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Transoesophageal echocardiogram may fail to diagnose perioperative myocardial infarction
F Chung1, C Seyone, H Rakowski
1Department of Anaesthesia, University of Toronto, Ont., Canada.
Insights
Transesophageal echocardiography may miss apical myocardial infarcts during surgery. Apical views or multiplane probes can improve detection of cardiac wall motion abnormalities.
Area of Science:
- Cardiology
- Medical Imaging
Background:
- Perioperative myocardial infarction (MI) is a serious complication during cardiac surgery.
- Electrocardiogram (ECG) and transesophageal echocardiography (TEE) are commonly used for intraoperative monitoring.
Observation:
- A 55-year-old man undergoing aortocoronary bypass developed ST elevation and new Q waves on ECG during skin closure.
- Simultaneous TEE monitoring showed no wall motion abnormalities or significant hemodynamic changes.
- Postoperative assessment confirmed a perioperative anteroapical myocardial infarct.
Findings:
- Intraoperative TEE, when the probe was at the midpapillary level, failed to detect the apical wall motion abnormality.
- ECG changes, although transient, indicated myocardial injury.
Implications:
- TEE's ability to detect myocardial ischemia can be limited by probe positioning, particularly for apical infarcts.
- Incorporating periodic apical views or using multiplane TEE probes can enhance the detection of cardiac wall motion abnormalities during surgery.
Abstract:
We report a case in which a 55-yr-old man undergoing aortocoronary bypass was monitored with electrocardiogram and transoesophageal echocardiogram. Intraoperative electrocardiogram and simultaneous ECG recordings using the Holter monitor showed an ST elevation of greater than 2 mm and new Q wave formation in leads AVF and V5 during skin closure. However, the transoesophageal echocardiogram showed no wall motion abnormalities. No significant haemodynamic abnormalities were observed during the period of intraoperative ECG changes. He was treated with nitroglycerin infusion. Confirmation of a perioperative myocardial infarct was documented by postoperative 12-lead ECG and CPK-MB. A post-operative transthoracic echocardiogram showed a hypokinetic left ventricle with an anteroapical infarct. Thus transoesophageal echocardiography failed to detect an apical wall motion abnormality when the probe was placed at the midpapillary level. This limitation can be overcome by periodically obtaining apical views or by using probes with more than one imaging plane.