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Figure 1: Advancing the TOE probe from bicaval view shows opening of RLPV and hepatic vein inside the inferior vena cava.
(RA) junction was incised to visualize the RLPV and hepatic vein openings. Both veins were found opening separately inside the IVC. A tanned pericardial patch was used to reroute the RLPV drainage into LA through ASD, which closed ASD as well. The hepatic vein and IVC continued to drain into the RA. TOE navigation after termination of cardiopulmonary bypass showed adequate flow in the rerouted RLPV, hepatic vein [Figure 2], and IVC [Figure 3]. Ten percent to 15% of ostium secundum atrial septal defects are associated with partial anomalous pulmonary venous connections (PAPVC). TOE is highly diagnostic for PAPVC and can obviate angiography. Accurate anatomic diagnosis may influence surgical management.[1] Pericardial patch may obstruct the flow of rerouted pulmonary vein and IVC, which should be ruled out after weaning the patient from CPB.
Shrinivas Gadhinglajkar, Rupa Sreedhar Department of Anaesthesiology Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India Address for correspondence: Dr. Shrinivas Gadhinglajkar, Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, Kerala, India. E-mail:
[email protected]
REFERENCE 1.
Figure 2: Inspection of inferior vena cava at the level of hepatic vein by advancing the probe from bicaval view and changing the sector angle to 70-80°. It reveals the pericardial patch; and unobstructed ßow through RLPV, hepatic vein, and IVC.
Ammash NM, Seward JB, Warnes CA, Connolly HM, O’Leary PW, Danielson GK. Partial anomalous pulmonary venous connection: Diagnosis by transesophageal echocardiography. J Am Coll Cardiol 1997;29:1351-8.
Transoesophageal echocardiography during Senning’s operation The Editor,
Figure 3: ModiÞed bicaval view revealing patch at the inferior vena cava–right atrial junction, with separate ßow via pulmonary vein and IVC
cava (IVC) 1 cm proximal to hepatic venous opening [Figure 1]. This finding was also confirmed by the surgeon after sternotomy. Hence direct anastomosis of RLPV to LA was deferred. On CPB with deep hypothermic circulatory arrest, the IVC-right atrium Annals of Cardiac Anaesthesia ! Vol. 11:2 ! July-Dec-2008
A 3-year-old male, diagnosed as a case of dextroposed transposition of great arteries (d-TGA) preoperatively, underwent Senning’s operation. TOE examination performed after induction of anaesthesia (using Philips Sonos 7500, USA) revealed pulmonary artery (PA) positioned posterior to the aorta [Figure 1] and ventriculoarterial discordance [right ventricle (RV) draining into the aorta and left ventricle (LV) draining into the PA] [Figure 2]. Dynamic left ventricular outflow tract obstruction (LVOTO) was present. Other features were enlarged right atrium and RV; intact interventricular septum (IVS); atrial septal defect (ASD) measuring 141
CMYK 141
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Letters to the Editor
7 mm; and normal position of left atrial appendage and coronary arteries. On cardiopulmonary bypass (CPB), after aortic cross-clamping and cardioplegic arrest, Senning’s operation was performed in three layers. No flow obstruction was observed in systemic venous chamber and pulmonary venous baffle [Figure 3] after
termination of CPB. RV (systemic ventricle) and LV function were good. Senning’s operation is still performed routinely in developing countries. Ventriculoarterial discordance; bulging of IVS toward LV; and the position of PA parallel and posterior to the aorta (double-barrel appearance) are important features associated with d-TGA. During Senning’s operation, a baffle is created in the atrium, which redirects systemic venous flow to LV and pulmonary venous flow to RV. Obstruction to the pulmonary and systemic venous pathway[1] may occur postoperatively, which should be ruled out in the post-CPB period. TOE is indicated for the evaluation of intra- or extra-cardiac baffles[2] and ventricular function following the Senning’s procedure.
Shrinivas Gadhinglajkar, Rupa Sreedhar Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India Figure 1: ModiÞed right ventricle inßow-outßow view showing pulmonary artery posterior to the aorta.
Address for correspondence: Dr. Shrinivas Gadhinglajkar, Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, Kerala, India. E-mail:
[email protected]
REFERENCES 1.
2.
Figure 2: The pulmonary artery is seen posterior and parallel to the aorta (doublebarrel appearance). Right ventricle opening into the aorta and left ventricle draining into the pulmonary artery are also seen in mid-oesophageal long-axis view. Interventricular septum is bulging toward left ventricle (arrow).
Khairy P, Landzberg MJ, Lambert J, O’Donnell CP. Long-term outcomes after the atrial switch for surgical correction of transposition: A metaanalysis comparing the Mustard and Senning procedures. Cardiol Young 2004;14:284-92 Ayres NA, Miller-Hance W, Fyfe DA, Stevenson JG, Sahn DJ, Young LT, et al. Indications and guidelines for performance of transoesophageal echocardiography in the patient with pediatric acquired or congenital heart disease: Report from the task force of the Pediatric Council of the American Society of Echocardiography. J Am Soc Echocardiogr 2005;18:91-8.
Utility of transoesophageal echocardiography during surgery on left atrial myxoma The Editor,
Figure 3: Systemic venous chamber, pulmonary venous bafße, left ventricle and pulmonary artery are seen in long-axis view at ventricular level.
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A 54-year-old female patient presented with dyspnoea on exertion and palpitations for the past 2 years, which had worsened over the last 3 months. A mass in the left atrium (LA), probably a myxoma, was detected on preoperative transthoracic echocardiography. Transoesophageal echocardiography (TOE) performed after induction of anaesthesia revealed a wellAnnals of Cardiac Anaesthesia ! Vol. 11:2 ! July-Dec-2008
