Year : 2012  |  Volume : 15  |  Issue : 4  |  Page : 312--314

Transesophageal echocardiography for diagnosis of inadvertant closure of Inferior Vena Cava opening during minimally invasive atrial septal defect closure

Kanwar A Baloria1, Marc St-Amand2, Biju S Pillai1, Nandini Selot1,  
1 Department of Cardiac Sciences, Max Superspecialty Hospital, New Delhi, India
2 Department of Anesthesia, London Health Sciences Centre, London, Ontario, Canada

Correspondence Address:
Kanwar A Baloria
E-84 Ekta Apartment, Saket, New Delhi- 110 017


Transesophageal echocardiography (TEE) is widely used in cardiac surgery. TEE provides important diagnostic and functional information before and after cardiopulmonary bypass thereby having a very important impact on perioperative clinical outcomes. We describe a case in which intraoperative TEE was instrumental in the timely diagnosis of inadvertant closure of the inferior vena cava (IVC) opening during minimally invasive surgical closure of atrial septal defect.

How to cite this article:
Baloria KA, St-Amand M, Pillai BS, Selot N. Transesophageal echocardiography for diagnosis of inadvertant closure of Inferior Vena Cava opening during minimally invasive atrial septal defect closure.Ann Card Anaesth 2012;15:312-314

How to cite this URL:
Baloria KA, St-Amand M, Pillai BS, Selot N. Transesophageal echocardiography for diagnosis of inadvertant closure of Inferior Vena Cava opening during minimally invasive atrial septal defect closure. Ann Card Anaesth [serial online] 2012 [cited 2021 Mar 8 ];15:312-314
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Full Text


Transesophageal echocardiography (TEE) is widely used in the management of patients in cardiac surgery. There are reports of using TEE for placement of cannulas for cardiopulmonary bypass (CPB) [1],[2],[3] as well as for diagnosing problems like poor venous return during CPB. [4] We present a case in which intraoperative TEE assisted in the diagnosis of inadvertant surgical obstruction of inferior vena cava (IVC) during minimally invasive atrial septal defect (ASD) closure.

 Case Report

A 39-year-old male patient was referred for minimally invasive ASD closure after he presented with a history of transient ischemic attacks (TIA) with episodes of syncope and dizziness in the previous two years. An attempt was made to close the defect percutaneously; however, due to unsuitable anatomy of the right atrium (i.e. secondary membrane between IVC and septum) percutaneous closure was not possible.

After taking written consent, patient was taken to the operating room and anesthesia was induced uneventfully. In addition to standard monitors, a radial artery pressure line, a right internal jugular venous line, a Foley catheter and a TEE probe were used for monitoring. The preoperative diagnosis was confirmed on TEE [Figure 1]. With the assistance of TEE the superior vena cava and IVC cannulas were inserted through right internal jugular vein and right femoral vein respectively. The arterial cannula was inserted through the femoral artery and its position in the ascending aorta was confirmed with the help of TEE. A right anterolateral thoracotomy incision was made. The patient was anticoagulated with heparin and an ACT of > 400 seconds was ensured. Thereafter, the aortic and venous cannulas were connected to extracorporeal circuit and CPB was initiated. After achieving total CPB, the balloon of the aortic cannula (endoaortic balloon) was inflated, endoaortic occlusion was achieved and cardioplegia was delivered through the terminal port of the endoaortic cannula and right atrium was opened. Evidence of a small ASD (patent foramen ovale, PFO) and presence of an anomalous membrane was seen. The defect was closed surgically by approximating the anomalous membrane onto the septum. Thereafter, the entire surgical field was inspected and no further evidence of any defect was seen in the septum. Right atriotomy was closed first and then the endoclamp was deflated. At this stage, the surgeon noticed one bite of the ASD suture line on the free wall of the right atrium (RA) near the RA-IVC junction. Since, the patient was on CPB, we decided to find out whether this suture was obstructing the IVC or not. We advanced the IVC cannula by more than 5 centimeters and tried to visualize it in midesophageal views; however, it was not seen entering the IVC-RA junction [Figure 2]. We inferred that IVC junction was blocked by the suture. Then we decided to re-explore the ASD repair under endoaortic occlusion and cardioplegic arrest. Right atriotomy was done, the area was exposed and it was found that the anomalous membrane had completely closed off the opening of the IVC. The closure was then taken down and the ASD was defined and repaired. Postoperative course was uneventful, and the patient was discharged from the hospital on fourth postoperative day.{Figure 1}{Figure 2}


Since the introduction of intraoperative TEE into clinical practice in the 1980s, its significance has steadily increased. The American Society of Anesthesiologists, the American Society of Echocardiography, and the Society of Cardiovascular Anesthesiologists have issued guidelines for the intraoperative use of TEE. [5],[6] Previous studies have suggested that in cardiac surgical patients, TEE provides essential information before and after CPB regarding cardiac performance, valve function, great vessel pathology, [7] and congenital anomalies and has been shown to have a favorable impact on perioperative clinical outcomes. [8],[9],[10] A comprehensive pre-CPB TEE examination allows the cardiac surgeon and anesthesiologist to validate the preoperative indication for surgery, and therefore to avoid an unnecessary intervention with its associated morbidity. In addition, newly identified pathologic findings provide an opportunity to change the planned procedure, and possibly improve patient outcome or avoid an additional surgical procedure in the future.

In the present case there was an anomalous membrane between the IVC and the septum, but there was no interference with the venous drainage from the cannula. When the surgeon closed the ASD, he inadvertently closed the IVC opening with the anomalous membrane. It is important to note that the limited access and alternate method of IVC drainage might have resulted in this complication as in the standard technique IVC cannula is inserted via a RA free wall purse string. The TEE in our case assisted in the diagnosis of the inadvertent obstruction of the IVC, and helped the surgeon in deciding for re-exploration and correcting the obstruction. Our case demonstrates that not only TEE is important for assisting cannulations in minimal invasive cardiac surgery, but also useful to diagnose inadvertent surgical errors. This report underlines the important role of TEE to monitor and guide cardiac surgical management.


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