DK2985_C000 1..28 - AlSharqia Echo Club

Echocardiography During Cardiac Surgery 309the pulmonary arteries is stopped by the lungs which act asa filter. Air in the RUPV is visualized near their junction tothe LA. Pooled air is also found in the superior aspectof the LA near the atrial septum, as well as in the apexof the left atrial appendage (LAA). Intracardiac air mayalso accumulate along the anterior mitral leaflet and inthe apex of the LV near the ventricular septum. Bubblesin the right sinus of Valsalva are easily mobilized andexpelled within several beats of left ventricular contraction(Fig. 13.25).When TEE still reveals the persistence of air in thecardiac chambers, other procedures to remove it aresuggested:1. Filling the cardiac chambers with blood duringsuturing with concomitant application of suctionto the left ventricular or aortic root vent.2. Venting through a balloon inserted into the LV inpatients undergoing mitral valve replacement.3. Allowing the air to flow out of the ascending Aothrough a cardioplegic needle with the patient’shead down.4. Applying hyperinflation of the lungs.5. Aspirating air through fine needles located in theLA or the left ventricular apex.6. Expelling air out of the LV by agitation.7. Administrating cardioplegia into the left ventricularvent.VI. CHANGES IN CARDIAC PHYSIOLOGYAFTER CARDIOPULMONARY BYPASSA. ProtamineAfter CPB, protamine sulfate administration may have anhypotensive effect partly by decreasing SVR. Additionalhuman data also suggest that protamine sulfate may havecardiovascular depressant properties which become apparentin patients with impaired left ventricular function (78).B. Right and Left Ventricular ContractileFunction and Valve FunctionRe-evaluation of right and left ventricular systolic anddiastolic function can be performed as previously(A)(B)LALVAoRV(C)SVC1LA23AoRALV4RV5Figure 13.25 (A, B) Mid-esophageal long-axis view in a 78-year-old woman after mitral valve replacement. Residual air was localisedin the left atrium (LA) with associated acoustic shadowing. (C) Most frequent sites of retained air after cardiopulmonary bypass:1, right upper pulmonary vein; 2, superior aspect of the LA at the atrial septal level; 3, atrial side of the anterior mitral leaflet; 4, right sinusof Valsalva; 5, apex of the left ventricle (LV) near the ventricular septum (Ao, aorta; RA, right atrium; RV, right ventricle; SVC, superiorvena cava). [Fig. C adapted with permission from Bettex and Chassot (77).]