Case report : Post-Operative mitral valve replacement complicating with a large cardiac mass and role of TEE in decision making

Post operative complications are elements of valve surgery which requires early detection. However, these complications are likely to worsen hemodynamic stability requiring quick assessment and management. TTE and TEE imaging are diagnostic modality of choice in detection of cardiac complications. Echocardiography is indicated if there is suspicion based on the onset of new symptoms like new onset of murmur, breathlessness or fever. Therefore patients undergoing valve replacement require careful follow up even when the symptoms do not manifest. Unlike the abovementioned complications, this case had an unusual presentation of hematoma that extrinsically compressed the right atrium with no evidence of pericardial tamponade. Hence we believe a thorough echocardiographic examination through multiple windows postoperatively is essential. The hematoma surrounding the RA was difficult to be distinguished as intrapericardial/extracardiac hematoma from adjacent tissues on TTE which required TEE as guidance for surgeons on table thereby minimizing anticoagulation and need of CPB. This case report provides insights into the importance of TEE and its utility both operatively and postoperatively, aiding surgeons in resolving this dilemma and considering appropriate management. Hence, we believe that TEE-guided re-exploration has enormously guided surgeons in making notable decisions.术后并发症是心脏瓣膜手术中需要早期识别的临床问题。此类并发症可能会加重血流动力学不稳定状态，因此需快速开展评估与处置。经胸超声心动图（Transthoracic Echocardiography, TTE）与经食管超声心动图（Transesophageal Echocardiography, TEE）是检测心脏并发症的首选影像学诊断手段。若患者出现新发杂音、呼吸困难或发热等疑似心脏并发症的症状，则需行超声心动图检查。因此，即便未出现相关临床症状，接受瓣膜置换术的患者也需接受细致的术后随访。与上述并发症不同，本病例表现为罕见的血肿：该血肿对右心房（Right Atrium, RA）造成外源性压迫，但未出现心包填塞征象。因此我们认为，术后通过多切面开展全面的超声心动图检查至关重要。经胸超声心动图难以区分右心房周围血肿属于心包内还是心外膜外血肿，且难以与周围组织鉴别，此时需借助经食管超声心动图为术中外科医师提供引导，以此减少抗凝治疗的需求及体外循环（Cardiopulmonary Bypass, CPB）的使用。本病例报告阐明了经食管超声心动图的重要性及其在术中与术后的应用价值，有助于外科医师解决诊疗困境并制定合理的处置方案。因此我们认为，经食管超声心动图引导下的再次探查术，可为外科医师作出关键性决策提供重要指导。