Transesophageal echocardiography (TEE) has become an important part of armamentarium for anesthesiologists in the management of patients undergoing cardiac surgery. Many studies have demonstrated the safety and utility of TEE in cardiac surgery. With advances in hardware and software, easy availability of resources for learning and optimal understanding of image generation and interpretation, many new findings crop up in the operating room (OR) which may have been missed in preoperative transthoracic echocardiography (TTE), leading to necessary changes in planned surgical procedure. In our retrospective analysis of 726 cases in which TEE was performed over the last 1 year, changes in decision was made in 65 (8.9%) of cases. This included 42 unanticipated findings prior to cardiopulmonary bypass and 23 new findings after CPB, requiring revision in 15 cases. With the increasing use and further impending advances of TEE, the number of cases in which surgical decision will be altered may increase in near future. How to cite this article Badamali AK, Madhavan JS, Ghuman BPS, Subash S, Raj R, Mishra A, Mishra A, Arya VK, Kumar B, Jayant A, Shyam KST, Rana SS, Singh H, Mishra A, Kuthe S, Mahajan S, Prasad S, Mathew S, Arora I, Puri GD. Routine Intraoperative Transesophageal Echocardiography: Impact on Intraoperative Surgical Decision Making, a Single Center Interim Analysis. J Perioper Echocardiogr 2013;1(1):16-20.

Iatrogenic mitral valve perforation following aortic valve replacement is a rare complication. We present a case of anterior mitral leaflet perforation following coronary artery bypass grafting (CABG) and aortic valve replacement detected by intraoperative transesophageal echocardiography (TEE). A 57-year-old male patient with preoperative diagnosis of coronary artery disease, sclerodegenerative aortic valve with severe aortic stenosis and mild central mitral regurgitation (MR) underwent CABG and aortic valve replacement. A post bypass TEE in midesophageal long axis view showed an additional MR jet across the body of the anterior mitral leaflet. We present intraoperative TEE images with a discussion on role of TEE in detection of mitral valve perforation and surgical decision making. Abbreviations AVR: Aortic valve replacement C ABG: Coronary artery bypass grafting 2D: Two-dimensional MR: Mitral regurgitation TEE: Transesophageal echocardiography TTE: Transthoracic echocardiography How to cite this article Raj R, Mathew S, Puri GD. Iatrogenic Mitral Valve Perforation following CABG and Aortic Valve Replacement: A Rare Complication detected by Post-bypass Transesophageal Echocardiography. J Perioper Echocardiogr 2014;2(2):75-76.

BACKGROUND Postoperative Junctional Ectopic Tachycardia (JET) remains one of the most common arrhythmias (8%-20%) after paediatric cardiac surgery. JET is associated with hemodynamic instability, longer mechanical ventilation time and longer stays in the Cardiac Intensive Care Unit (ICU). AIM The aim of this study is to evaluate the effect of prophylactic administration of magnesium on the occurrence of postoperative arrhythmias in patients undergoing intracardiac repair for Tetralogy of Fallot and to determine the incidence of hypomagnesaemia in paediatric patients undergoing cardiac surgery who require CPB. METHODS Forty five patients with Tetralogy of Fallot undergoing intracardiac repair were enrolled to receive saline, 25mg/kg and 50mg/kg of Magnesium as three groups intraoperatively. Postoperative ECG monitored for JET and magnesium levels measured. RESULTS Hypomagnesaemia was present in 28% of patients. None of the patients who were administered magnesium developed hypomagnesaemia. The incidence of JET was found to be increased (53.3%) in the placebo group as compared to 13.3% and 6.7% in the groups receiving 25 and 50mg/kg of magnesium (p<0.001). Eleven patients having JET 7 (64%) had hypomagnesaemia and rest of the 4(36%) occurred in patients with normal magnesium levels (p<0.01). The mean mechanical ventilation time and the mean length of ICU stay were both prolonged those with hypomagnesaemia. The mean mechanical ventilation time and length of ICU stay were both prolonged in the patients with JET (p<.001) CONCLUSIONS Hypomagnesemia is one of the factors responsible for JET and in turn with prolonged ICU stay and prolonged mechanical ventilation.

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