Letters to Editor

RT-3D-TEE has ability to demonstrate tumor REFERENCES characteristics in its en-face view, which may be more 1. Asch FM, Bieganski SP, Panza JA, Weissman NJ. Real-time 3-dimensional convincingly appreciated by the operating surgeon echocardiography evaluation of intracardiac masses. Echocardiography than the 2D imaging. It facilitates understanding of 2006;23:218-24. attachments of the myxoma to different parts of the 2. Mehmood F, Nanda NC, Vengala S, Winokur TS, Dod HS, Frans E, et al. Live three-dimensional transthoracic echocardiographic assessment of LA; structural damage to the mitral valve; and degree left atrial tumors. Echocardiography 2005;22:137-43. of free space available for blood flow inside the LA and 3. Culp WC Jr, Ball TR, Armstrong CS, Reiter CG, Johnston WE. Three- across the mitral valve. dimensional transesophageal echocardiographic imaging and volumetry of giant left atrial myxomas. J Cardiothorac Vasc Anesth 2009;23:66-8. Isolated echolucent areas observed on live RT-3D-TEE are consistent with hemorrhage/necrosis in the tumor mass. These findings are typical of a myxoma and the Pulsus alternans after areas of echolucencies correspond to tumor hemorrhages and/or necrosis found on pathological examination of aortic valve replacement: the resected myxomas.[2] This echocardiographic feature Intraoperative recognition of a LA myxoma may be utilized to differentiate it from a hemangioma, which comprises much more extensive and role of TEE and closely packed echolucencies practically involving the whole extent of the tumor mass with relatively DOI:10.4103/0971-9784.62932 sparse solid tissue. Virtual cropping at different sequential levels in the three-dimensional data set Sir, enabled us to demonstrate echolucencies, which was Pulsus alternans (P ) is beat-to-beat variability in not possible on 2D examination. ALT systolic blood pressure, which occurs due to alternating stroke volumes of left ventricle (LV). It is known Major limitations of 2D echocardiography (both to be associated with severe left ventricular TTE and TEE) in examining the LA myxoma are dysfunction.[1,2] Although a large number of factors difficulty in evaluating it from all possible planes and have been implicated in induction of PALT in the operator dependent interpretations of the findings. intraoperative period, it has not been reported to 2DE measurements underestimate the true maximum occur as a result of cardiac handling after aortic valve diameter and tumor size of irregularly shaped replacement (AVR). A 33-year-old male patient was intracardiac tumors like LA myxoma. Although, operated for AVR on cardiopulmonary bypass (CPB). there are reports suggesting utility of RT-3D-TEE in Preoperative transthoracic echocardiography (TTE) volumetric assessment of LA myxomas;[2,3] it has not revealed a dilated left ventricle and severe aortic yet been validated like RT-3d-TTE. Virtual volume regurgitation (AR) with left ventricular ejection fraction estimated using RT-3D-TEE in those reported cases of 25%. After establishment of CPB and cardioplegic arrest, the native aortic valve was excised and replaced was comparable to the volume measured with the with a 23-mm bileaflet prosthetic valve (St. Jude gold standard water displacement. The size of an Medical, USA). The patient was weaned from CPB using intracardiac mass (vegetation, tumor, or thrombus) 0.1 mcg/ kg/ minute of epinephrine infusion. A stable is an important predictor for embolic events and for hemodynamic condition was maintained in the period response to treatment. immediately after weaning. TEE examination revealed a global LV hypocontractility with the left ventricular In summary, the intraoperative RT-3D-TEE has a fractional area change of 24% [video 1]. The AV potential role to play in the assessment of LA myxoma. prosthesis worked satisfactorily without any evidence of a paravalvular leak [video 2]. As the heart rate Shrinivas Gadhinglajkar, Rupa Sreedhar decreased to 60/ minute from 84/ minute after cardiac Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical decannulation, atrial pacing (AAI) was started at a rate of Sciences and Technology, Trivandrum, Kerala, India. 90/ minute. When the surgeon started retracting the heart Address for correspondence: Dr. Shrinivas Gadhinglajkar during surgical hemostasis, the systolic BP decreased from Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India. Video available at www.annals.in E- mail: [email protected]

Annals of Cardiac Anaesthesia  Vol. 13:2  May-Aug-2010 181 Letters to Editor

120 mmHg to 70 mmHg. When the heart manipulations Intraoperative transaortic Doppler profile characteristics ceased, the PALT was observed on the monitoring screen of PALT are rarely described in the literature. Contractile with a systolic pressure difference of 30 mmHg between and hemodynamic mechanisms have been proposed to two consecutive beats [figure 1], which lasted for about explain the phenomenon of the PALT.[1,2] The contractile two minutes. The continuous wave Doppler (CWD) tracing mechanism refers to incomplete recovery of contractile recorded across the prosthetic valve in deep transgastric cells, leading to an alternating force of left ventricular long axis (DTG-LAX) view revealed velocity time integrals contraction. The hemodynamic theory [3] is based on (VTI)s of large and small sizes alternating with each other three factors affecting preloading conditions or left [figure 2C, 3 pulsus alternans]. A regular trace ventricular end-diastolic volume (LVEDV): appeared with similar paced rhythm after two minutes, which was accompanied with a regular systolic ejection 1. Duration of the diastole: The diastolic filling time [figure 2A]. We also observed a transient increase followed of consecutive beats determines the end-diastolic by a progressive decrease in the size of VTIs during volume. As the diastolic interval preceding a smaller positive pressure breathing, when the left atrial pressure beat is short, the resultant LVEDV would be lesser was 3 mmHg [figure 2B]. The surgeon was requested to than that of a larger beat, which succeeds a longer minimize the phenomenon of alternans as it was seen repeatedly on cardiac manipulation. The alternans did not occur after the closure of sternum. Tracheal extubation Table 1: Intervals for components of different doppler beats was carried postoperatively after six hours of elective Period on a CWD Regular Larger Smaller ventilation. His postoperative recovery was uneventful. profile beat beat of beat of pulsus pulsus We viewed the AV CWD profile off-line and measured RR alternans alternans intervals and atrial pacing signal-to-R wave intervals on Interval between ECG 0.661 0.661 0.661 consecutive R waves ECG, which remained constant during successive cardiac (seconds) cycles of regular beats and beats during PALT [figures Interval between ECG 0.229 0.229 0.229 3, 4]. CWD for a beat was considered as pacing signal to R wave (seconds) interval between onsets of systolic ejection of that beat Duration of systolic 0.223 0.229 0.216 and the next beat. The duration of CWD cardiac cycles ejection (seconds) also was constant for regular and PALT beats. The systolic Interval between 0.439 0.432 0.445 ejection phase lasted longer in the bigger beat of PALT end-systole of a beat than the smaller one. On the contrary, the remaining to commencement of systole of a succeeding cardiac cycle interval was longer for the smaller beat beat (seconds) than the larger beat [figure 4]. Characteristically, the Duration of Doppler 0.662 0.661 0.661 period between the AV prosthetic end-systolic excursion cardiac cycle (seconds) preceding and following a large beat was longer than Duration between AV 0.661 0.675 0.648 that between a smaller beat. Their addition, however, excursion preceding was equal to the summation of the period over two and following a beat (seconds) consecutive cardiac cycles [figure 3B]. The Doppler CWD: continuous wave Doppler intervals of different beats are summarized in table 1.

Figure 1: A snapshot from the monitoring screen showing PALT with a large beat Figure 2: Transaortic CWD flow profile is recorded during three separate events. (white arrow) and a small beat (black arrow) alternating with each other. ECG A: VTIs of same magnitude are seen during a regular cardiac beating. The white is showing cardiac rhythm after atrial pacing (White arrow head). The atrium arrow and white arrow head are indicating beginning of systolic ejection and was paced at a rate of 90/ minute. Abbreviations: - PALT: pulsus alternans; VTI: end-systole respectively. B: The VTIs are becoming progressively smaller in size velocity-time integral; CWD: continuous wave Doppler during a positive pressure breath. C: PALT indicated by alternating in size VTIs.

182 Annals of Cardiac Anaesthesia  Vol. 13:2  May-Aug-2010 Letters to Editor

Figure 3: Time-intervals are recorded off-line from both the CWD flow profile and ECG. Regular: During regular cardiac ejection, the intervals A and B (aortic valve Figure 4: CWD cardiac cycles for different beats, which constituted an ejection systolic excursions) are equal to the intervals E and F (RR intervals). Intervals systolic interval and rest of the interval (interval of diastolic phase + interval C and D (atrial pacing signal-to-R wave) are remaining constant. PALT: In PALT, of isovolemic contraction phase), are seen in the figure. The ejection systolic the intervals G and H (atrial pacing signal-to-R wave) and intervals K and L intervals for a regular beat, a smaller beat of PALT and a larger beat of PALT (R-R intervals) are constant. The period I is less than period J (prosthetic valve are intervals E, A and C respectively. Rests of the intervals for these three types end-systolic excursions related to smaller and larger beats); however, Period I of beats are intervals F, B and D respectively. The duration of a CWD cardiac + J = Period K + L. cycle for a regular beat (E+F) is same as that of a smaller beat (A+B) and a larger beat (C+D) of PALT. diastolic interval. If the diastolic interval is short, the volume will be less and the beat will be smaller premature contractions, hypocalcemia, hypercapnea than the beat following a longer diastolic time under halothane anesthesia[5] and administration of interval. large boluses of fentanyl[6] have been implicated in 2. Left ventricular residual volume: The residual generation of PALT. None of them were involved in our volume at the end-systole contributes to the left scenario. We attribute this alternation in our patient to ventricular filling for the next beat. The end- distortion of ventricles, which impaired the ventricular systolic volume affects the end-diastolic volume of filling. It was not observed after the sternal closure and the following cardiac cycle. A forceful contraction in postoperative period. during a large beat facilitates emptying of the The potential role of TEE in dealing with the PALT has ventricle and reduces the contribution of residual been summarized in table 2. TEE helps in identifying volume to the left ventricular filling preceding a prosthetic valve dysfunction. The transvalvular gradient smaller beat. and cardiac output estimated from the beat of a small VTI 3. Impaired left ventricular diastolic compliance: is expected to be much less than the beat of a high VTI. Inadequate recovery of the left ventricular Keeping this in mind, an echocardiographer should avoid myocardium after a large beat decreases the diastolic performing these calculations in the presence of PALT. filling before the small beat. We observed that duration of systolic ejection phase was more during In summary, the PALT can occur as a result of cardiac a larger beat than a small beat of PALT. Remaining handling during surgical hemostasis after AVR in the portion of the cardiac cycle, which was constituted presence of severe left ventricular dysfunction. At a by the isovolemic relaxation phase, diastolic phase constant Doppler cardiac cycle interval, the systolic and isovolemic contraction phase, was shortened ejection phase of a larger beat lasts longer than the following a large beat. Characteristically, the period between the two consecutive prosthetic valve end- systolic excursions was varying alternately during Table 2: Potential role of intraoperative TEE in dealing with pulsus alternans PALT. It occurred because the smaller beat was • To diagnose pulsus alternans preceded by a short filling interval, which was • To differentiate pulsus alternans from electrical alternans or to opposite for the larger beat. identify concurrent electrical alternans on surface ECG • To discern pulsus alternans from pulsus bigeminus and pulsus The PALT is considered a marker of poor prognosis bisferiens, and systolic arterial flow changes during a positive pressure breath in a failing heart. Appearance of PALT in a heart with • To diagnose associated with mechanical poor baseline function may further de-stabilize systolic alternans performance. Hence an aggressive approach should • To evaluate prosthetic function (mitral, aortic) be adapted toward prevention and early treatment of • To detect factors known to precipitate the incidence of alternans. • To exclude coronary air embolism Hypovolemia, administration of vasodilators, rapid • To assess left ventricular systolic function atrial pacing,[4] dobutamine administration, ventricular • To identify the pathophysiology behind pulsus alternans (possibly)

Annals of Cardiac Anaesthesia  Vol. 13:2  May-Aug-2010 183 Letters to Editor smaller beat. Characteristically, the period between the in femoral vessel with some difficulty due to ongoing AV end-systolic excursion preceding and following a hypotension. Continuous renal replacement therapy was large beat remains longer than that between a smaller started. In due course of therapy the patient recovered beat. The TEE has a potential role in dealing with this from and also renal failure. The dialysis support phenomenon in the intraoperative period. was thus terminated after three days of commencement. The coagulation profile was normal. On removal of the dialysis catheter there was massive gush of arterial blood Shrinivas Gadhinglajkar, Rupa Sreedhar, Aveek Jayant coming out of the insertion site leading to hemodynamic Department of Anesthesia, Sree Chitra Tirunal Institute instability requiring fluid resuscitation and prolonged for Medical Sciences and Technology, Trivandrum, Kerala-695 011, India. manual pressure to achieve hemostasis. Neither limb Address for correspondence: Dr. Shrinivas Gadhinglajkar ischemia nor thromboembolism was encountered after Department of Anesthesia, Sree Chitra Tirunal Institute catheter removal and compression following it. for Medical Sciences and Technology, Trivandrum, Kerala-695 011, India E-mail: [email protected] Usually the physician can easily recognize an arterial puncture by the pulsatile blood flow and the bright REFERENCES red color. In patients with significant hypoxemia and/ or reduced circulatory flow (shock), this distinction 1. Edwards P, Cohen GI. Both diastolic and systolic function alternate may be difficult. Therefore inadvertent arterial in pulsus alternans: A case report and review. J Am Soc Echocardiogr cannulation may be mistaken for a successful venous 2003;16:695-7. cannulation. Though ultrasound guided cannulation 2. Perk G, Tunick PA, Kronzon I. Systolic and diastolic pulsus alternans in severe heart failure. J Am Soc Echocardiogr 2007;20:905,e5-7. has resulted in substantial decrease in procedure related [1-3] 3. Harris LC, Nghiem QX, Schreiber MH, Wallace JM. Severe pulsus complications, this practice is not yet the standard alternans associated with primary myocardial disease in children: of care for want of ultrasound machines. Observations on clinical features, hemodynamic findings: Mechanisms and prognosis. Circulation 1966;34:948-61. Although dialysis may be undertaken safely and 4. Hirashiki, A, Izawa H, Somura F, Obata K, Kato T, Nishizawa T, et al. [4] Prognostic value of pacing-induced mechanical alternans in patients effectively through an arterial catheter; one must with mild-to-moderate idiopathic dilated cardiomyopathy in sinus strive early identification of appropriate site of catheter rhythm. J Am Coll Cardiol 2006;47:1382-9. placement, in order to avoid likely complications 5. Saghaei M, Mortazavian M. Pulsus alternans during general anesthesia due to wrong vessel cannulation. When in doubt, with halothane: Effects of permissive hypercapnia. Anesthesiology we recommend determination of catheter placement 2000;93:91-4. after resuscitation by any one of the methods: 1) 6. Freeman AB, Steinbrook RA. Recurrence of pulsus alternans after fentanyl injection in a patient with aortic stenosis and congestive heart Identifying the vessel cannulated by the pressure failure. Can Anaesth Soc J 1985;32:654-7. measurement on pressure manometer present on the panel of dialysis machine 2) Connecting the catheter to pressure transducer to see the pressure waveform on the hemodynamic monitor; 3) blood gas analysis, of the Emergency sample from the catheter.[5] resuscitative If unintended arterial cannulation occurs, its identification and early removal should be planned, dialysis: The which will avoid complications such as limb ischemia or thromboembolism. Severe bleeding at time of importance of catheter removal as it happened in this case may also be avoided. If subclavian has been cannulated, possible assistance from vascular surgeon may be identification of necessary prior to catheter removal. It is reasonable therefore to conclude that dialysis may be carried out cannulation site without checking the type of the vessel cannulated while carrying out emergency resuscitative dialysis, DOI: 10.4103/0971-9784.62931 however, a check must be carried out soon after a stable situation is reached. Sir, P Bhaskar Rao, Mohan Gurjar, Afzal Azim, A 38-year-old female was admitted to ICU with shock Arvind K Baronia and renal failure requiring urgent venous access for renal Department of Critical Care Medicine, Sanjay Gandhi Post Graduate replacement therapy. A dialysis catheter was inserted Institute of Medical Sciences, Lucknow, UP, India.

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