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Importance of transoesophageal echocardiography in preventing complications due to intraoperative dislodgement of left atrial thrombus

Indian Journal of Anaesthesia
Medknow Publications
Publication Date
DOI: 10.4103/0019-5049.72655
  • Letters To Editor
  • Medicine


Sir, A 61-year-old man presented with central chest tightness. Although the Electrocardiogram (ECG) did not show ischemic changes, the troponin was raised. He was in fast atrial fibrillation with haemodynamic compromise. He was given two Direct Current (DC) shocks after which it converted to sinus rhythm. Cardiac risk factors included Diabetes Mellitus (DM), hypercholestrolaemia and smoking. A Transthoracic Echocardiography (TTE) and a Coronary Angiography was planned. Transthoracic Echocardiography revealed the following findings — 1. Left Ventricle (LV) borderline dilated; 2. LV systolic function moderate to severely reduced; 3. Severe posterior wall hypokinesia; 4. Ejection Fraction (EF) of 25 to 35%; 5.Heavily calcified aortic valve with poor cusp excursion. Max systolic gradient=20 mmHg. Cardiac Catheterisation confirmed these findings and showed significant three-vessel coronary artery disease. It was planned to do a Coronary Artery Bypass Graft with / without Aortic Valve Replacement (AVR). Transoesophageal Echocardiography (TOE) was performed (four days after performing the TTE), on the evening prior to the surgery, to assess whether an AVR should be done. It was decided to do a coronary artery bypass graft (CABG) plus AVR. Incidentally a thrombus in the left atrial appendage was found [Figure 1]. Figure 1 TOE image showing the left atrium and the left ventricle and the thrombus in the left atrial appendage On the operation day the patient was taken to the theatre. Along with the usual monitoring for cardiac surgery a transoesophageal echo (TOE) probe was also inserted. Surgery started, sternotomy and pericardiectomy were done and the heart was exposed. Prior to handling of the heart, the presence of a thrombus in the Left Atrial Appendage (LAA) was confirmed by TOE. The surgeons aimed to minimise the manipulation of the heart to avoid the thrombus from dislodging. Aortic cannulation was done and prior to the right-sided cannulation the

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