TEE Zebras. Case Cardiac Anesthesia Group
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1 TEE Zebras Edwin G. Avery, IV, M.D., C.P.I. Chief, Division of Cardiac Anesthesia University Hospitals Case Medical Center Associate Professor of Anesthesiology Case Western Reserve University School of Medicine
2
3 Disclosures None
4 Objectives: Review 5+ unusual cases involving the use of perioperative TEE Discuss some advanced TEE concepts related to these cases Have some fun!
5 Case #1
6 Case #1 60 YOM with advanced heart failure is scheduled for HM II LVAD implantation as BTT Diagnosis: NYHA class IV 2 ischemic cardiomyopathy Procedure: Heartmate II LVAD implantation (± RVAD) A complete pre-cpb TEE exam for LVAD implantation has many essential facets Rule out ASD/PFO/VSD Assess RV function & TV competence (i.e. TV ring) Rule out thrombus in the left heart Assess aortic valve competence
7 Case #1 ME Bicaval view (modified)
8 BP = 125/72 Case #1 ME LAX view w/color
9 Case #1 ME 2C view w/zoom
10 Case #1 ME 2C view w/zoom
11 Case #1 ME 2C view w/zoom
12 Case #1 Summary: Something as seemingly simple as assessing the left atrial appendage to rule out thrombus has important consequences for all patients, especially those receiving an LVAD There are a number of aspects to optimizing the TEE assessment of the left atrial appendage Use a higher frequency mode to resolution (axial & lateral) Perform a multi-omniplane exam of the structure Apply color Doppler as its respect for solid structures can be helpful Apply PW spectral Doppler analysis to the LAA (velocities > cm/sec make clot formation less likely)
13 Case #2
14 Case #2 65 YOM s/p MV repair 4 months earlier returns to the cardiac OR with severe mitral regurgitation and CHF for redo-sternotomy and MV repair vs. MVR The initial repair was performed for severe MR secondary to isolated prolapse of the P2 segment Diagnosis: NYHA class IV HF 2 to severe MR Procedure: redo-sternotomy, MV repair vs. MVR
15 Case #2 ME 4C view
16 BP = 135/80 Case #2 ME LAX view
17 Case #2 ME 5C view w/zoom
18 Artifact? Case #2 ME 4C view (modified)
19 Case #2 Gross surgical view
20 Case #2 ME commissural view All is well that ends well we replaced it on the second pass as the pledgeted neochord had torn through the P2 scallop
21 Case #2 Summary TEE artifacts are frequently not artifacts at all, rather structures we are not accustomed to identifying. Knowing the patients medical and surgical history in detail can help one to discern unknown structures encountered while performing perioperative TEE exams Air bubbles in the CW Doppler spectrum
22 Case #3
23 Case #3 58 YOF with known pulmonary adenocarcinoma presents with sxms of SOB and CHF (NYHA class III) She was turned down by the cardiologists as a candidate for a pericardial pigtail drain Diagnosis: chronic pericardial effusion (with some features of tamponade physiology per TTE report) Procedure: sub-xiphoid pericardial window
24 Case #3 Any concerns with anesthesia induction before we get to the TEE images?
25 Case #3 The sympathectomy associated with anesthesia induction along with the transition from spontaneous respiration to intermittent positive pressure ventilation can precipitate cardiovascular collapse in patients with tamponade physiology Avery EG, Shernan SK Comp Text Periop TEE 2010
26 Case #3 ME 4C w/right rotation
27 Case #3 ME 4C view
28 Case #3 TG SAX Mid-Pap w/right
29 Case #3 TG SAX Mid-Pap w/left
30 Case #3 ME Bicaval view
31 Case #3 ME 4C w/right rotation Pre surgical correction Post surgical correction
32 Case #3 ME 4C w/right rotation Zebra tamponade
33 Case #3 Summary: Always be cautious with tamponade inductions, especially if the echo data is not recent. Lysis of adhesions may be necessary to effectively drain a pericardial effusion if adhesions/loculation exist Pigtail drainage of a pericardial effusion may not be effective in relieving tamponade physiology in cases involving loculated effusions Pigtail drainage of a pericardial effusion prior to anesthesia induction can be life saving
34 Case #4
35 Case #4 68 YOF with TR, MR and CHF presents for MV repair and TV annuloplasty Diagnoses: severe MR, moderate to severe TR Procedure: MV repair & TV annuloplasty
36 Case #4 ME 4C view
37 Case #4 ME LAX view
38 SBP = 119/72 Case #4 ME 2C view
39 SBP = 119/72 Case #4 ME 2C (commissural) view w/color Doppler & zoom
40 PAP = 51/27 Case #4 ME 4C view w/color Doppler
41 SBP = 119/72 Case #4 ME AV SAX view w/color Doppler & zoom
42 SBP = 119/72 Case #4 ME LAX view w/color Doppler & zoom
43 Post MV Repair Case #4 ME LAX view w/color Doppler & zoom
44 Post MV Repair Case #4 ME AV SAX view w/color Doppler & zoom
45 Case #4
46 Post MV Repair & AVR Case #4 ME LAX view w/color Doppler & zoom
47 Case #4 Summary: Complete TEE exams are indicated both before and after CPB Failure to perform a complete exam can result in major morbidity and/or mortality Anybody who tells you assessing valves on CPB is useless and nonsensible, please send them to me for reprogramming! The cardiac valves and conduction system are all neighbors and complete assessment of these structures is necessary post-cpb
48 Case #5 (last one)
49 Case #5 36 YOM with severe mitral regurgitation, NYHA class III CHF secondary to bileaflet prolapse Diagnosis: Barlow s MV with severe MR VCW = 0.6 cm
50 Case #5 ME 4C view
51 Case #5 ME 2C view (modified)
52 SBP = 114/78 Case #5 ME LAX view w/color Doppler
53 Case #5 ME LAX view w/zoom VCW = 0.6 cm
54 Post-CPB MV repair Case #5 ME LAX w/color Doppler
55 Post-CPB MV repair Case #5 ME 4C view (modified)
56 Case #5 ME LAX view w/zoom
57 Case #5 ME LAX view (modified) C-sept = 3.3 cm
58 Post-CPB II myectomy Case #5 ME LAX view Septal thickness = 2.1 cm
59 Case #5 ME 5C view (modified) Distance from aortic valve annulus to point of maximal thickness
60 SBP = 108/73 Case #5 ME LAX view w/color Doppler
61 Case #5 Trans-LVOT CW spectral Doppler Peak = 19 mmhg Mean = 11 mmhg C.I. = 2.4 L/min/m 2
62 Case #5 Summary: All repaired or replaced valves should have a post- CPB assessment that includes: Degree of regurgitation ± mechanism 2D assessment of leaflets 2D assessment of annulus (i.e. well seated) Peak and mean gradients across repair Some index of cardiac function (ideally C.I.)
63 Bonus Case
64 Bonus Case 50 YOF w/a severe paravalvular leak associated with a bileaflet tilting disc valve in the mitral position Diagnosis: NYHA class III HF & hemolytic anemia Procedure: repair of bileaflet tilting disc MV
65 Bonus Case ME bicaval view w/color Doppler
66 Bonus Case ME bicaval view
67 Courtesy of Martha Craycroft, RN Bonus Case Gross surgical view
68 The end Thank you
69
70
71 Reprogramming It checks the valves before CPB separation or it gets the hose again.
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