Asian Cardiovasc Thorac Ann 2005;13:366-368
© 2005 Asia Publishing EXchange Ltd
Site-Specific Detection of Bleeder Using Transesophageal Echocardiography
Harpreet Wasir, MCh,
Sanjay Mittal, DM1,
Yugal Mishra, PhD,
Yatin Mehta, FRCA2,
Naresh Trehan, MD
Department of Cardiovascular Surgery
1 Department of Cardiology
2 Department of Cardiovascular Anesthesia, Escorts Heart Institute and Research Centre, New Delhi, India
For reprint information contact: Sanjay Mittal, DM Tel: 91 11 2682 5000 Fax: 91 11 2682 5013 Email: preeti_joyas{at}hotmail.com, Department of Cardiology, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110 025, India.
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ABSTRACT
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Transesophageal echocardiography continues to be an indispensable postoperative diagnostic tool for cardiac surgical patients. Transesophageal echocardiography was carried out postoperatively in 30 consecutive hypotensive patients with low cardiac output who had undergone coronary bypass surgery. In 19 of these patients, a cause of low cardiac output requiring surgical intervention was excluded, and they were managed conservatively. In 11 patients, a surgical cause of low cardiac output was indicated: diffuse bleeding from no particular site in 5, and from a specific site in 6. They underwent urgent re-operation, and the echocardiography findings were confirmed on the operating table. Not only is transesophageal echocardiography important in diagnosis, but it is also highly specific in locating the site of bleeding.
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INTRODUCTION
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Hypotension after cardiac surgery is an emergency that necessitates immediate action. A thorough clinical assessment supported by investigations such as electrocardiography, chest radiography, and hemodynamic data may not always provide a lead to the ongoing problem and its treatment. Conventional transthoracic echocardiography has limitations in postoperative patients.1 Transesophageal echocardiography (TEE) circumvents these problems.
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PATIENTS AND METHODS
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From January 2003 to January 2004, 3,299 patients underwent coronary artery bypass graft surgery in our institution, of which 123 (3.7%) were re-explored for various reasons. In 93 patients, a re-operation was required for significant postoperative bleeding with associated hemodynamic instability. No preliminary investigation was necessary, and these patients were directly re-explored. In 30 patients with equivocal signs, TEE was performed to confirm the cause of low cardiac output and to decide whether re-exploration was warranted.
In 19 of these patients, TEE ruled out a cause of low cardiac output requiring surgical intervention, and they were managed conservatively. In 11 patients, TEE indicated a surgical cause of low cardiac output. In 6 of these patients, who are the focus of this study, a specific site of bleeding was detected by TEE. In the 5 cases where no specific site of bleeding was found on TEE, this was confirmed intraoperatively; these patients had diffuse bleeding not pertaining to one particular site.
Our indications for TEE remained the same as described previously.2 All TEE investigations were performed by a single consultant cardiologist with extensive experience of postoperative echocardiography, as these images are not easy to interpret. All studies were carried out with a Sonos 5500 (Philips Medical Systems India Pvt. Ltd., India) using a 5-MHz omniplane probe. If needed, intravenous midazolam (2–4 mg) was used for sedation in the intubated patient. In all 6 patients in the study group, there was evidence of pericardial collection, and an attempt was made to localize the site of surgical bleeding.
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RESULTS
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The TEE was performed without complications in all 6 patients. The probe was inserted by blind intubation. The mean time from probe insertion to diagnosis was 18.4 minutes. Transthoracic echocardiography had been inconclusive for the detection of the exact site of bleeding in all 6 patients, and in two of them, it did not reveal a posterior-based collection, due to a poor acoustic window.
In case number 1, a 55-year-old female who had undergone coronary artery bypass grafting with aortic valve replacement, pericardial patch closure of an atrial septal defect, and De Vega tricuspid annuloplasty, TEE was performed on the day of surgery while the patient was still on full mechanical ventilation. She had decreased systolic blood pressure (70 mm Hg) with an increase in central venous pressure to 19 mm Hg, and decreased urine output (50 mL in 3 hours). Immediate resuscitation was undertaken with volume replacement and inotropic agents. The patient’s cardiac index, as determined by a thermodilution pulmonary artery catheter, fell from 2.9 to 1.1 L·min–1·m–2 within 2 hours. Transthoracic echocardiography was inconclusive because of a poor acoustic window, but TEE revealed a large clot, measuring 7 x 4 x 5 cm, posterolateral to the right atrium and right ventricle, compressing the right atrial cavity to the extent of near obliteration (Figure 1
). There was an echolucent area in the otherwise organized clot, seen surrounding the saphenous vein graft, which showed Doppler signals (color as well as pulsed-wave). The Doppler signals could be traced to the site of anastomosis of the vein graft to the posterolateral branch of the right coronary artery (Figure 2, 3, 4 and 5). Thus a diagnosis of cardiac tamponade due to a large clot compressing the right atrium and right ventricle was established, and the source of the bleeding was suspected to be the site of insertion of the vein graft to the posterolateral branch of the right coronary artery. The patient immediately underwent re-exploration. Intraoperatively, the TEE findings were confirmed and a large clot compressing the right atrium was removed from the pericardial space. At the same time, the site-specific diagnosis of TEE was confirmed on finding a bleeding distal saphenous vein branch, which was tackled appropriately. Subsequently, the patient did well intraoperatively. The postoperative course was uneventful and she was discharged from hospital on the 7th postoperative day.
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Figure 1. Transesophageal echocardiography showing an organized pericardial collection on the right lateral aspect of the right atrium (RA). The RA and superior vena cava are compressed suggesting elevated intrapericardial pressure and thus cardiac tamponade. The tubular shadow of the vein graft to the posterolateral branch of the right coronary artery is seen traversing through the clot. There is an echolucent area in the otherwise organized clot, where Doppler investigation may reveal the site of the bleeding. PE = pericardial effusion.
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Figure 2. Transgastric view showing a significant pericardial collection (fluid or fresh blood). Ao = aorta, LA = left atrium, RA = right atrium.
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Figure 3. The saphenous vein graft (SVG) is seen traversing the blood-filled pericardial space adjacent to the right atrium. PE = pericardial effusion, RA = right atrium.
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Figure 5. When the graft was traced to its site of insertion into the posterior left ventricular branch of the right coronary artery, a color-flow jet could be identified, suggestive of a leak into the pericardial space.
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In 2 other cases, the site of bleeding was localized to the insertion of the venous graft on the lateral wall, with compression of the obtuse marginal area. Re-exploration revealed a distal anastomotic bleed in one patient, and a vein tributary in the other.
In another 2 cases, the bleeding was suspected to be from the area of the left anterior descending coronary artery. Surgical re-exploration revealed a large clot lying anterior to the right ventricle with the bleeding originating from a branch of the internal mammary artery. In the 6th case, a large clot was discovered around the right atrium, in the region of the superior vena cava, and there was an echolucent area corresponding to the right atrial appendage. In this patient, the bleeding was from the cannulation site at the right atrial appendage. All of these patients did well postoperatively, and they were discharged without any further complications.
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DISCUSSION
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A prompt diagnosis is required for any hemodynamic instability in the postoperative period. Many studies now reflect the inconsistency of TTE compared to TEE, especially immediately after cardiac surgery.3–6 The utility and superiority of TEE for this assessment has been well demonstrated.4–5,7 A good TEE examination can identify the cause of hemodynamic changes and may prevent unnecessary re-exploration.8 To extend the use of TEE by a competent cardiologist to pinpointing the site of bleeding is rare. In all 6 cases where a site of bleeding was identified, the diagnosis was confirmed by identifying an echolucent area within the clot. Such echolucency is suggestive of fresh blood, in contrast to the non-echolucent area that indicates clotted blood, and the source of the bleeding could be traced with the aid of color Doppler.
Detecting the site of bleeding by TEE could be an important factor in the successful outcome of re-exploration. Occasionally, posterior surface bleeders cease to bleed on lifting the heart, due to a fall in arterial pressure. If one is aware of the site of bleeding, by TEE prior to re-exploration, not only would it avoid unnecessary handling of the heart but it would also prevent missing actual bleeders.
To our knowledge, this is the first report of cases where the exact site of bleeding could be detected using TEE. Two-dimensional TEE is of unequivocal importance in establishing a definite diagnosis. As its usefulness becomes more widely recognized, it will be used more often, thus becoming an indispensable tool in cardiac intensive care units.
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REFERENCES
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ABSTRACT
INTRODUCTION
