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INTERESTING IMAGE  
Year : 2011  |  Volume : 14  |  Issue : 2  |  Page : 152-153
Unmasking of patent ductus arteriosus on cardiopulmonary bypass: Role of intraoperative trans-esophageal echocardiography in a patient with severe pulmonary hypertension due to pulmonary vein stenosis and cor triatriatum


1 Department of Cardiac Anesthesiology, Fortis Hospitals, Bangalore, India
2 Department of Cardiac Surgery, Fortis Hospitals, Bangalore, India

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Date of Web Publication25-May-2011
 

How to cite this article:
Kandachar S, Chakravarthy M, Krishnamoorthy J, Suryaprakash S, Muniappa G, Pandey S, Jawali V, Xavier J. Unmasking of patent ductus arteriosus on cardiopulmonary bypass: Role of intraoperative trans-esophageal echocardiography in a patient with severe pulmonary hypertension due to pulmonary vein stenosis and cor triatriatum. Ann Card Anaesth 2011;14:152-3

How to cite this URL:
Kandachar S, Chakravarthy M, Krishnamoorthy J, Suryaprakash S, Muniappa G, Pandey S, Jawali V, Xavier J. Unmasking of patent ductus arteriosus on cardiopulmonary bypass: Role of intraoperative trans-esophageal echocardiography in a patient with severe pulmonary hypertension due to pulmonary vein stenosis and cor triatriatum. Ann Card Anaesth [serial online] 2011 [cited 2019 Nov 18];14:152-3. Available from: http://www.annals.in/text.asp?2011/14/2/152/81573


A 15-year-old African girl, weighing 27 kilos, with a height of 148 cm was admitted to the hospital for repair of pulmonary venous obstruction and cor triatriatum. She was comfortable at rest, but had severe limitation of activities beyond those of daily living. Pulse oximetry on room air was 92%, which improved to 95% with oxygen.

Blood investigations were unremarkable except for hemoglobin 19 g/dL and her Sickling test was negative. Preoperative transthoracic echocardiogram revealed stenosis of right upper and left lower pulmonary veins with a peak gradient of 15 mmHg at their respective junctions with the left atrium (LA). Normal flow was noted in the other pulmonary veins. A membrane was visualized in the left atrium without significant obstruction to flow. Severe pulmonary hypertension (94/65 mmHg) was detected. The pulmonary artery pressure was noted to be 95% of the systemic pressure. Flow velocities in the pulmonary artery and descending aorta were normal, there was no pericardial effusion. A computerized tomographic angiogram confirmed the anatomical findings noted by the transthoracic echocardiogram. The patient was scheduled for repair of pulmonary venous obstruction. After induction of general anesthesia, transesophageal echocardiography (TEE) probe was inserted. TEE confirmed the diagnosis made earlier. Further, a restrictive fleshy membrane in the left atrium (cor triatriatum) contributing to pulmonary vein stenosis was observed. Surgery commenced via mid-sternotomy. Total body heparinisation was achieved with 6000 IU of heparin; the resultant activated clotting time was 450 s. The pulmonary artery (PA) pressure measured via a fine needle inserted in the main pulmonary artery revealed supra-systemic PA pressure. The systemic pressure was 73/56 and mean 63 mmHg, while the PA pressure was 98/60 mmHg. Cardiopulmonary bypass (CPB) was instituted without events after cannulation of ascending aorta and cannulation of superior and inferior vena cavae. It is our institution policy to confirm the empty status of the heart with adequate venous return and absence of aortic regurgitation after establishing CPB using TEE. During such routine examination in this patient, hitherto unreported ductal flow was detected and patent ductus arteriosus (PDA) was diagnosed [Video 1].-

PDA was visualized in the upper esophageal view. As the tee probe is withdrawn gradually from the mid-esophageal position, just beyond the left atrium, the ascending aorta in cross-section and the pulmonary artery and its main branches in longitudinal section come into view. Further withdrawal reveals the arch and its branches. The duct can be visualized communicating with the aorta superiorly and pulmonary artery inferiorly both with the probe at 0° and 90° rotation. Visualization can be accomplished with gentle handling of the probe without much difficulty. PDA was visualized in the upper esophageal view with about 90° rotation of the transducer.

The operating surgeon was warned of this new finding. Even prior to carrying out the planned intra-cardiac repair, the surgeon searched for and found the PDA, which was subsequently ligated. The colour Doppler signals on TEE now ceased. It is our standard protocol to ligate the ligamentum arteriosum/ductus arteriosus and rule out persistent left-sided vena cava in patients with congenital heart defects. The intracardiac repair was completed under moderate hypothermia.

The membrane over the junction of left pulmonary vein and left atrium was excised. The left atrium and the openings of the pulmonary veins were widened with autologous pericardial patch. After the completion of surgery, the CPB was terminated. The PA pressure was 70% of the systemic soon after disconnecting the CPB. The patient was mechanically ventilated for four hours. A routine postoperative transthoracic echocardiogram was normal.


   Discussion Top


It is not uncommon for anesthesiologists to detect new anatomical lesions using TEE. [1] Many of such detections may be lifesaving for the patient. [2] In the case reported here, the presence of PDA was not recognised by both the cardiologist who performed echocardiography and the radiologist who performed the computerized tomographic scan. Non recognition of PDA by echocardiography (both TTE and TEE) was probably because of the absence of flow across the PDA; presence of such duct is diagnosed by the Doppler characteristic of the flow. [3] A few workers have however claimed that TEE might be superior to CT angiograms in patients with Eisenmenger syndrome. [3] Similarly, even during CT assessment, the presence of a shunt is diagnosed by the presence of the intraluminal flow. The flow was probably minimal in the reported case due to near systemic pulmonary hypertension. The diagnosis of PDA after establishment of CPB in the reported case brings up the issue of the need to use TEE intra-operatively at least once after establishing CPB. Most anesthesiologists set the TEE equipment in standby mode once CPB is established. Had this been done in the reported case, the presence of PDA may have gone unnoticed.


   Conclusion Top


It is a good practice to assess the heart soon after establishing CPB and check the heart on and off CPB.

 
   References Top

1.Sousa RC, García-Fernandéz MA, Moreno M, Tizón M, Valdeviesos M, Rubio M, et al. The contribution and usefulness of routine intraoperative transesophageal echocardiography in cardiac surgery. An analysis of 130 consecutive cases. Rev Port Cardiol 1995;14:15-27.  Back to cited text no. 1
    
2.Kupferwasser I, Mohr-Kahaly S, Wittlich N, Meyer J. Diagnostic value of transesophageal echocardiography in diseases of the heart valve system. Herz 1993;18:290-300.  Back to cited text no. 2
[PUBMED]    
3.Shyu KG, Lai LP, Lin SC, Chang H, Chen JJ. Diagnostic accuracy of transesophageal echocardiography for detecting patent ductus arteriosus in adolescents and adults. Chest 1995;108:1201-5.  Back to cited text no. 3
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Correspondence Address:
Suman Kandachar
Fortis Hospitals, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.81573

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