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Ann Thorac Surg 2004;78:866
© 2004 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, University of California, San Diego, 200 West Arbor Dr, MC Suite 8892, San Diego, CA 92103, USA
Department of Anesthesia, University of California, San Diego, 200 West Arbor Dr, San Diego, CA 92103, USA
pthistlethwaite{at}ucsd.edu
gmanecke{at}ucsd.edu
Emergency pulmonary embolectomy is often performed within a short time frame from diagnosis, without extensive preoperative workup, with the surgeon focusing on the removal of clot from one area: the large pulmonary arteries. In the above study, Rosenberger and associates provide evidence that transesophageal echocardiography (TEE) is a useful adjunct to planning operative strategy and guiding the surgical approach to acute embolism in the chest.
Those of us using TEE routinely for cardiac operations do so believing that its benefits far outweigh its relatively low risk and cost. There are few clinical studies, however, actually proving its worth. By conducting a systematic investigation of the utility of TEE for emergency pulmonary embolectomy, the authors have made a valuable contribution that may guide the practice of other surgeons performing this operation.
The results presented mirror our experience at the University of California, San Diego, with pulmonary thromboendarterectomy (PTE) for chronic thromboembolic disease [1]. We find TEE to be important in the assessment of right ventricular structure and function, right atrial size, tricuspid regurgitation, left-sided filling characteristics, diagnosis of extrapulmonary thrombus, and detection of intracardiac air at the conclusion of the procedure. There are two assessments, in addition to those mentioned by the authors, we find useful in our PTE patients. The first is the midesophageal ascending aortic short-axis view, which, in addition to being the preferred view for examination of the right pulmonary artery, provides a view of the upper portion of the superior vena cava (SVC). This, being above the level of the bicaval view, allows assessment of an additional portion of the SVC for thromboembolic material. Second, we perform an agitated "bubble test" for the detection of a patent foramen ovale (PFO). Acute pulmonary embolism patients, as well as patients with chronic thromboembolic pulmonary hypertension, may experience instances in which right atrial pressure exceeds left atrial pressure, placing them at risk for paradoxical embolus. It is our experience that the agitated saline test with TEE is highly sensitive (more so than transthoracic echocardiography) for the detection of PFO, and PTE patients benefit from having the PFO closed intraoperatively. We would think that such a test would be beneficial in acute pulmonary embolectomy patients, even if a transthoracic study had been done.
We believe TEE to be essential in the management of patients undergoing pulmonary artery surgery, and appreciate the work of the authors in clarifying this issue. Perhaps pulmonary artery surgery will soon join mitral valve repair, complex aortic reconstruction, and assessment of unexplained hemodynamic instability as a "class I" indication for perioperative TEE.
References
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