(Chest. 1999;115:1749-1751.)
© 1999
American College of Chest Physicians
Intraoperative Detection of Pulmonary Thromboemboli With Epicardial Echocardiography*
Amnon Y. Zlotnick , MD;
Paul F. Lennon , MD;
Samuel Z. Goldhaber , MD, FCCP and
Sary F. Aranki , MD
*
From the Department of Cardiothoracic Surgery (Dr. Zlotnik), Carmel
Medical Center, Haifa, Israel; and the Departments of Anesthesia (Dr. Lennon),
Medicine (Dr. Goldhaber), and Surgery (Dr. Aranki), Brigham and Women's
Hospital, Boston, MA.
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Abstract
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We report a novel intraoperative use of epicardial
echocardiography in detecting and guiding the removal of pulmonary
arterial thromboemboli. We describe a patient with a right atrial
thrombus that could not be visualized with intraoperative
transesophageal echocardiography. Because we suspected acute pulmonary
embolization, epicardial echocardiography was used to visualize the
right and left pulmonary arteries. Pulmonary thromboemboli were
identified, and pulmonary thromboembolectomy was successfully
performed.
Abbreviation:
TEE = transesophageal echocardiography
Key Words: epicardial echocardiography • pulmonary embolus • thromboembolus • thrombus • transesophageal echocardiography
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Introduction
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We
report on a patient with a right atrial thrombus and pulmonary emboli
in whom a surgical thromboembolectomy of the right atrial thrombus was
planned. Intraoperatively, the right atrial thrombus could not be
visualized with transesophageal echocardiography (TEE); distal
embolization of the thrombus into the pulmonary vasculature was
suspected. By utilizing epicardial echocardiography in a novel manner,
we visualized thromboemboli within the pulmonary vasculature and
successfully performed a pulmonary thromboembolectomy. Because of the
often dynamic clinical course of a right atrial thrombus,1
patients with right atrial thrombi may benefit from intraoperative
epicardial echocardiography.
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Case Report
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A 54-year-old man was evaluated for shortness of breath. His
medical history was significant for hypertension and squamous cell
tongue carcinoma that had been treated with surgery and radiation. The
physical examination revealed a dyspneic middle-aged man with a heart
rate of 83 beats/min, a respiratory rate of 24 breaths/min, a BP of
180/90 mm Hg, and bilateral clear breath sounds. An ECG revealed sinus
rhythm at 85 beats/min. A chest radiograph revealed "pruning" of
the pulmonary vasculature and mild cardiomegaly without infiltrate or
effusion. A ventilation/perfusion scan was interpreted as "high
probability" for bilateral pulmonary emboli. IV heparin therapy was
initiated. A transthoracic echocardiogram revealed a mobile right
atrial mass (1 x 2 cm in diameter) with intermittent prolapse
through the tricuspid valve, a dilated and hypokinetic right ventricle
with paradoxical septal motion, severe tricuspid regurgitation, and an
estimated systolic pulmonary artery pressure of 70 mm Hg.
Surgical management was chosen rather than thrombolytic therapy because
of both the large size (> 1 cm) of the presumed thrombus and the
patient's systemic arterial hypertension. The diagnosis of a right
atrial thrombus was confirmed using inferior vena cava contrast
injection following the placement of an inferior vena cava filter, and
preoperative coronary angiography demonstrating no significant
coronary artery disease. The patient was transported to the
operating room, general anesthesia was induced, and a TEE biplane
transducer (model V510B; Acuson; Mountain View, CA) was placed. On TEE
examination, the right atrial mass was no longer visible. Distal
embolization of the right atrial thrombus into the pulmonary
vasculature was suspected. A TEE examination of the pulmonary
vasculature did not reveal thrombi in either the main pulmonary artery
or the proximal right and left pulmonary arteries. After surgical
exposure of the heart and great vessels, the pulmonary vasculature was
further examined using an epicardial echocardiographic transducer
(model V714; Acuson) that revealed thrombi in both the right and left
pulmonary arteries (Fig 1
). Aortic and bicaval cannulas were placed, and cardiopulmonary bypass
commenced. Via an incision in the main pulmonary artery, thrombi that
appeared to be fresh were removed from the right and left
pulmonary arteries. Histopathologic examination revealed early
organized laminated red thrombus. The right atrial thrombus was not
present when the right atrium was opened. Following the termination of
cardiopulmonary bypass, a repeat examination of the pulmonary
vasculature with the epicardial transducer demonstrated the absence of
thrombi. The postoperative course was significant for transient atrial
fibrillation and the gradual resolution of pulmonary hypertension. On
the seventh postoperative day, the patient was discharged to home on a
regimen of anticoagulant therapy. The patient had a full recovery, and
anticoagulant therapy was continued indefinitely.
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Figure 1. Intraoperative epicardial echocardiography
demonstrating thromboemboli in the right pulmonary artery (left,
A) and the left pulmonary artery (right, B).
AO = aorta; LPA = left pulmonary artery; RPA = right pulmonary
artery.
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Discussion
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We describe the use of epicardial echocardiography to detect
pulmonary vascular thromboemboli originating from the right atrium. Our
inability to visualize the pulmonary emboli with biplane TEE in our
patient was most likely because of the relatively distal location of
the emboli. We then used epicardial echocardiography to visualize the
pulmonary emboli and to guide our surgical therapy. Although its use
was not evaluated, multiplane TEE also may have allowed us to visualize
the pulmonary emboli.2
Epicardial echocardiography acquires data from a transducer placed
directly on the heart or great vessels. An epicardial echocardiographic
transducer is a particularly versatile tool for the immediate
intraoperative assessment of vascular and myocardial structures. The
intraoperative use of epicardial echocardiography has also been
described in the assessment of ascending aortic atherosclerosis,
ventricular function, valvular function, coronary artery location,
coronary arterial bypass graft flow, intracardiac shunts, intracardiac
masses, congenital cardiac abnormalities, and aortic vascular
anatomy.3
,4
,5
,6
,7
,8
In summary, we report the novel intraoperative use of an epicardial
echocardiographic transducer in detecting and guiding the removal of
pulmonary arterial thromboemboli. Because right heart thrombi are often
dynamic, intraoperative detection may require versatile and immediate
imaging techniques. Epicardial echocardiography offers an additional
and powerful intraoperative diagnostic tool to detect pulmonary
thromboemboli and to guide surgical therapy.
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Footnotes
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Correspondence to: Paul F. Lennon, MD, Anesthesia Division, Maine
Medical Center, 22 Bramhall St, Portland, ME 04102
Received for publication September 30, 1998.
Accepted for publication December 28, 1998.
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References
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Farfel, Z, Shechter, M, Vered, Z, et al (1987) Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management. Am Heart J 113,171-178[CrossRef][ISI][Medline]
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Pepi, M, Barbier, P, Doria, E, et al (1996) Intraoperative multiplane vs biplane transesophageal echocardiography for the assessment of cardiac surgery. Chest 109,305-311[Abstract/Free Full Text]
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Shankar, S, Sreeram, N, Brawn, WJ, et al (1997) Intraoperative ultrasonographic troubleshooting after the arterial switch operation. Ann Thorac Surg 63,445-448[Abstract/Free Full Text]
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McPherson, DD, Johnson, MR, Collins, SM, et al (1993) Validation by high-frequency epicardial echocardiography of a new method of analyzing coronary angiography quantitatively in coronary artery disease. Am J Cardiol 71,28-32[Medline]
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Kenny, A, Cary, NR, Murphy, D, et al (1994) Intraoperative epicardial echocardiography with a miniature high-frequency transducer: imaging techniques and scanning planes. J Am Soc Echocardiogr 7,141-149[Medline]
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Rousou, JA, Tighe, DA, Rifkin, RD, et al (1998) Echocardiography allows safer venous cannulation during excision of large right atrial masses. Ann Thorac Surg 65,403-406[Abstract/Free Full Text]
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de Simone, G, Devereux, RB, Ganau, A, et al (1996) Estimation of left ventricular chamber and stroke volume by limited M-mode echocardiography and validation by two-dimensional and Doppler echocardiography. Am J Cardiol 78,801-807[CrossRef][ISI][Medline]
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Ungerleider, RM, Kisslo, JA, Greeley, WJ, et al (1995) Intraoperative echocardiography during congenital heart operations: experience from 1,000 cases. Ann Thorac Surg 60,S539-S542
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Abstract
Introduction
