml was inoculated into each of an Isolator tube, Septi-chek bottle, and a nonvented Trypticase soy broth bottle. Broth cultures were incubated for 14 days. Blood from the Isolator tube was plated onto appropriate media for recovery of bacteria and fungi. Two patients were excluded from analysis because the final two sets of blood cultures could not be obtained. Among the remaining 47 study patients, two preprocedure control blood cultures were positive, and two of 141 subsequent cultures were positive. All isolates were considered contaminants. Thus, we found no significant bacteremia due to pathogenic oral flora during transesophageal echocardiography (0%; 95% CI, 0.0-7.5%). CONCLUSIONS: Although recommendations for antimicrobial prophylaxis for transesophageal echocardiography should be individualized for each patient, many patients may not require antimicrobial prophylaxis.
Asunto(s)
Ecocardiografía/efectos adversos , Sepsis/etiología , Adulto , Anciano , Anciano de 80 o más Años , Técnicas Bacteriológicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de RiesgoRESUMEN
In a 70-year-old man who had angina, exercise-induced ventricular tachycardia, and presyncopal symptoms, transthoracic and transesophageal echocardiography disclosed a large atrial mass that resembled a myxoma. Subsequent evaluation by magnetic resonance imaging identified the mass as an intracardiac lipoma attached to the posterior wall of the right atrium, a diagnosis that was confirmed by surgical intervention. Thus, the diagnostic utility of magnetic resonance imaging as an adjunct to echocardiographic evaluation of intracardiac masses was demonstrated.
Asunto(s)
Neoplasias Cardíacas/diagnóstico , Lipoma/diagnóstico , Imagen por Resonancia Magnética , Anciano , Diagnóstico Diferencial , Ecocardiografía , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/patología , Neoplasias Cardíacas/diagnóstico por imagen , Neoplasias Cardíacas/patología , Humanos , Lipoma/diagnóstico por imagen , Lipoma/patología , MasculinoRESUMEN
Endothelin (ET) is a 21-amino-acid peptide of endothelial origin, is a potent systemic and renal vasoconstrictor associated with sodium retention and modulation of the renin-angiotensin-aldosterone system. The present study was designed to determine if plasma ET is elevated in humans with cirrhosis (n = 12), a state characterized by sodium retention and increased plasma renin activity (PRA) and plasma aldosterone (PA), and to determine the effect of orthotopic liver transplantation (OLT) upon plasma ET, PRA, and PA at 1, 3, and 7 days after transplantation. Plasma ET before OLT was 1.62 +/- 0.23 pg/ml, which was not different as compared with normal controls. Plasma ET significantly increased to 4.18 +/- 0.66, 3.87 +/- 0.58, and 4.07 +/- 0.61 pg/ml, respectively following OLT. PRA remained elevated throughout the postoperative course, in contrast to PA that decreased following OLT. Mean arterial pressure increased significantly from 82 +/- 4 pre-OLT to 98 +/- 4 and 103 +/- 2 mmHG on days 3 and 7 respectively.
Asunto(s)
Endotelinas/sangre , Hipertensión/diagnóstico , Trasplante de Hígado/fisiología , Aldosterona/sangre , Factor Natriurético Atrial/sangre , Biomarcadores/sangre , Presión Sanguínea , Femenino , Humanos , Hipertensión/etiología , Hepatopatías/cirugía , Masculino , Persona de Mediana Edad , Renina/sangreRESUMEN
The cause of hypotension after reversal of heparin by protamine has not been well defined. In this study we evaluated complement activation (C3a and C4a) by the heparin-protamine complex in 46 consecutive patients (40 received protamine sulfate to reverse heparin, and six did not) during and after coronary angiography. In patients receiving protamine sulfate, there was a significant increase in C3a over the value before protamine sulfate administration (P less than .001) or in patients who did not receive protamine sulfate (P less than .05): 807 +/- 100 ng/ml vs. 274 +/- 75 ng/ml. There were no significant changes in C4a after protamine sulfate administration. These results indicate that the alternate complement pathway is activated when protamine sulfate is administered after coronary angiography. This may induce hypotension as well as platelet aggregation and thrombus formation and may contribute to coronary instability. Therefore, in unstable patients, heparin reversal by protamine should not be done routinely.