Intraoperative intracardiac echocardiography (ICE) during CABG surgery – A case report

Introduction. Today, in case of severe perioperative hemodynamic instability a multiplane transeosophageal echocardiography (TOE) is recommended to determine underlying pathophysiological causes, e.g. hypovolaemia, reduced myocardial contractility [1, 2]. However, there exist some contraindications to TEE insertion, e.g. eosophageal pathology, and an intraoperative transthoracic approach (TTE) is mostly impossible. Therefore, we here present our first experience of intraoperative ICE usage. Methods & Results. A 72-year old man suffering a 2-vessel coronary artery disease was schedulded for elective CABG surgery. He presented with a reduced left ventricular ejection fraction (LVEF 45%) and had previous eosophageal surgery due to cancer. After uncomplicated induction of general anaesthesia a 9 French introducer was inserted in the right internal jugular vein. The ICE probe (AccuNavs, 8 French) was covered with a sterile plastic sheet, which is normally used for pulmonary artery catheter, and then inserted via the introducer. The plastic sheet was connected to the retainer of the introducer. It was thus possible to advance, withdraw or rotate the probe in an absolute sterile manner. Finally, the probe was connected to a standard echocardiographic hardware system. With this approach we were able to qualitatively estimate a) filling and global contractility of both ventricles, b) the mitral valve, c) the aortic valve [3], d) the tricuspid valve and e) the pulmonary valve. Self-limitating rhythm disturbances when advancing the probe into the right ventricle for evaluation of the left ventricle and the subvalvular apparatus of the mitral valve were the only recognised ICE related side effects. Conclusion. Intraoperative ICE was feasible during CABG surgery. Biventricular function and all valves could be qualitatively examined. ICE thus seems to be an useful alternative in situations where TOE and TTE are impractical.