[Usefulness of transesophageal echocardiography during myocardial revascularization surgery without extracorporeal circulation]. / Utilidad de la ecocardiografía transesofágica intraoperatoria durante revascularización miocárdica sin circulación extracorpórea.

OBJECTIVE: Intraoperative transesophageal echocardiography can be a highly useful monitoring technique during myocardial revascularization surgery when extracorporeal circulation (ECC) is not being used. Transesophageal echocardiography provides real-time images on both volume status and segmental myocardial contractility without interfering with the surgical field. PATIENTS AND METHODS: A total of 25 patients undergoing myocardial revascularization by sternotomy without ECC were monitored by transesophageal echocardiography during surgery. RESULTS: The 18 men and 7 women studied had a mean (SD) age of 71.3 (8) years. A third of them had hypertension and diabetes, 3 had suffered a cerebrovascular accident, and 2 had renal failure. Nine patients had a history of acute myocardial infarction and 3 had undergone angioplasty. Baseline echocardiograms on all patients established that 6 had a low ejection fraction (<30%). Twelve had altered segmental contractility, which was transient in 11 cases. Six patients had improved ejection fraction at the final assessment. Transesophageal electrocardiography also monitored volume status and the effects of inotropic drugs and beta-blockers in 83% of the patients. CONCLUSION: Transesophageal electrocardiography is a minimally invasive, safe, and precise way to directly monitor the beating heart in real time during myocardial revascularization without ECC. Image quality is good.

Utilidad de la ecocardiografía transesofágica intraoperatoria durante revascularización miocárdica sin circulación extracorpórea / Usefulness of transesophageal echocardiography during myocardial revascularization surgery without extracorporeal circulation

OBJETIVO: La ecocardiografía transesofágica intraoperatoria(ETE) puede ser un sistema de monitorización dealta utilidad durante la revascularización miocárdica sincirculación extracorpórea (CEC), ya que permite obtenerimágenes en tiempo real tanto del estado de la volemiacomo de la contractilidad segmentaria miocárdica, sininterferir en el campo quirúrgico.PACIENTES YMÉTODOS: Se estudian 25 pacientes sometidosa revascularización miocárdica por esternotomía sinCEC monitorizados con ETE durante su intraoperatorio.RESULTADOS: 18 hombres y 7 mujeres, con edad promediode 71,3 ± 8 años fueron estudiados. Un tercio de ellospresentaba hipertensión arterial y diabetes, 3 habían tenidoun accidente vascular encefálico previo y 2 eran portadoresde insuficiencia renal. Un total de 9 pacientes teníahistoria de infarto agudo al miocardio y 3 casos de elloshabían sido sometidos a angioplastias previas. A todos lospacientes se les realizó ETE basal donde seis tenían malafracción de eyección (FE) < 30%. Se detectaron alteracionesde la contractilidad segmentaria en 12 pacientes, deéstos en 11 fueron alteraciones sólo transitorias. En la evaluaciónfinal se determinó que en 6 enfermos hubo unamejoría de la FE. La ETE permitió además evaluar elestado de la volemia, el efecto de fármacos inotropos y betabloqueadores en el 83% de los pacientes.CONCLUSIÓN: La ETE es un monitor mínimamenteinvasivo y en tiempo real que permite evaluar en formadirecta, segura y precisa al corazón latiendo durante larevascularización miocárdica sin CEC con buena calidadde imágenes

OBJECTIVE: Intraoperative transesophageal echocardiographycan be a highly useful monitoring techniqueduring myocardial revascularization surgery whenextracorporeal circulation (ECC) is not being used.Transesophageal echocardiography provides real-timeimages on both volume status and segmental myocardialcontractility without interfering with the surgicalfield.PATIENTS AND METHODS: A total of 25 patients undergoingmyocardial revascularization by sternotomy withoutECC were monitored by transesophageal echocardiographyduring surgery.RESULTS: The 18 men and 7 women studied had amean (SD) age of 71.3 (8) years. A third of them hadhypertension and diabetes, 3 had suffered a cerebrovascularaccident, and 2 had renal failure. Nine patientshad a history of acute myocardial infarction and 3 hadundergone angioplasty. Baseline echocardiograms on allpatients established that 6 had a low ejection fraction(<30%). Twelve had altered segmental contractility,which was transient in 11 cases. Six patients had improvedejection fraction at the final assessment. Transesophagealelectrocardiography also monitored volumestatus and the effects of inotropic drugs and ß-blockersin 83% of the patients.CONCLUSION: Transesophageal electrocardiography isa minimally invasive, safe, and precise way to directlymonitor the beating heart in real time during myocardialrevascularization without ECC. Image quality isgood

[Intracoronary air embolism detected during intraoperative transesophageal echocardiography]. / Detección de embolia aérea intracoronaria con ecocardiografía transesofágica intraoperatoria.

A 39-year-old hypertensive man with severe aortic stenosis underwent aortic valve replacement monitored by intraoperative transesophageal echocardiography. Upon weaning the patient off extracorporeal circulation, hemodynamics became severely compromised, with hypotension, tachycardia, and elevated precordial electrocardiographic tracings. The echocardiographic images were instrumental during the episode to demonstrate that the anterior wall presented hypokinesis consistent with ischemia in the region but that there were also images of hyperrefringence highly suggestive of intracoronary air embolism. Intraoperative transesophageal echocardiography allowed us to diagnose the real cause of the ischemic event and rule out an atheromatous plaque as the source. Perfusion pressure was increased to treat the air embolism. The echocardiographic image demonstrated success, specifically restoration of left ventricular regional contractility. This experience revealed the usefulness of transesophageal echocardiography in intraoperative monitoring to diagnose ischemia, assess the cause, and guide treatment.

Detección de embolia aérea intracoronaria con ecocardiografía transesofágica intraoperatoria / Intracoronary air embolism detected during intraoperative transesophageal echocardiography

Se presenta el caso clínico de un paciente de 39 años, portador de hipertensión arterial y estenosis aórtica severa sometido a recambio valvular aórtico, que fue monitorizado con ecocardiografía transesofágica intraoperatoria (ETE). Al finalizar la circulación extracorpórea presentó compromiso severo de su estado hemodinámico, caracterizado por hipotensión, taquicardia y elevaciones del trazado electrocardiográfico en la pared anterior miocárdica. Durante este episodio las imágenes ecocardiográficas fueron útiles y categóricas para demostrar que la pared anterior presentaba hipocinesia compatible con isquemia de este territorio, pero además existieron en esta zona imágenes de hiperrefringencia altamente sugerentes de aire intracoronario. La ETE permitió diagnosticar la causa de este fenómeno isquémico, desestimando como etiología una placa ateromatosa. El tratamiento de la embolía aérea intracoronaria fue aumentando la presión de perfusión, cuyo éxito se evidenció también con la ecocardiografía que demostró la restauración de contractilidad segmentaria del ventrículo izquierdo. A través de la evolución de este paciente se evidenció la alta utilidad de la ecocardiografía transesofágica como monitor intraoperatorio para diagnosticar isquemia, estimar su etiología y guiar su terapia

A 39-year-old hypertensive man with severe aortic stenosis underwent aortic valve replacement monitored by intraoperative transesophageal echocardiography. Upon weaning the patient off extracorporeal circulation, hemodynamics became severely compromised, with hypotension, tachycardia, and elevated precordial electrocardiographic tracings. The echocardiographic images were instrumental during the episode to demonstrate that the anterior wall presented hypokinesis consistent with ischemia in the region but that there were also images of hyperrefringence highly suggestive of intracoronary air embolism. Intraoperative transesophageal echocardiography allowed us to diagnose the real cause of the ischemic event and rule out an atheromatous plaque as the source. Perfusion pressure was increased to treat the air embolism. The echocardiographic image demonstrated success, specifically restoration of left ventricular regional contractility. This experience revealed the usefulness of transesophageal echocardiography in intraoperative monitoring to diagnose ischemia, assess the cause, and guide treatment

[Transesophageal echocardiography: experience with the first 500 consecutive cases]. / Ecocardiografía transesofágica: experiencia en los primeros 500 casos consecutivos.

The results of all the transesophageal echocardiographies (TEE) performed between June 1989 and February 1992 are analyzed. Five hundred patients (240 male) with a median age of 57 years (range 13-88) were examined; during the same period, 5180 transthoracic echocardiographies were performed. TEE were requested for the following reasons: valvular prosthesis disfunction in 132 patients, rheumatic valvulopathy in 103, search for embolic origins in 97, study of congenital cardiopathies in 48, bacterial endocarditis in 35, aortic dissection in 25 and miscellaneous in 78. Among congenital cardiopathies there were 29 cases of interauricular communication and among miscellaneous cases, 9 patients with cardiac tumors. No major complications occurred. The imaging quality of this technique renders it specially important in the study of prosthesis disfunction, mitral valve analysis before valvuloplasty, detection of cardiac origins of emboli and infective endocarditis complications and anatomical and dynamic analysis of aortic dissection. It is concluded that TEE is a safe technique that provides high quality images and visualizes segments of the heart and great vessels formerly inaccessible with transthoracic echocardiography. It has enlarged the diagnostic capacity of echocardiography and improved the support of therapeutic decisions.