Intraoperative Transesophageal Echocardiography Influences Surgery.

Dear Sir,

A 54-year-old male patient presented with retrosternal chest pain and shortness of breath. On evaluation, he was found to have anterior wall myocardial infarction with atrial fibrillation of unknown duration. Coronary angiography revealed severe triple vessel disease. Transthoracic echocardiography showed left ventricular ejection fraction of 45% with hypokinetic anterior wall and no evidence of clot in cardiac chamber. Patient had no history of any neurological symptom. Patient was scheduled for emergency off pump coronary artery bypass grafting surgery (OPCABG) just 6 h after the angiogrpahy. After induction of anesthesia, transesophageal echocardiography (TEE) was done before surgery as a routine protocol. TEE 2 chamber view revealed freely mobile clot with high embolic potential in left atrial appendage (LAA). Clot size was 1.02 cm2 [Figure 1, Video Clip 1]. After consulting surgeon, it was decided to change surgical plan from off pump to on pump. After instituting cardiopulmonary bypass, LAA clot was removed followed by coronary artery bypass grafting (CABG). Patient's postoperative course was smooth without any evidence of organ ischemia. Off pump, CABG involves frequent manipulations of heart which can easily dislodge the clot into a systematic circulation and cause embolic ischemic injury.

Figure 1

Tranesophageal echocardiography 2 chamber view showing left atrial appendage clot marked with arrow

Elayda et al. have reported the impact of intraoperative TEE on valve surgery, with changes in the operative plan based on TEE findings in 11-14% of cases.[1] Studies have emphasized utility and impact of TEE in the setting of other cardiac surgical procedures.[2] OPCABG is associated with significantly lower incidence of permanent focal neurologic events than with on pump CABG.[3]

Transesophageal echocardiography has important pivotal role in deciding surgical plan.

In the present case, though the initial plan of surgery was OPCABG, significant clot finding of TEE changed the surgical plan to on pump CABG considering risk thromboembolic event in this patient in off pump surgery.