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Table of Contents
CASE REPORT  
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 100-102
A rare case report of early myocardial ischemia after coronary artery bypass surgery due to mechanical compression of vein graft by pericardial drainage tube: Role of transesophageal echocardiography


1 Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
2 Department of Cardiothoracic and Vascular Surgery, PGIMER, Chandigarh, India

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Date of Submission11-Dec-2018
Date of Decision28-May-2019
Date of Acceptance31-May-2019
Date of Web Publication07-Jan-2020
 

   Abstract 


New onset regional wall motion abnormality (RWMA) following coronary artery bypass grafting adversely affects the patient outcome. Early detection and addressing the cause of RWMA improves overall morbidity and mortality of the patient. We report a rare case of early myocardial ischemia detected by intraoperative transesophageal echocardiography due to mechanical compression of a vein graft by a pericardial drain tube.

Keywords: Myocardial ischemia, pericardial drain, transesophageal echocardiography

How to cite this article:
Damodaran S, Gourav KP, Aspari A, Kumar V, Negi P, Negi SL. A rare case report of early myocardial ischemia after coronary artery bypass surgery due to mechanical compression of vein graft by pericardial drainage tube: Role of transesophageal echocardiography. Ann Card Anaesth 2020;23:100-2

How to cite this URL:
Damodaran S, Gourav KP, Aspari A, Kumar V, Negi P, Negi SL. A rare case report of early myocardial ischemia after coronary artery bypass surgery due to mechanical compression of vein graft by pericardial drainage tube: Role of transesophageal echocardiography. Ann Card Anaesth [serial online] 2020 [cited 2020 Jan 29];23:100-2. Available from: http://www.annals.in/text.asp?2020/23/1/100/275295





   Introduction Top


Myocardial ischemia due to graft occlusion/thrombosis is common after coronary artery bypass grafting (CABG) surgery. Left ventricle (LV) diastolic dysfunction is one of the earliest clinical manifestations after coronary artery occlusion, and it generally precedes the development of an abnormal systolic function. However, regional wall motion abnormality (RWMA) detected by transesophageal echocardiography (TEE) has been shown to be a more sensitive method of detecting myocardial ischemia in patients undergoing CABG, compared with ST-segment changes.[1]


   Case Report Top


A 61-year-old male patient diagnosed to be a case of coronary artery disease (CAD) scheduled for CABG. The patient had a history of chest pain and dyspnoea on exertion of New York heart association classification II (NYHA II). General physical examination revealed a pulse rate of 68/min with a blood pressure of 122/74 mmHg in sitting position. His respiratory rate was 14/min and systemic oxygen saturation was 98% on room air. No murmur was heard on auscultation. Preoperative Chest X-ray and blood investigations were found to be normal. An echocardiographic assessment revealed LV Ejection fraction (EF) of 55% with no RWMA, LV diastolic dysfunction grade I, and no valvular abnormalities. Angiography revealed critical triple vessel disease. In the operating room (OR) after instituting standard American Society of Anaesthesiologist monitoring, cannulation of the right radial artery, and the right internal jugular vein was accomplished under local anesthesia. Anesthesia was induced and maintained using the balanced narcotic technique. A 5 MHz phased array transducer (6VT) transesophageal probe was inserted orally.

TEE was performed using a GE vivid E9 (Norway) echocardiography system. No RWMA was found in TEE during the pre-bypass period. On pump, CABG was performed by anastomosing left internal mammary artery to left anterior descending artery, saphenous venous grafts to the obtuse marginal artery and posterior descending artery (PDA). Weaning from cardiopulmonary bypass was uneventful. Aortic cross-clamp time and cardiopulmonary bypass time were 83 and 110 min, respectively. In our institute, we routinely use to perform TEE after cardiopulmonary bypass (CPB) in patients undergoing CABG. Incidentally, we found the presence of RWMA in the inferolateral wall of the left ventricle in two dimensional (2D) trans-gastric short axis view [Video 1]. Further, on speckle tracking echocardiography (STE), we observed that segment 5 (basal inferolateral) and segment 11 (mid inferolateral) in 17 segmental model had the strain value of +3 and +1, respectively (represented as blue color in Bull's eye, [Figure 1]a). However, we did not observe any electrocardiography (ECG) or hemodynamic changes during the period. The surgeon was informed about RWMA and surgeon assessed graft supplying inferolateral wall of LV and found venous graft to the PDA was being compressed by the 28 size pericardial drain tube [Figure 2]. Following which, the drain tube was repositioned, which relieved the mechanical compression on the venous graft anastomosed to PDA. Again, we performed TEE after tube repositioning, which showed no RWMA in the inferolateral wall of the left ventricle [Video 2]. In addition, on STE, we noticed that segment 5 and segment 11 of 17 segment model had the better strain value of −8 and −8, respectively (blue zone changed to the red zone in Bull's eye as shown in [Figure 1]b). The patient was shifted to the surgical Intensive care unit (ICU) and the trachea was extubated after 6 hours of mechanical ventilation. Following an uneventful postoperative period, the patient was shifted to ward on the third postoperative day and discharged from hospital on the tenth postoperative day.
Figure 1: (a) Speckle tracking echocardiography showing changes in 5 and 11 segments during drain compression. (b) Speckle tracking echocardiography showing improvement in 5 and 11 segments after drain removal

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Figure 2: Surgical field showing compression of graft to PDA by pericardial drain

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   Discussion Top


Intraoperative TEE is an integral part of the treatment of patients undergoing valve surgery.[2] However, the impact of intraoperative TEE in patients undergoing CABG is less well documented.[3] The utility of intraoperative TEE in revascularization surgery should be considered to confirm the preoperative diagnosis, detect new unsuspected pathology, manage both anesthetic and surgical plans appropriately, and evaluate surgical results.[4] Also, it is reasonable to consider TEE for monitoring of hemodynamic status, ventricular function, RWMA, and valvular function in patients undergoing CABG.[5]

New RWMAs may be related to loading conditions of the ventricle, electrolyte abnormalities, blood viscosity, air embolism, level of inotropic support, hypothermia, cardiac pacing, and bundle branch conduction abnormalities. Perioperatively, it is extremely difficult to determine whether new segmental wall motion abnormality represents inadequate revascularization, ongoing ischemia, or stunned myocardium. Treatment of new onset RWMA includes increasing the coronary perfusion pressure, normalizing electrolytes, and arterial blood gas, and inspecting coronary graft patency. On extreme situations, it may warrant a need to return to cardiopulmonary bypass. Savage et al. found that the use of intraoperative TEE decreased mortality and morbidity in patients undergoing on-pump procedures and the intraoperative TEE should be used routinely in cardiac operations.[6] In another study by Bergquist et al., use of intraoperative TEE in CABG can optimize volume replacement therapy in 47% of cases. Moreover, intraoperative TEE played a significant role in decision making regarding the use of inotropes, vasodilators, and volume replacement.[7]

Although previous studies mentioned that left ventricular diastolic dysfunction is an earlier, more sensitive sign of myocardial ischemia and persists longer than the systolic disturbance, it may not hold good immediately after CPB.[8],[9] McKenney et al. observed temporary impairment in diastolic dysfunction following on-pump CABG surgery.[10] Possible mechanisms of diastolic dysfunction after CPB can be due to free oxygen radicals, altered intracellular calcium homeostasis, or both.[11] Perioperatively, regional wall motion changes detected by 2D echocardiography guide us to locate the exact coronary vessel involvement. Further, study by Smith et al. indicated that RWMAs occur earlier and are a more sensitive indicator of myocardial ischemia than the abnormal changes detected with an ECG.[12] Similarly, we observed RWMA in TEE before ECG changes in our case. However, adequacy of RWMA analysis by echocardiography may be influenced by artifacts and inter-observer variations. In addition, RWMA analysis does not differentiate stunned or hibernating myocardium from acute ischemia. Here, comes the role of advanced echocardiographic technologies, such as tissue Doppler, strain, and strain rate, which improve the diagnostic accuracy in detecting myocardial ischemia.

Myocardial strain can be measured by tissue Doppler imaging (TDI) or by speckle-tracking echocardiography (STE). STE is a recently developed technique that provides a non-Doppler, relatively angle-independent measurement of myocardial deformation, and LV systolic and diastolic dynamics.[13] Moreover, it provides an accurate and reproducible measurement of regional and global LV contractility. While in normal myocardium, longitudinal shortening is associated with more negative strain, whereas in ischemic myocardium, strain value becomes more positive. Further, subjective variations and variations due to pacing are less with STE. In our case, strain analysis exactly predicted the location of myocardial involvement, which helped in rectifying the cause. Thus, perioperative strain analysis plays a crucial role in assessing regional wall motion.


   Conclusion Top


Intraoperative TEE is one of the most sensitive modalities in the diagnosis of myocardial ischemia, detecting RWMA within a minute after inadequate myocardial perfusion, which can be due to inadequate revascularization or due to mechanical compression of grafts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Comunale ME, Body SC, Ley C, Koch C, Roach C, Mathew JP, et al. The concordance of intraoperative left ventricular wall-motion abnormalities and electrocardiographic S-T segment changes: Association with outcome after coronary revascularization. Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Anesthesiology 1998;88:945.  Back to cited text no. 1
    
2.
Koch CG, Milas BL, Savino JS. What does transesophageal echocardiography add to valvular heart surgery? Anesthesiol Clin North Am 2003;21:587-611.  Back to cited text no. 2
    
3.
Fry SJ, Picard MH. Transesophageal echocardiography: The evaluation of coronary artery disease. Coron Artery Dis 1998;9:399-410.  Back to cited text no. 3
    
4.
An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010;112:1084-96.  Back to cited text no. 4
    
5.
Qaddoura FE, Abel MD, Mecklenburg KL, Chandrasekaran K, Schaff HV, Zehr KJ, et al. Role of intraoperative transesophageal echocardiography in patients having coronary artery bypass graft surgery. Ann Thorac Surg 2004;78:1586-90.  Back to cited text no. 5
    
6.
Savage RM, Lytle BW, Aronson S, Navia JL, Licina M, Stewart WJ, et al. Intraoperative echocardiography is indicated in high-risk coronary artery bypass grafting. Ann Thorac Surg 1997;64:368-73; discussion 373-4.  Back to cited text no. 6
    
7.
Bergquist BD, Bellows WH, Leung JM. Transesophageal echocardiography in myocardial revascularization: II. Influence on lntraoperative decision making. Anesth Analg 1996;82:1139-45.  Back to cited text no. 7
    
8.
Cavalcante JL, Marwick TH, Hachamovitch R, Popovic ZB, Aldweib N, Starling RC, et al. Is there a role for diastolic function assessment in era of delayed enhancement cardiac magnetic resonance imaging? A multimodality imaging study in patients with advanced ischemic cardiomyopathy. Am Heart J 2014;168:220-8.e1.  Back to cited text no. 8
    
9.
Hillis GS, Møller JE, Pellikka PA, Gersh BJ, Wright RS, Ommen SR, et al. Noninvasive estimation of left ventricular filling pressure by E/e' is a powerful predictor of survival after acute myocardial infarction. J Am Coll Cardiol 2004;43:360-7.  Back to cited text no. 9
    
10.
McKenney PA, Apstein CS, Mendes LA, Connelly GP, Aldea GS, Shemin RJ, et al. Increased left ventricular diastolic chambers stiffness immediately after coronary artery bypass surgery. JAAC 1994;24:1189-94.  Back to cited text no. 10
    
11.
Gardin JM, Arnold AM, Bild DE, Smith VE, Lima JA, Klopfenstein HS, et al. Left ventricular diastolic filling in the elderly: The cardiovascular health study. Am J Cardiol 1998;82:345-51.  Back to cited text no. 11
    
12.
Smith JS, Cahalan MK, Benefiel DJ, Byrd BF, Lurz FW, Shapiro WA, et al. Intraoperative detection of myocardial ischemia in high- risk patients: Electrocardiography versus two-dimensional transesophageal echocardiography. Circulation 1985;72:1015-21.  Back to cited text no. 12
    
13.
Belghitia H, Brette S, Lafitte S, Reant P, Picard F, Serri K, et al. Automated function imaging: A new operator-independent strain method for assessing left ventricular function. Arch Cardiovasc Dis 2008;101:163-9.  Back to cited text no. 13
    

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Correspondence Address:
Sunder Lal Negi
Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_233_18

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  [Figure 1], [Figure 2]



 

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