SHA24/087004

How to Detect Intraoperative Complications Post Cardiac Surgery GHA 10 / SHA 24 Joint Scientific Conference 13th-16th February 2013 Riyadh, Saudi Arabia Dr. Maie S. Al Shahid Heart Center King Faisal Specialist Hospital and RC

Perioperative TEE

Application

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Patients undergoing cardiac surgery Patients undergoing non-cardiac surgery Use in Intensive care

Intraoperative TEE

Indication: General 

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Monitor overall LV cardiac function in high-risk patients undergoing non-cardiac surgery Detect LV ischemia by identifying wall motion abnormalities and lack of systolic thickening Assess LV filling and volume status Monitor / Assess RV function: pulmonary embolus Assess unexplained hypotension and hemodynamic instability Assess cause of hypoxemia and for right-to-left intra-cardiac shunting through PFO

Intraoperative TEE

Indication: Cardiac Surgery     

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Assess adequacy of valve repair Assess adequacy of valve replacement: Special cases Assess adequacy of repair of CHD Assess aortic pathology and result of aortic surgery Evaluate cause of intra-operative hypotension and difficulty to wean off bypass Monitor for ischemia Exclude pericardial tamponade / mediastinal bleeding Detect coronary air embolization

Intraoperative TEE

Indication: Newer Applications   

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Minimally invasive cardiac surgery Off-pump Bypass surgery During placement of LV assist devices  Atrial shunting  Aortic regurgitation  Intracardiac thrombi  RV function Positioning of cannulae Aortic valve repair

Intraoperative Monitoring 

Guide prompt therapeutic management using:  Fluid adminstration  Vasodilator therapy  Anti-ischemic therapy  Vasopressor or inotrope therapy  Intra-aortic balloon pump  Even re-instituting CPB

Bergquist et al. Anesth Analg 1996;82:1139

Intraoperative Monitoring by TEE

Newer Technological Advances ď Ž

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Real-time 3-Dimensional echo; Simultaneous multiple images of coronary distribution improving the ischemia detection capacity of TEE Use of tissue Doppler to demonstrate LV asynchronyas an early, more sensitive marker of myocardial ischemia

Intraoperative TEE Assessment of Repair / Replacement 

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Evaluate residual regurgitation: Degree and mechanism Evaluate residual gradient Exclude paravalvar regurgitation Detect complications Assess global and segmental LV function

Intraoperative TEE

Impact on Surgery 

Preoperative study 

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During aortic cross-clamp removal 

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Modify procedure Re-cross clamp the aorta

Post by-pass study Re-institute bypass for further surgical intervention  Fluid / pharmacological manipulation 

Case # 1: Failure to Wean off Bypass!     

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43 years old lady S/P OMC in 1994 S/P MVR and AVR with bioprostheses in 1998 Followed up for several years with increasing TR Referred with degeneration of mitral bioprosthesis and severe TR in 2005 Argued about redo AVR. Decision made to address the three valves Had MVR AVR with mechanical prostheses, and TVR with bioprosthesis

Failure to Wean off Bypass!

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Surgeon opted to do 2 grafts to LAD and CX Accepted the paravalvar AR

S/P Second Run

Case # 2: Emergency Back on Bypass       

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53 years old lady post MVR with CM 29 prosthesis Increasing shortness of breath One disc of prosthesis stuck by TTE Thrombus on mitral prosthesis by TEE Had redo MVR with CM 29 mm prosthesis Collapsed after closure of the chest, initially with VT Had to have chest re-opened and put on bypass again Cannulated under very difficult position We were asked to come and do a TEE!

Case # 2: Emergency Back on Bypass

Epicardial Echo

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Surgeon went back on bypass Ascending aorta replaced AV repair done

Case # 3: Failure to Get off Bypass        

46 yrs old lady post closed mitral commissurotomy in the 70’s Had re-stenosis: Had open mitral commissurotomy in 1989 Had re-stenosis in 2001: Mitral balloon was attempted and failed.

Refused surgery, modified her life style, and we followed her up for next 6 years on diuretics and beta-blockers!

Pulmonary artery pressure slowly increased, we exercised her, and she agreed to have surgery Had MVR with CM 29 mm Could not be waned off bypass TEE done

Case # 3: Failure to Get off Bypass

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Surgeon went back and re-positioned the mitral mechanical prosthesis

Post 2nd Run

Post 2nd Run

Post 2nd Run

Post 2nd Run

Post 2nd Run

Case # 4 

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40 years old man with 4 months history of exertional dyspnea Known to have MVP for years Decision made for MV repair Had MV repair Routine postoperative TEE

Postoperative TEE

Post “Manipulation”

Case # 5     

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57 years old man No risk factors except for smoking Presented with intermittent claudication Planned for Aorto-femoral bypass Anesthetist noted abnormal ECG and difficulty in ventilation Inserted a probe, noted wall motion abnormality, requested confirmation