Ecocardiograma transesofágico intraoperatorio: utilidad en reparación de cardiopatías congénitas / Intraoperative transesophagel echocardiogram: Usefulness in congenital heart defects repair

El control ecocardiográfico al momento de la reparación de las cardiopatías congénitas es una estrategia cardiológica para mejorar los resultados quirúrgicos de nuestros pacientes. En este artículo les contamos cómo es el método, qué información nos brinda y cómo influye en la toma de decisiones en el quirófano y en el manejo posoperatorio (AU)

Echocardiographic monitoring at the time of congenital heart defects repair is a strategy to improve the surgical outcomes of our patients. In this article we discuss the method, what information it provides, and how it influences decision-making in the operating room and postoperative management (AU)

Perforación esofágica durante el monitoreo intraoperatorio con ecocardiografía transesofágica. Reparación en el mismo acto quirúrgico / Esophageal injury secondary to transesophageal ecocardiography monitoring and repair

Monitoring with intraoperative Transesophageal Echocardiography (TEE) has proven to be a tool of very high utility for both control of the hemodynamic status, cardiac function and to make new diagnoses. It is a minimally invasive technique and, like any medical procedure, it is not exempt from complications that do not exceed 1%. These range from mild oropharyngeal lesions to the most serious lesion, esophageal perforation. We describe a case of esophageal perforation from the esophagogastric junction to the middle third of the esophagus in the intraoperative period of laparoscopic Nissen surgery. The injury was repaired immediately and the closure of the lesion was verified with pneumatic maneuvers through the nasogastric tube. The patient was discharged after 35 days

El monitoreo con Ecocardiografía Transesofágica intraoperatorio (ETE) ha demostrado ser una herramienta de muy alta utilidad tanto para control del estado hemodinámico, función cardíaca y para realizar nuevos diagnósticos. Se trata de una técica seiinvasiva y como todo procedimiento médico no está exento de complicaciones que no superan al 1%. Estas son desde lesiones leves orofaríngeas hasta la lesión más grave que es la perforación esofágica. Se describe un caso de perforación esofágica con desgrarro de éste desde la unión esofagogástrica hacia el tercio medio del esófago en el íntraoperatorio de cirugía de Nissen laparoscópico. La reparación de la injuria se realizó en forma inmediata y se comprobó con maniobras neumáticas a través de la sonda nasogástrica el cierre de la lesión. La paciente fue dada de alta a los 35 días.

Consenso sobre Ecocardiografia Transesofágica Perioperatória da Sociedade Brasileira de Anestesiologia e do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia / Consensus on Perioperative Transesophageal Echocardiography of the BrazilianSociety of Anesthesiology and the Department of Cardiovascular Image of theBrazilian Society of Cardiology

RESUMO A Sociedade Brasileira de Anestesiologia, pelo Núcleo Vida de Ecocardiografia Transe-sofágica Intraoperatória (ETTI/SBA) juntamente com o Departamento de Imagem Cardiovascularda Sociedade Brasileira de Cardiologia (DIC/SBC), fez uma forc ̧a-tarefa para normatizar afeitura da ecocardiografia transesofágica intraoperatória para os anestesiologistas e ecocar-diografistas brasileiros com base nas evidências científicas da Sociedade dos AnestesiologistasCardiovasculares/Sociedade Americana de Ecocardiografia (SCA/ASE) e da Sociedade Brasileirade Cardiologia.

ABSTRACT Through the Life Cycle of Intraoperative Transesophageal Echocardiography(ETTI/SBA) the Brazilian Society of Anesthesiology, together with the Department of Cardi-ovascular Image of the Brazilian Society of Cardiology (DIC/SBC), createded a task force tostandardize the use of intraoperative transesophageal echocardiography by Brazilian anesthesi-ologists and echocardiographers based on scientific evidence from the Society of CardiovascularAnesthesiologists/American Society of Echocardiography (SCA/ASE) and the Brazilian Society ofCardiology.

Anafilaxias y reacciones alérgicas durante cirugías y procedimientos médicos / Anaphylaxis and allergic reactions during surgery and medical procedures

Las reacciones anafilácticas intraoperatorias son impredecibles, infrecuentes y pueden poner en riesgo al paciente. Tienen una incidencia de 1/10 000 a 1/20 000 produciéndose en la mayoría de los casos por bloqueantes musculares, látex y antibióticos. No hay estadística de las reacciones alérgicas sistémicas durante otros procedimientos médicos. El estudio diagnóstico posterior a una reacción es complejo debiendo incluir toda la medicación utilizada en el procedimiento. En este estudio retrospectivo describimos 15 pacientes, de los cuales 10 tuvieron reacciones anafilácticas en un procedimiento quirúrgico, 2 en endoscopías y 1 en una ecografía transvaginal. Los dos pacientes restantes presentaron una reacción alérgica sistémica durante una ecografía transvaginal y un procedimiento odontológico. Estudiamos los pacientes con toda la medicación utilizada, incluimos látex y, eventualmente, los detergentes y desinfectantes, de haber sido empleados. Tres de las 10 cirugías no pudieron realizarse por desarrollarse la reacción durante la inducción anestésica, en cinco casos debieron interrumpirse y solo en dos se terminaron. Las reacciones posteriores a endoscopías fueron severas, requiriendo internación en terapia intensiva; las reacciones en ecografías transvaginales y procedimientos odontológicos fueron asistidas en emergencias. Los agentes causales en las cirugías incluyeron bloqueantes musculares, látex, cefalosporina, azul patente y ranitidina; en endoscopías el agente causal fue el orto-ftalaldehído (OPA), en las ecografías transvaginales el látex y en el procedimiento odontológico la amoxicilina. El objetivo de este artículo es describir la etiología de las reacciones alérgicas sistémicas y anafilácticas intraoperatorias y en procedimientos médicos, recalcando su gravedad y la necesidad de su identificación.

Anaphylaxis during anesthesia is an unpredictable, severe, and rare reaction. It has an incidence of 1/10 000 to 1/20 000 surgeries. In most series, the responsible drugs include neuromuscular blocking agents, latex, or antibiotics. The frequency and etiology of systemic allergic reactions in other medical procedures are largely unknown. The identification of responsible drugs of anaphylaxis is a complex task, requiring testing of all medications and substances used during surgery. We describe our experience in a retrospective study of 15 patients. Ten subjects developed anaphylaxis during surgery, two in endoscopic studies and one in a trans-vaginal ultrasound. The remaining two subjects, one in a trans-vaginal ultrasound and another during a dental procedure had a systemic allergic reaction. We studied all patients with all medications administered during the procedures, including latex and detergents and disinfectants. Three surgeries had to be suspended at induction of anesthesia, five were stopped incomplete and two were completed. Both patients that presented a reaction during endoscopy required intensive care unit admission and the rest were observed in a Hospital. The responsible drugs during surgery anaphylaxis were neuromuscular blocking agents, latex, patent blue, and ranitidine. Ortho-phthalaldehyde (OPA) was identified during endoscopic studies; latex was responsible in transvaginal ultrasounds; and amoxicillin in the dental procedure. The aim of the present article is to review our experience studying allergic systemic reactions and anaphylaxis during general anesthesia and medical procedures, emphasizing the severity of these reactions and the need for causative drug identification.

Impacto do fentanil associado ao midazolam na sedação para ecocardiograma transesofágico / Impact of fentanyl associated with midazolam in sedation for transesophageal echocardiography / Impacto del Fentanil Asociado al Midazolam en la Sedación para Ecocardiograma Transesofágico

Introdução: O ecocardiograma transesofágico é atualmente uma das principais ferramentas no diagnóstico de diversas alterações cardíacas. Para uma maior segurança e conforto na sua realização, o exame tem sido realizado sob sedação consciente moderada, sendo os benzodiazepínicos os agentes de escolha. Nessa classe de medicamentos, o midazolam é o mais utilizado, todavia não está isento de possíveis complicações relacionadas ao seu uso, como hipóxia, hipotensão, entre outras. Sabemos que grau de sedação é dose-dependente, portanto, quanto menor a dose utilizada, será menor o risco de complicações do procedimento.Objetivo: Verificar o impacto do uso do fentanil na administração endovenosa de midazolam, no intuito de avaliar eficiência de protocolo de sedação de pacientes submetidos a ecocardiograma transesofágico, utilizando ambos os medicamentos. Metodologia: : Estudamos 201 pacientes (idade média de 51,5 anos, 115 homens) submetidos a ecocardiograma transesofágico, com sedação por via endovenosa divididos em dois grupos: Grupo A (n = 89), seguindo protocolo definido com uso de fentanil associado ao midazolam; e Grupo B (n = 112), sem o emprego de fentanil. Comparou-se então a dosagem de midazolam administrada em ambos os grupos. Monitorização adequada dos sinais vitais foi realizada durante todo o procedimento. Resultados: A dose média de midazolam utilizada foide 2,6 ± 1,4 mg no Grupo A e de 4,0 ± 2,7 mg no Grupo B (p < 0,01). A dose de fentanil empregada foi de 66,2 ± 24,8 mcg. Não houve diferença significativa entre idade (p = 0,08) e gênero (p > 0,1) nos grupos estudados. Conclusão: O uso de fentanil na sedação para realização de ecocardiograma transesofágico associado à administração de midazolam permite a administração de uma dose menor desse benzodiazepínico.

Introduction: Transesophageal echocardiography is currently one of the main tools in the diagnosis of various cardiac abnormalities. For greater safety and comfort, the test has been performed under moderate conscious sedation and benzodiazepines were the agents of choice. In this class of drugs, midazolam is the most commonly used, however it is not free of potential complications related to its use, such as hypoxia, hypotension, among others. We know that sedation level is dose-dependent. Therefore, the lower the dose, the lower the risk of complications from the procedure.Objective: To check the impact of fentanyl in the intravenous administration of midazolam in order to assess the sedation protocol efficiency on patients undergoing transesophageal echocardiography using both drugs.Methodology: We have studied 201 patients (mean age 51.5 years, 115 men) who underwent transesophageal echocardiography with intravenous sedation divided into two groups: Group A (n = 89), following the protocol with fentanyl associated with midazolam; and Group B (n = 112) without the use of fentanyl. The dose of midazolam administered in both groups was then compared. Proper monitoring of vital signs was performed throughout the procedure.Results: The mean dose of midazolam used was 2.6 ± 1.4 mg in Group A and 4.0 ± 2.7 mg in Group B (p < 0.01). The dose of fentanyl used was 66.2 ± 24.8 mcg. There was no significant difference between age (p = 0.08) and gender (p > 0.1) in the groups studied. Conclusion: The use of fentanyl in sedation for transesophageal echocardiography associated with administration of midazolam allows the administration of a lower dose of this benzodiazepine.

Introducción: El ecocardiograma transesofágico es actualmente una de las principales herramientas en el diagnóstico de diversas alteraciones cardíacas. Para una mayor seguridad y confort en su realización, el examen ha sido realizado bajo sedación conciente moderada, siendo los benzodiazepínicos los agentes de elección. En esa clase de medicamentos, el midazolam es el más utilizado, sin embargo no está exento de posibles complicaciones relacionadas a su uso, como hipoxia, hipotensión, entre otras. Sabemos que grado de sedación es dosis-dependiente, por lo tanto, cuanto menor es la dosis utilizada, será menor el riesgo de complicaciones del procedimiento.Objetivo: Verificar el impacto del uso del fentanil en la administración endovenosa de midazolam, con el propósito de evaluar eficiencia de protocolo de sedación de pacientes sometidos a ecocardiograma transesofágico, utilizando ambos medicamentos.Metodología: Estudiamos 201 pacientes (edad media de 51,5 anos, 115 hombres) sometidos a ecocardiograma transesofágico, con sedación por vía endovenosa divididos en dos grupos: Grupo A (n = 89), siguiendo protocolo definido con uso de fentanil asociado al midazolam; y Grupo B (n = 112), sin el empleo de fentanil. Se comparó entonces el dosaje de midazolam administrada en ambos grupos. Monitoreo adecuado de los signos vitales fue realizada durante todo el procedimiento. Resultados: La dosis media de midazolam utilizada fue de 2,6 ± 1,4 mg en el Grupo A y de 4,0 ± 2,7 mg en el Grupo B (p < 0,01). La dosis de fentanil empleada fue de 66,2 ± 24,8 mcg. No hubo diferencia significativa entre edad (p = 0,08) y género (p > 0,1) en los grupos estudiados. Conclusión: El uso de fentanil en la sedación para realización de ecocardiograma transesofágico asociado a la administración de midazolam permite la administración de una dosis menor de ese benzodiazepínico

Practice guidelines for perioperative transesophageal echocardiography: Recommendations of the Indian association of cardiovascular thoracic anesthesiologists.

Transoesophageal Echocardiography (TEE) is now an integral part of practice of cardiac anaesthesiology. Advances in instrumentation and the information that can be obtained from the TEE examination has proceeded at a breath-taking pace since the introduction of this technology in the early 1980s. Recognizing the importance of TEE in the management of surgical patients, the American Societies of Anesthesiologists (ASA) and the Society of Cardiac Anesthesiologists, USA (SCA) published practice guidelines for the clinical application of perioperative TEE in 1996. On a similar pattern, Indian Association of Cardiac Anaesthesiologists (IACTA) has taken the task of putting forth guidelines for transesophageal echocardiography (TEE) to standardize practice across the country. This review assesses the risks and benefits of TEE for several indications or clinical scenarios. The indications for this review were drawn from common applications or anticipated uses as well as current clinical practice guidelines published by various society practicing Cardiac Anaesthesia and cardiology . Based on the input received, it was determined that the most important parts of the TEE examination could be displayed in a set of 20 cross sectional imaging planes. These 20 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination. Because variability exists in the precise anatomic orientation between the heart and the esophagus in individual patients, an attempt was made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

Compression of undiagnosed aberrant right subclavian artery during transesophageal echocardiography probe insertion.

Transesophageal echocardiography (TEE) has become an important monitoring tool for the anesthesiologist during repair of intracardiac defects. Although the incidence of reported complications associated with its use is low, one should be careful during the insertion and use of TEE probe, as it may result in potential devastating problems. We present a case of undiagnosed aberrant right subclavian artery (ARSA) that got compressed by the TEE probe during its insertion. It was noticed because of the presence of the right radial artery catheter, else it would have passed unnoticed.

Aporte de volumen en el perioperatorio: ¿debemos modificar nuestro enfoque? / Transesophageal echocardiography to monitor fluid administration during the perioperative period

Background: During the perioperative period an adequate intravascular volume must be maintained. Current recommendations overestimate perioperative volume requirements. Aim: To compare perioperative volume administration using standard monitoring methods or guided by left ventricular filling parameters. Material and Methods: Twenty-four patients subjected to colon resection were randomized to monitoring by electrocardiography, blood and central venous pressure, or by transesophageal echocardiography. In the latter, volume administration was adjusted to maintain basal values of left ventricular end diastolic volume and cardiac index. Results: Patients with the standard monitoring system and transesophageal echocardiographic monitoring received 21.1±12 and 6.3 ± 2 ml/kg/h of fluids during the perioperative period, respectively (p < 0.01). Conclusions: The use of transesophageal echocardiography significantly reduced the perioperative fluid administration.

Segurança da ecocardiografia transesofágica em adultos: Estudo em um hospital multidisciplinar / Safety of transesophageal echocardiography in adults: study in a multidisciplinary hospital / Seguridad de la ecocardiografía transesofágica en adultos: Estudio en un hospital multidisciplinario

FUNDAMENTO: A ecocardiografia transesofágica (ETE) é um exame semi-invasivo amplamente utilizado e seu uso associado a sedativos poderá influenciar a segurança do procedimento. OBJETIVO: analisar aspectos da segurança da ETE associada ao uso de midazolam (MZ) e flumazenil (FL) e a influência de variáveis clínicas na taxa de eventos. MÉTODO: estudo prospectivo com 137 pacientes que realizaram ETE com MZ associado à sedação moderada. Analisamos as seguintes ocorrências: complicações com anestesia tópica, ao uso do MZ e complicações relacionadas ao procedimento. Análises uni e multivariada foram usadas para testar a influência das variáveis clínicas: idade, sexo, acidente vascular cerebral (AVC), miocardiopatia (MP), duração do exame, insuficiência mitral (IM) e dose de MZ. RESULTADOS: todos pacientes (65±16 anos; 58 por cento masculino) completaram o exame. As doses médias de MZ e FL foram de 4,3±1,9 mg e 0,28±0,2 mg, respectivamente. A duração do exame e a fração de ejeção (FE) média foram de 16.4±6.1 minutos e 60±9 por cento, respectivamente. O evento mais comum foi a hipóxia leve (SO2<90 por cento), em 11 pacientes; 3 pacientes (2 por cento) apresentaram hipóxia transitória por obstrução da via aérea superior na passagem da sonda, enquanto 8 (5,8 por cento) apresentaram hipóxia devido ao uso do MZ. Hipotensão transitória (PAS<90 mmHg) ocorreu em 1 paciente (0,7 por cento). A análise multivariada mostrou que insuficiência mitral (IM) importante, MP (FE<45 por cento) e altas doses do MZ (>5mg) tiveram associação com tais eventos (p<0,001). A FE no grupo com MP foi de 40 por cento, ao passo que, no grupo com insuficiência mitral (IM), esse percentual foi de 44 por cento, podendo ser este um fator associado a eventos clínicos neste último grupo. CONCLUSÃO: ETE com sedação tem baixas taxas de eventos. Não se observou eventos graves e não houve a necessidade de interrupção dos exames.

BACKGROUND: TEE is a semi-invasive tool broadly used and its utilization associated to sedatives drugs might to affect the procedure safety. OBJECTIVE: to analyze aspects of TEE safety associated to the use of Midazolan (MZ) and Flumazenil (FL) and the influence of the clinical variables on the event rate. METHOD: prospective study with 137 patients that underwent TEE with MZ associated to moderate sedation. We analyzed the following events: complications related with the topical anesthesia, with MZ use and with the procedure. Uni- and multivariate analyses were used to test the influence of the clinical variables: age, sex, stroke, myocardiopathy (MP), duration of the test, mitral regurgitation (MR) and the MZ dose. RESULTS: All patients (65±16 yrs; 58 percent males) finished the examination. The mean doses of MZ and FL were 4.3±1.9 mg and 0.28±0.2 mg, respectively. The duration of the examination and the mean ejection fraction (EF) were 16.4±6.1 minutes and 60±9 percent, respectively. Mild hypoxia (SO2<90 percent) was the most common event (11 patients); 3 patients (2 percent) presented transient hypoxia due to upper airway obstruction by probe introduction and 8 (5.8 percent) due to hypoxia caused by MZ use. Transient hypotension (SAP<90mmHg) occurred in 1 patient (0.7 percent). The multivariate analysis showed that severe MR, MP (EF<45 percent) and high doses of MZ (>5mg) were associated with events (p<0.001). The EF was 40 percent, in the group with MP and 44 percent in the group with severe MR and it can be a factor associated with clinical events in the last group. CONCLUSION: TEE with sedation presents a low rate of events. There were no severe events and there was no need to interrupt the examinations.

FUNDAMENTO: La ecocardiografía transesofágica (ETE) es un examen semiinvasivo ampliamente utilizado y su uso asociado a sedantes puede influir sobre la seguridad del procedimiento. OBJETIVO: Analizar aspectos de la seguridad de la ETE asociada al uso de midazolam (MZ) y flumazenil (FL) y la influencia de variables clínicas en la tasa de complicaciones. MÉTODO: Estudio prospectivo con 137 pacientes, a quienes se realizó ETE con MZ asociado a la sedación moderada. Analizamos los siguientes eventos: complicaciones con anestesia local, relacionadas al uso de MZ y complicaciones relacionadas con el procedimiento. Se utilizaron análisis uni y multivariados para evaluar la influencia de las variables clínicas: edad, sexo, accidente cerebrovascular (ACV), miocardiopatía (MP), duración del estudio, insuficiencia mitral (IM) y dosis de MZ. RESULTADOS: Todos los pacientes (65±16 años; 58 por ciento masculino) completaron el estudio. Las dosis promedio de MZ y FL fueron de 4,3±1,9 mg y 0,28±0,2 mg, respectivamente. La duración del estudio y la fracción de eyección (FE) promedio fueron de 16.4±6.1 minutos y 60±9 por ciento, respectivamente. El evento más común fue la hipoxia leve (SO2<90 por ciento), en 11 pacientes; 3 pacientes (2 por ciento) presentaron hipoxia transitoria por obstrucción de la vía aérea superior con el pasaje de la sonda, mientras que 8 (5,8 por ciento) presentaron hipoxia debido a la utilización del MZ. Un paciente (0.7 por ciento) padeció hipotensión transitoria (PAS<90 mmHg). El análisis multivariado mostró que IM significativa, MP (FE<45 por ciento) y altas dosis de MZ (>5mg) se asociaron a tales complicaciones (p<0,001). La FE en el grupo con MP fue de 40 por ciento, mientras que, en el grupo con insuficiencia mitral, ese porcentaje fue de 44 por ciento, pudiendo ser éste un factor asociado a complicaciones clínicas en este último grupo. CONCLUSIÓN: ETE con sedación presenta bajas tasas de ...

Intra-operative trans-esophageal echocardiography in congenital heart disease.

Intra-operative trans-esophageal echocardiography (TEE) is an important monitoring and diagnostic tool used during surgery for repair of congenital heart disease. In several studies,TEE has been shown to provide additional intra-cardiac anatomic information. Its ability to be used intra- operatively before and after cardiac repair makes it a unique tool. Before TEE was available for intra-operative use, significant residual abnormalities were frequently not detected. The result was often substantial post-operative morbidity and mortality and sometimes the need for re-operation. According to practice guidelines established by the Society of Cardiovascular Anesthesiologists and the American Society of Anesthesiologists, there is strong evidence for the usefulness of TEE in surgery for congenital heart disease because it significantly improves the clinical outcome of these patients. Before surgical correction, TEE helps confirm diagnosis and spot any additional lesion, while after the surgical correction, it provides baseline parameters for comparison after the surgical correction.

How do I get an optimal image.

Trans-esophageal echocardiography (TEE) is fast becoming an indispensable monitoring and diagnostic modality in cardiac operation rooms. Its convenience and dependability in making important and crucial decisions intra-operatively, during cardiac operative procedures, makes it one of the most useful weapons in a cardiac anesthesiologist's armory. But to make reliable inferences based on intra-operative TEE, creation and development of a proper image is one of the fundamental requirements. The image quality can be affected by factors like patient anatomy, quality of the ultrasound system, and skill of the echocardiographer. Since the first two cannot be changed, in most of cases, we will have to work on the third factor to optimize image quality. A working knowledge of the physics of ultrasound imaging and a sufficient familiarity with the various knobs and controls on the machine will go a long way in helping one acquire an optimum image.

Study of the fate of detectable left atrial thrombi at repeated tranesophagealechocardiography in patients with mitral stenosis

Previous studies did not encourage balloon mitral valvuloplasty [BMV] when left atrial and /or LAA thrombi are present. Patients with LA and/or LAA thrombi are considered at high risk for thromboembolic events. So it is considered a major cause of morbidity and mortality in patients with mitral stnosis. To investigate the fate and stability of LA and/or LAA thrombi under the effect of oral anticoagulation this study included thirty patients with mitral stenosis having LA and/or LAA thrombi detected by TEE. They were subjected to full anticoagulation therapy controlled by INR of 2-3. Repeated TEE were done three and six months later. According to the results of this study the patients were grouped into two main groups: Group 1: included sixteen patients who had dissolved LA or LAA thrombi after anticoagulation therapy. It represented [53.33%] of all cases included in this study. In thirteen patients out of all the total sixteen patients representing group I, the thrombi were dissolved after three months therapy as they had clear LA and LAA in the second TEE study. They represented [81.25%] of group I and [43.33%] of all patients included in this study. In three patients the thrombi were dissolved after six month anticoagulation therapy, they represented [18.75%] of group I and [10%] of the whole patients included in this study. Group II: which included eleven patients [36.66%] all of them had non dissolved thrombi in LA and LAA in spite of six months anticoagulation therapy, three patients were excluded from the study. In conclusion: Complete resolution of LA and/or LAA thrombi occurs in a considerable number of patients [53.33%]. Age of the patients, size of the left atrium and size of LAA or LAA thrombi are considered the only significant factors influencing thrombus resolution. No other clinical or echocardiographic parameters could influence thrombus resolution. Majority of LA andyor LAA thrombi dissolve in the first three months with less incidence of resolution in the next months

Prospective evaluation of the risk of bacteremia induced by transesophageal echocardiography.

BACKGROUND: The incidence of bacteremia induced by transesophageal echocardiography is controversial in the Indian population. This study aimed to find out the occurrence of bacteremia following transesophageal echocardiography. METHODS AND RESULTS: Between February 2000 and January 2001, 47 patients (26 males and 21 females) were enrolled for the study. Their ages ranged from 13 to 61 years (mean: 35 +/- 11.4 years). Patients with prosthetic valves, suspected infective endocarditis and those on antibiotics were excluded. For each procedure, two sets of blood cultures were obtained immediately before and after the procedure. For each blood culture, 10 ml of blood was evenly inoculated into brain-heart infusion broth and biphasic infusion medium and incubated for 7 days. Transesophageal echocardiography was carried out under oropharyngeal anesthesia (xylocaine gel and spray). Two blood cultures taken before the procedure were positive and excluded from the final analysis. Of the remaining 45 patients whose preprocedure blood cultures were sterile, 6 samples (13.3%) were positive after the procedure diphtheroids in 3, micrococci in 2 and aerobic spore formers in 1. CONCLUSIONS: This study demonstrates that the incidence of bacteremia related to transesophageal echocardiography is not insignificant, as reported in previous studies. Though routine antibiotic prophylaxis before transesophageal echocardiography is not advocated, it should be recommended in high-risk patients such as those with prosthetic valves, multivalvular involvement or those with a past history of infective endocarditis.

Ecocardiografia transesofágica: quando indicar / Indications for transesophageal echocardiography

Neste artigo de revisäo, apresentamos a técnica da Ecocardiografia Transesofágica: Indicaçöes, complicaçöes e oito casos ilustrativos retirados dos arquivos de nosso Laboratório

Transesophageal echocardiography.

TEE is the most recent and significant addition to the already existent array of cardiovascular ultrasound imaging techniques. Never before have cardiologists reaped so many benefits from their exploitation of the close anatomic relationship between the heart and esophagus, and never before has there been such a close co-operation and imparting of expertise between gastroenterologists and cardiologist. TEE consists of two-dimensional cardiac and vascular imaging via the esophagus by a flexible echoscope which contains a phased-array mono- or biplane transducer (5MHz) mounted on its distal end. It completely bypasses the transthoracic acoustic impedance and thereby provides superior resolution. TEE requires training of a cardiologist by a gastroenterologist in safe insertion and handling of the echoscope necessary for imaging. The indications and contraindications of TEE have been quickly defined in view of the past TTE and upper gastrointestinal endoscopic experience (ref. Tables 1 and 2). Our own and others experience indicate that only 8%-10% of the indicated TTE studies require supplementary TEE studies either because of inadequate or nondiagnostic TTE imaging for various technical reasons -- e.g., obesity, hyperinflation of lungs, thoracic age abnormalities such as severe pectus excavatum or kyphoscoliosis-or difficult areas of imaging such as left atrial appendage or interatrial septum in the sinus venosus region, aortic dissection, prosthetic valve dysfunction, valvular vegetation, complex congenital heart disease etc. One area in which TEE has made a significant impact is in the intraoperative and perioperative cardiac monitoring for left ventricular function during CABG, repair of intracardiac shunt, cardiac valve repair or replacement and complete removal of intracardiac air before discontinuation of cardiopulmonary bypass. In these contexts, TEE has also proved more practical, convenient and superior to TTE. TEE has also improved the imaging and problem solving in critical care units, particularly in those patients who have recently undergone cardiothoracic surgery and those who are on mechanical ventilation, traditionally the two clinical situations where TTE provides suboptimal results. TEE can safely be performed at the patient's bedside in these units. Refinement and miniaturizing of the transesophageal echoscope (5MHz, small, 6 to 8-mm circumference) has made it possible to perform TEE in infants and young children and improve the diagnosis and surgical management of both cyanotic and acyanotic congenital heart disease.(ABSTRACT TRUNCATED AT 400 WORDS)