DK2985_C000 1..28 - AlSharqia Echo Club

Echocardiography During Cardiac Surgery 289in patients with a history of transient ischemic attacks,stroke, severe peripheral vascular disease, palpable calcificationsin the ascending Ao, calcified aortic knob onCXR, and those older than 60 years (15).Focal areas of moderate to severe atheromas withthickness .3 mm located in the surgical field warrantchange in operative technique to avoid manipulation anddisruption of these lesions (see Figs. 12.13 and 12.14).More aggressive management of severe extensivedisease, especially protuding plaques, is more controversialbecause the changes in technique often involve deephypothermic circulatory arrest and atherectomy or aorticreplacement (15).D. Coronary Sinus CatheterThe technique for inserting the retrograde cardioplegiacatheter from the internal jugular vein has been describedusing the Port-access system (Heartport Inc., RedwoodCity, CA). Transesophageal echocardiography has beenused to visualize the catheter entering the coronary sinusorifice. Fluoroscopy is then used to advance the wire andcatheter to the correct depth. The coronary sinus can bevisualized from a four-chamber view at a lower esophageallevel at 08 in which it appears longitudinally(Fig. 13.4). However, catheter guidance is best performedusing the bicaval view at 1008 (Fig. 13.5 A, B) while locatingthe orifice of the sinus from this plane: as the inferiorvena cava (IVC) is visualized, the probe shaft is rotatedtowards the patient’s left; the coronary sinus can beidentified following its course in the left atrioventriculargroove where it appears in cross-section as a circular structure.A transgastric right ventricular longitudinal view at908 may also be used to visualize the coronary sinus(Fig. 13.5 C, D). Simultaneous visualization of bothSVC and coronary sinus is often facilitated by changingthe viewing angle to 1108 or more. The coronary sinusmust be distinguished from the IVC, which is twice asbroad in diameter, located to the right of the coronarysinus and leads to the liver (18).Insertion of a coronary sinus catheter from the RA ismost often uncomplicated and its position, easily confirmedby palpation and pressure tracing measurements.However, difficult insertion may be anticipated whenFigure 13.4 Coronary sinus (CS) visualization. (A, B) Lower esophageal view at 08: longitudinal view of the CS in the left posterioratrioventricular groove near the gastroesophageal junction. (C) Intraoperative view of the CS in a 56-year-old woman before tricuspidannuloplasty through right atriotomy. The suctionning device is in the CS (LV, left ventricle; RA, right atrium; RV, right ventricle).(Photo C courtesy of Dr. Louis P. Perrault.)