Vaggar Jagadeesh N, Gadhinglajkar Shrinivas, Pillai Vivek, Sreedhar Rupa, Cahndran Roshith, Roy Suddhadeb
Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
Ann Card Anaesth. 2015 Oct-Dec;18(4):579-83. doi: 10.4103/0971-9784.166474.
We report an incident of detection of a free-floating thrombus in the left ventricle (LV) using intraoperative two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) during proximal coronary artery bypass graft anastomosis. A 58-year-old man presented to us with a 6-month history of chest pain without any history suggestive of myocardial infarction or transient ischemic attacks. His preoperative echocardiography revealed the systolic dysfunction of LV, mild hypokinesia of basal and mid-anterior wall, and the absence of an aneurysm. He was scheduled for on-pump coronary artery bypass surgery. On intraoperative TEE before establishing cardiopulmonary bypass (CPB), a small immobile mass was found attached to LV apical area. After completion of distal coronary artery grafting, when the aortic cross-clamp was removed, the heart was filled partially and beating spontaneously. TEE examination using 2D mode revealed a free-floating mass in the LV, which was suspected to be a thrombus. Additional navigation using biplane and 3D modes confirmed the presence of the thrombus and distinguished it from papillary muscles and artifact. The surgeon opened the left atrium after re-establishing electromechanical quiescence and removed a thrombus measuring 1.5 cm Χ 1 cm from the LV. The LV mass in the apical region was no longer seen after discontinuation of CPB. Accurate TEE-detection and timely removal of the thrombus averted disastrous embolic complications. Intraoperative 2D and recent biplane and 3D echocardiography modes are useful monitoring tools during the conduct of CPB.
我们报告了一例在近端冠状动脉搭桥吻合术中，使用术中二维（2D）和三维（3D）经食管超声心动图（TEE）检测到左心室（LV）游离血栓的事件。一名58岁男性因胸痛6个月前来就诊，无任何提示心肌梗死或短暂性脑缺血发作的病史。其术前超声心动图显示左心室收缩功能障碍，基底和前壁中部轻度运动减弱，且无动脉瘤。他被安排进行体外循环冠状动脉搭桥手术。在建立体外循环（CPB）前的术中TEE检查中，发现左心室心尖区域附着有一个小的固定肿块。在完成远端冠状动脉搭桥后，当松开主动脉阻断钳时，心脏部分充盈并自主跳动。使用2D模式的TEE检查显示左心室内有一个游离肿块，怀疑是血栓。使用双平面和3D模式的进一步检查确认了血栓的存在，并将其与乳头肌和伪像区分开来。在重新建立电机械静止后，外科医生打开左心房，从左心室取出一个大小为1.5 cm×1 cm的血栓。停止CPB后，心尖区域的左心室肿块不再可见。准确的TEE检测和及时清除血栓避免了灾难性的栓塞并发症。术中2D以及最近的双平面和3D超声心动图模式是CPB实施过程中的有用监测工具。
