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
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Disclosures None
Objectives: Review 5+ unusual cases involving the use of perioperative TEE Discuss some advanced TEE concepts related to these cases Have some fun!
Case #1
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
Case #1 ME Bicaval view (modified)
BP = 125/72 Case #1 ME LAX view w/color
Case #1 ME 2C view w/zoom
Case #1 ME 2C view w/zoom
Case #1 ME 2C view w/zoom
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 > 40-50 cm/sec make clot formation less likely)
Case #2
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
Case #2 ME 4C view
BP = 135/80 Case #2 ME LAX view
Case #2 ME 5C view w/zoom
Artifact? Case #2 ME 4C view (modified)
Case #2 Gross surgical view
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
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
Case #3
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
Case #3 Any concerns with anesthesia induction before we get to the TEE images?
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
Case #3 ME 4C w/right rotation
Case #3 ME 4C view
Case #3 TG SAX Mid-Pap w/right
Case #3 TG SAX Mid-Pap w/left
Case #3 ME Bicaval view
Case #3 ME 4C w/right rotation Pre surgical correction Post surgical correction
Case #3 ME 4C w/right rotation Zebra tamponade
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
Case #4
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
Case #4 ME 4C view
Case #4 ME LAX view
SBP = 119/72 Case #4 ME 2C view
SBP = 119/72 Case #4 ME 2C (commissural) view w/color Doppler & zoom
PAP = 51/27 Case #4 ME 4C view w/color Doppler
SBP = 119/72 Case #4 ME AV SAX view w/color Doppler & zoom
SBP = 119/72 Case #4 ME LAX view w/color Doppler & zoom
Post MV Repair Case #4 ME LAX view w/color Doppler & zoom
Post MV Repair Case #4 ME AV SAX view w/color Doppler & zoom
Case #4
Post MV Repair & AVR Case #4 ME LAX view w/color Doppler & zoom
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
Case #5 (last one)
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
Case #5 ME 4C view
Case #5 ME 2C view (modified)
SBP = 114/78 Case #5 ME LAX view w/color Doppler
Case #5 ME LAX view w/zoom VCW = 0.6 cm
Post-CPB MV repair Case #5 ME LAX w/color Doppler
Post-CPB MV repair Case #5 ME 4C view (modified)
Case #5 ME LAX view w/zoom
Case #5 ME LAX view (modified) C-sept = 3.3 cm
Post-CPB II myectomy Case #5 ME LAX view Septal thickness = 2.1 cm
Case #5 ME 5C view (modified) Distance from aortic valve annulus to point of maximal thickness
SBP = 108/73 Case #5 ME LAX view w/color Doppler
Case #5 Trans-LVOT CW spectral Doppler Peak = 19 mmhg Mean = 11 mmhg C.I. = 2.4 L/min/m 2
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.)
Bonus Case
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
Bonus Case ME bicaval view w/color Doppler
Bonus Case ME bicaval view
Courtesy of Martha Craycroft, RN Bonus Case Gross surgical view
The end Thank you
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Reprogramming It checks the valves before CPB separation or it gets the hose again.