The Utility of Routine Intraoperative Transesophageal Echocardiography During Coronary Artery Bypass Graft Surgery: An Unexpected Reminder

To the Editor,

Intraoperative transesophageal echocardiography (TEE) can provide a wide range of therapeutically relevant information in patients undergoing various cardiac surgeries. However, the role of routine intraoperative TEE remains debatable, especially in the setting of isolated coronary artery bypass graft surgeries (CABG).[1,2] We recently encountered a case in which intraoperative TEE provided a completely unanticipated information that changed the surgical plan and potentially averted future complications and possibly, even a repeat cardiac surgery.

A 64-year-old woman with triple vessel coronary artery disease was taken up for CABG. Her left ventricular ejection fraction was normal, and all the cardiac valves were reported normal on preoperative transthoracic echocardiography (TTE). As an institutional practice, a TEE probe was inserted after induction of anesthesia (X7-2t probe, CX50 Philips Ultrasound machine, Bothell, WA, USA). A comprehensive TEE examination showed a mobile, echogenic mass attached to the right coronary cusp of the aortic valve, projecting toward the ascending aorta [Figures 1 and 2]. The echocardiographic appearance was highly suggestive of papillary fibroelastoma (PFE). The opening of the aortic valve was normal [Figure 3], and there was no aortic regurgitation [Figure 4]. Other cardiac chambers and valves were normal. Given the mobile nature of the mass with high risk of embolic complications, it was decided to excise the mass. Accordingly, under cardiopulmonary bypass and through aortotomy, a jelly-like mass measuring 8 mm × 4 mm was removed [Figure 5], and CABG was performed. After excision of the mass, the aortic valve appeared normal in structure and function [Figure 6]. The histopathology examination of the mass showed multiple, branching fronds of fibroelastic tissue, suggestive of a PFE. The patient made an uneventful recovery.

Figure 1.

Intraoperative transesophageal echocardiography showing an echogenic mass attached to the right coronary cusp of the aortic valve (arrow)

Figure 2.

Real-time three-dimensional transesophageal echocardiographic image of the mass attached to the right coronary cusp of the aortic valve

Figure 3.

Two-dimensional midesophageal aortic valve short axis view showing normal opening of the aortic valve

Figure 4.

Midesophageal aortic valve long-axis view with color comparison showing no aortic regurgitation

Figure 5.

Photograph of the excised mass

Figure 6.

Transesophageal echocardiography image after excision of the mass showing normal aortic valve

Papillary fibroelastomas are rare, primary, benign cardiac tumors with a reported prevalence of 0.02%.[3] They can potentially lead to transient ischemic attack, retinal artery occlusion, stroke, myocardial infarction, ventricular fibrillation, and sudden cardiac death. PFEs are often diagnosed incidentally during workup for other conditions.[3] The differential diagnosis of PFE includes vegetations resulting from infective endocarditis or nonbacterial endocarditis, lupus, thrombus, and Lambl’s excrescences. TEE is more sensitive in identifying PFEs compared with TTE, which may miss these tumors because of their small size, as happened in this case.[4] Surgical excision is recommended for larger (>1 cm), left-sided PFEs in low surgical-risk patients because of the risk of systemic embolization or at the time of cardiac surgery for other indications.[5] If TEE had not been performed in this patient, it would have resulted in missing an excellent opportunity to resect this PFE and leaving the patient at risk of developing embolic complications in future. An embolic event in this patient might have necessitated a repeat cardiac surgery with its associated risks.

The present case highlights the potential utility of routine intraoperative TEE in patients undergoing isolated CABG. In addition, TEE is also helpful in identifying immediate postsurgical complications (e.g., new wall motion abnormalities, severe valvular lesion, and residual perivalvular leak) and providing valuable hemodynamic information. Through all these mechanisms, intraoperative TEE may favorably influence the perioperative outcomes. Indeed, a recent, very large retrospective study, consisting of 1.25 million patients, showed that intraoperative TEE usage during planned isolated CABG was associated with lower operative mortality, particularly in higher-risk patients.[1] Furthermore, the use of intraoperative TEE was associated with nearly five-fold higher odds of an unplanned, yet necessary valve procedure at time of isolated CABG. Similar findings have been reported by some other studies as well.[6] The current guidelines recommend that intraoperative TEE should be considered during isolated CABG for detection of new or unsuspected pathology, although the strength of the recommendation has been inconsistent.[7,8]

In conclusion, intraoperative TEE is a useful diagnostic modality, and its use may improve overall clinical outcomes in patients undergoing isolated CABG.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.