Advantage of Transesophageal Over Transthoracic Echocardiography Diagnosis of Mitral Valve Endocarditis

in the

Robert E. Lubanski, Jr, MD, and Carol L. Lake, MD

T

FUNSESOPHAGEAL echocardiography (TEE) is an increasingly popular choice for a diagnostic tool and intraoperative monitor by both anesthesiologists and cardiologists. TEE has an advantage over transthoracic echocardiography (‘RE) in diagnosing intracardiac masses and valvular dysfunction by providing a clearer image, finer detail, and larger echocardiographic “windows”.‘+’ The following case is reported in which TEE provided a definitive diagnosis of infective endocarditis when TTE results were inconclusive. CASE REPORT

A Sl-year-old, 60-kg woman initially presented to her local physician with the complaint of bronchitis. Over the next few days the patient developed fever, chills, abdominal pain, nausea, vomiting, and dysuria. She initially refused hospita1 admission, but as her symptoms worsened over the next 2 days she was admitted for evaluation. Her past medical history was significant for hypertension, cigarette smoking, and alcohol abuse. She had no known allergies and was not receiving any medication at the time of admission. On admission, the patient bad complaints of abdominal pain, nausea, and anorexia. Physical examination was remarkable for an oral temperature of 39.X and a mildly tender abdomen to palpation. Cardiac examination showed no abnormalities. Blood cultures were drawn, and the patient was started on a course of treatment with intravenous (IV) gentamicin and clindamicin. Laboratory studies were unremarkable, except for an amylase leve1 of 528 UIL. However, ultrasound examination of the abdomen showed no abnormalities. Two days after admission the patient developed shortness of breath and was noted to have bibasilar rales. A pulmonaty arterial catheter was inserted and the initial pulmonary capillary wedge pressure was 35 mm Hg. There was no comment on the medical record about the pulmonaty artery pressure waveform, and no murmur was noted on physical examination. The patient remained febrile (39 to 395°C). Blood cultures yielded Staphylococcus aureus and, on the basis of drug sensitivities, nafcillin was added to the antibiotic regimen. IV furosemide was given to treat pulmonaty edema. The following day the patient developed severe respiratory distress, requiring endotracheal intubation. ‘ITE showed mild mitral regurgitation. Ventricular function appeared normal. NO other abnormalities were noted. Physical examination the following day demonstrated a holosystolic murmur, graded 2/6, consistent with mitral regurgitation. Abdominal pain and tenderness persisted. A computed tomography scan of the abdomen showed a large edematous pancreas. With continued deterioration of the patient’s clinical condition, she was transferred to this tertiary care center with the diagnosis of acute pancreatitis and congestive heart failure. On arrival, the patient was receiving IV nafcillin, gentamicin, clindamicin, digoxin, ranitidine, and lorazepam. Her temperature was 39.5”C. Mechanica1 ventilation was provided via an oral endotracheal tube. Bibasilar rales, a 2-3/6 holosystolic murmur, and abdominal tenderness were noted on physical examination. Laboratory studies showed a white blood cel1 count of ll.7 K/uL, hematocrit of 23%, and normal electrolytes. Amylase leve1 was 595 U/L and lipase was 2,926 UIL. Pulmonary arterial pressure waveforms showed prominent V waves, with a pressure of 42/22 mm Hg. On the next day, examination with TTE noted a normal Journal of Cardiothoracic and Vascutar Anesthesia,

Vol 5,

left atrium and ventricle, and grossly normal mitral valve appearante. However, the mitral valve was not wel1 observed because only subcostal images were obtained due to narrow intercostal windows and soft tissue interference (Fig 1). On the following day, the cardiac anesthesiology service was consulted for aid in performing TEE. After sedation with midazolam (2 mg, IV), topical 10% lidocaine was applied to the oropharynx. A TEE probe (Sonos 500, Hewlett-Packard, Palo Alto, CA) was placed by digital guidance into the esophagus. Excellent views of the left atrium and mitral valve were obtained, and showed a large exophytic mass on the posterior leaflet of the mitral valve (Fig 2). The patient then underwent emergency cardiac catheterization to evaluate the coronary vasculature prior to operation. This study showed normal coronary artery anatomy without occlusive disease. In the operating suite, a 1Cgauge IV catheter was placed into the right antecubital vein. An already existing 20-gauge left radial arterial catheter, right internal jugular pulmonary arterial catheter, and 8F right femoral arterial sheath were checked for patency and position, and secured. The patient had a 7.0-mm intemal diameter oral endotracheal tube in appropriate position. Therapy at this time consisted of 10 @kg/min of IV dopamine. Because of persistent low systemic blood pressures (SOWOmm Hg), epinephrine, 10 p,g, was administered as an IV bolus, and an infusion of epinephrine was started at 1 ug/min. Dopamine was discontinued. Systemic blood pressure subsequently increased to 130170mm Hg. The patient was awake, but only intermittently responsive to commands. Anesthesia was induced with 2.5 @kg of sufentanil, with pancuronium, 0.05 mg/kg, and metocurine. 0.2 mg/kg, used to provide muscle relaxation. Scopolamine, 0.3 mg, was given to provide amnesia. Systemic blood pressure remained relatively stable during induction (100160 to 110170 mm Hg). Pulmonary arterial pressures decreased from 50132 to 42/27 mm Hg after induction of anesthesia. A TEE probe (Hewlett-Packard Sonos 500) was then placed with digital guidance into the esophagus. Images were similar to those previously obtained in the intensive care unit. Mitral regurgitation was estimated to be 4+ on the basis of color-flow and pulsed-wave Doppler imaging (Fig 3). NO systolic wal1 motion abnormalities were noted. The four-chamber view was monitored continuously to check for particulate or en mass embolization of the mitral valve vegetation during dissection of the mediastinum and cannulation of the great vessels. There was no evidente of such embolization. The patient had an uneventful prebypass course, while maintained on epinephrine. 1 @min. Cardiopulmonary bypass was instituted, with ascending aortic and separate superior and inferior vena cava cannulation sites. A large vegetation, consistent in appearance with the echocardiographic image, was removed attached to the mitral valve leaflets. A porcine prosthesis (No. 29 Hancock) was placed in the mitral valve annulus. After closure of the left atriotomy, the aortic cross-clamp was removed, and electrical defibrillation (15 J, then 20 J) was attempted after pretreatment with lidocaine. 100 mg. Sinus rhythm

From the Department of Anesthesiology. Univeersityof Virginia, Charlottesville, VA. Address reprint requests to Carol L. Lake, MD, Professor, Depa& ment of Anesthesiology, University of Virginia, Charlottewille, VA 22908. Copyright o 19916~ W.B. Saunders Company 1053-077019110501-0014$03.00/0

NO 1 (Februaryl, 1991: pp 63-65

63

64

LUBANSKI

Fig 1. Subcostal four-chambered image of the heart by lTE. Poor image quality is due to the limitation of the window by soft tissue. Intercostal windows were not obtainable. X, location of the mitral valve.

could not be maintained because of atrioventricular (AV) nodal black. AV pacing at a rate of 90 beatsimin with a delay of 150 milliseconds was begun. In preparation for discontinuing cardiopulmonary bypass, epinephrine was restarted at 1 pgmin. Calcium chloride, 1 g, was administered through the central venous catheter. Pulmonary diastolic pressure reached 16 mm Hg, and cardiopulmonary bypass was discontinued. However, without extracorporeal bypass support, the patient was unable to sustain systemic pressures above 60 mm Hg. Epinephrine was increased to 2 and then 3 PgImin, without success. Bypass was reinstituted, and an intraaortic balloon pump (IABP) was inserted over a guidewire through the preexisting right femoral sheath. IABP counterpulsation at 1:l was instituted on insertion. Nitroglycerin was added at 0.25 &kg/min in an attempt to dilate the pulmonary and coronary vasculature. The patient was then successfully weaned from bypass with a pulmonary diastolic pressure of 18 mm Hg and augmented systolic blood pressures of 75 to 85 mm Hg. Nitroglycerin was carefully titrated to a dose of 0.5 @kg/min; epinephrine dosage remained at 3 &min. Pulmonary arterial pressures were 25118mm Hg. Color-flow and pulsed-wave Doppler imaging did not show any significant mitral regurgitation. Protamine was carefully titrated to return the activated clotting time to the normal range. The patient was then transferred without further incident to the cardiac postoperative intensive care unit. Over the next 48 hours, the support from the IABP and epinephrine were gradually discontinued, while maintaining stable hemodynamics. However, she continued to have a complicated hospita1 course, secondary to her pancreatitis and poor nutritional state. She has remainedventilatordependent with a tracheostomy. Presently, her pancreatitis is subsiding, and prospects for recovery are good.

AND LAKE

for inadequate precordial cchocardioknown reasons graphic images are obesity, chest wal1 abnormalities, and emphysema.’ In this case, precordial views were limited by inadequate intercostal windows and a chest wal1 thickened by soft tissue. TEE was able to provide a more direct visualization of the mitral valve and thereby yield a definitive diagnosis. The sensitivity and specificity of TEE in diagnosing valvular endocarditis are affected by the sizc of the vegetation, experience of the echocardiographer. and clinical evidente of infective endocarditis.” In patients with strong clinical evidente of infective endocarditis, TEE demonstrates 80% to 100% positive findings comparcd with less than 70% with TTE.” Recent reports suggest that negative results of TTE should be confirmed by TEE when endocarditis is suspected clinically.’ The necessity of cardiac catheterization in patients with mitral valve disease has been questioned.‘.’ However, in this patient catheterization was performed to examine the coronary arteries, not to make the diagnosis. Although she did not have any symptoms of coronary artery disease, she did have the risk factors of age, smoking, and hypertension. Cardiac catheterization also permitted accurate measurement of left ventricular end-diastolic pressure and the gradient, if any, between pulmonary artery diastolic and left ventricular diastolic pressure, secondary to chronic obstructive pulmonary disease. The collaboration of the anesthesiology and cardiology services in performing TEE yielded a definitive diagnosis and immediately altered the patient’s management. Because the anesthesiologists were involved in the diagnostic phase, a thorough preoperative examination and assessment allowed better familiarity in viewing the intraoperative images. This familiarity with the shape and characteris-

DISCUSSION

This case presents a somewhat complicated diagnostic dilemma in which the traditionally accepted means of diagnosis (‘ITE) was unable to provide an answer. Wel1

Fig 2. Four-chambered view of the heart by TEE. Note the clarity of structures and the vegetatlon with this vlew. X, vegetation on the mitral valve; LA, left atrium; LV, left ventricle.

ADVANTAGE

65

OF TEE OVER lTE

Fig 3. TEE four-chamber color flow image, demonstratlng a Iarge amount of mitrrl mgurgitatlon. The turbulente on color-flow obscuree the vegetation on the posterior Ieaflet of the mitral valve.

tics of the lesion allowed the anesthesiologists to monitor more closely for evidente of embolization. This case serves not only to document the advantages of TEE over ‘ITE, but also to emphasize the potential role for anesthesiologists outside the operating room.

ACKNOWLEDGMENT

The authors wish to thank John Dent, MD, Division of Cardiol-

ogy at the University of Virginia Health Sciences Center, for his help with the echocardiograms, and Patty Jenkins for her assistante in the preparation of this manuscript.

REFERENCES

1. Gussenhoven E, Taams M, Roelandt J, et al: Transesophageal two-dimensional echocardiography: Its role in solving clinical problems. J Am cO11Cardiol8:1975-1979,1986 2. Geibel A, Hofmann T, Behrin A, et al: Echocardiographic diagnosis of infective endocarditis-Additional information by transesophageal echocardiography. Circulation 76:IV38,1987 3. Erbel R, Rohmann S, Drexler M: Improved diagnostic value of echocardiography in patients with infective endocarditis by transesophageal approach. A prospective study. Eur Heart J 9:43-53,1988 4. Maisch B, Ertl G, Kleinert C, Kochsiek K: Sensitivity and specificity of transesophageal echocardiography in the diagnosis of vegetations and abcesses in infective endocarditis, in Erbel R, Khandheria BK, Brennecke R, et al (eds): Transesophageal

Echocardiography. New York, NY. Springer-Verlag, 1989, pp 99-106 5. Hanrath P, Kreis A, Schneider B, et al: Diagnostic value of transesophageal echocardiography in critically ill patients, in Erbel R, Khandheria BK, Brennecke R, et al (eds): Transesophageal Echocardiography. New York, NY, Springer-Verlag, 1989, pp 193-196 6. Bryg R, Williams G, Labovitz A, et al: Effect of atria1 fibrillation and mitral regurgitation on calculated mitral valve area in mitral stenosis. Am J Cardiol57:634-638, 1986 7. Saint John Sutton MG, Saint John Sutton M, Oldershaw P: Valve replacement without preoperative cardiac catheterization. N Eng1 J Med 305:1233-1238,198l

Advantage of transesophageal over transthoracic echocardiography in the diagnosis of mitral valve endocarditis.

Advantage of Transesophageal Over Transthoracic Echocardiography Diagnosis of Mitral Valve Endocarditis in the Robert E. Lubanski, Jr, MD, and Carol...
2MB Sizes 0 Downloads 0 Views