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Intraoperative TEE for the management of pulmonary tumour embolism during chondroblastic osteosarcoma resection

[L’ETO peropératoire comme mesure diagnostique d’une embolie tumorale pulmonaire pendant la résection d’un ostéosarcome chondroblastique]

Lee Newkirk, MD^*, Youri Vater, MD^*, Donald Oxorn, MD.CM FRCPC FACC^*, Michael Mulligan, MD and Ernest Conrad, MD

^* From the Departments of Anesthesiology,
Surgery,
and Orthopedic Surgery, University of Washington Medical Center, Seattle, Washington, USA.

Address correspondence to: Dr. Youri Vater, Department of Anesthesiology, University Washington School of Medicine, POB 356540, 1959 Pacific Street, Seattle, WA 98195 USA. Phone: 206-598-4260; Fax 206-598-4544; E-mail: yvater{at}u.washington.edu

Purpose: Chondroblastic osteosarcoma requiring surgical intervention is associated with a high risk of pulmonary tumour embolism. Rapid intraoperative diagnosis with transesophageal echocardiography (TEE) allowed changing the management plan and treatment of a life-threatening pathology.

Clinical features: A 32-yr-old female with right pelvic chondrosarcoma presented for right hemipelvectomy. Two hours into the operation during ligation of the iliac blood vessels the patient’s hemodynamic condition deteriorated and was followed by cardiac arrest. TEE was performed immediately and revealed massive tumour embolism in the right and left pulmonary arteries. Large tumour emboli were removed from the right and left pulmonary arteries after median sternotomy under cardiopulmonary bypass and moderate hypothermia. The hemipelvectomy was completed on the next day after fluid and inotropic agent resuscitation. An inferior vena cava filter was placed below the renal veins. The patient was discharged from hospital ten days after the surgery.

Conclusion: This case report illustrates the important role TEE can play in the early diagnosis and subsequent surgical treatment of noncardiac emergencies. Intraoperative TEE can have a significant impact on the decision making process in life threatening emergencies.