INTRAOPERATIVE, real-time, three-dimensional transesophageal echocardiography (RT 3D TEE) has become common in addition to conventional two-dimensional (2D) TEE. However, an efficient application of RT 3D TEE to cardiac surgery is still evolving.1  The images were obtained from a 36-yr-old woman with Marfan syndrome during aortic root replacement and mitral valve plasty immediately after aortic unclamping. 2D TEE detected a floating object with acoustic shadow above the mitral valve in the left atrium (arrow, midesophageal mitral commissural view; left).

Because RT 3D TEE revealed that the object was rectangular-shaped and about 6 mm per side (arrow, en-face view of mitral valve; right), it was suspected to be a pledget used as a suspended suture. A second pump run with cardioplegic arrest was performed to remove the object, and the floating object was confirmed to be a pledget.

In the present case, RT 3D TEE played a pivotal role in object identification and surgical decision-making. The 3D image was sufficient to convince the surgeons to remove the object. From this point of view, RT 3D TEE may have some advantages over conventional 2D TEE. First, spatial information from RT 3D TEE allows for easily identifying objects.2  Second, RT 3D TEE facilitates sharing of findings among surgical team members because en-face views of structures obtained by 2D TEE are subject to each observer’s perception.1,2  Given that information sharing is critical for team performance and patient safety in cardiac surgery,3  the role of RT 3D TEE is crucial for making appropriate clinical decisions.

The authors declare no competing interests.

1.
Mahmood
F
,
Jeganathan
J
,
Saraf
R
,
Shahul
S
,
Swaminathan
M
,
Mackensen
GB
,
Knio
Z
,
Matyal
R
:
A practical approach to an intraoperative three-dimensional transesophageal echocardiography examination.
J Cardiothorac Vasc Anesth
2016
;
30
:
470
90
2.
Mackensen
GB
,
Swaminathan
M
,
Mathew
JP
:
PRO editorial: PRO: Three-dimensional transesophageal echocardiography is a major advance for intraoperative clinical management of patients undergoing cardiac surgery.
Anesth Analg
2010
;
110
:
1574
8
3.
Wahr
JA
,
Prager
RL
,
Abernathy
JH
III
,
Martinez
EA
,
Salas
E
,
Seifert
PC
,
Groom
RC
,
Spiess
BD
,
Searles
BE
,
Sundt
TM
III
,
Sanchez
JA
,
Shappell
SA
,
Culig
MH
,
Lazzara
EH
,
Fitzgerald
DC
,
Thourani
VH
,
Eghtesady
P
,
Ikonomidis
JS
,
England
MR
,
Sellke
FW
,
Nussmeier
NA
;
American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research
:
Patient safety in the cardiac operating room: Human factors and teamwork: A scientific statement from the American Heart Association.
Circulation
2013
;
128
:
1139
69