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Cardiovascular Anesthesiology: Echo Rounds

Free-Floating Intracardiac Mass After Cardiopulmonary Bypass for Aortic Valve Replacement

Brakke, Tara R. MD, FASE; Agrawal, Ankit; Harden, Kimberly S. MD; Shillcutt, Sasha K. MD, FASE; Montzingo, Candice R. MD, FASE

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doi: 10.1213/ANE.0b013e318230b2c6

A 58-year-old woman presented for aortic valve (AV) replacement (AVR) because of a severely calcified bicuspid AV with a peak gradient of 99 mm Hg and an AV area of 0.58 cm2 on preoperative transthoracic echocardiogram. Consent for publication of this case has been obtained from the patient.

Intraoperative transesophageal echocardiography (TEE) demonstrated a severely calcified AV (valve area 0.56 cm2) measured by continuity equation and peak and mean gradients were verified using continuous-wave Doppler through the AV in the deep transgastric view. Moderate aortic regurgitation was also observed. The left ventricle (LV) was moderately depressed and hypertrophied; LV septal and posterior wall thickness equaled 15 mm. The mitral valve revealed trace regurgitation with moderate mitral annular calcification, including calcification of the leaflets but sparing of the subvalvular apparatus (Video 1, see Supplemental Digital Content 1, Severe calcification of the native AV made it difficult to assess with 2-dimensional echocardiography (Video 1, see Supplemental Digital Content 1, Katz grade V (mobile) atheromatous plaques were noted in the ascending aorta (Video 2, see Supplemental Digital Content 2, Cardiopulmonary bypass (CPB) was instituted using bicaval cannulation, and an LV vent was placed.1 After placement of a bileaflet mechanical AV and closure of the aorta, TEE revealed a perivalvular leak that required repair on CPB. After that repair, a free-floating echodense mass (measuring 4 × 7 mm) was observed within the LV (Video 3, see Supplemental Digital Content 3, The mass was confirmed in multiple imaging planes, including midesophageal (ME) 4-chamber, ME 2-chamber, ME long-axis view, and the transgastric short-axis view. A left atriotomy was made, the LV was irrigated, and a calcific piece of debris consistent with the echo findings was extracted (Figs. 1 and 2). Subsequent TEE was clear of the mass, and the patient was removed from CPB without incident and without neurologic sequelae.

Figure 1
Figure 1:
Transgastric, mid-papillary view showing echodense mass measuring 4 mm by 7 mm. LV = left ventricle.
Figure 2
Figure 2:
Calcific mass removed from left ventricle.


The prevalence of bicuspid AVs is 1%–2% in the general population. Patients with bicuspid valves present with advanced surgical aortic stenosis around the 5th or 6th decade, earlier than patients with senile sclerosis of AVs with normal anatomy. Imaging severely calcified AVs requires multiple 2-dimensional imaging planes, as well as color and spectral Doppler. ME short-axis view and the ME long-axis view of the AV allow assessment of the anatomy, LV outlow tract diameter, degree of calcification, amount of excursion, and doming of the valve leaflets. These views also evaluate the degree of calcification and poststenotic dilation of the ascending aorta. Severe calcification, particularly in the posterior aorta, makes imaging more difficult because of shadowing. Off-axis views enhance the ability to interrogate the valve. Adding color Doppler to the ME long-axis view evaluates the presence of turbulent blood flow in the ascending aorta, indicating a stenotic lesion. Additional pathology or coexisting aortic regurgitation may also cause turbulent blood flow in the long-axis view. Spectral Doppler in the deep transgastric view assesses the AV area via the continuity equation, and also delineates peak and mean gradients across the AV. After replacement, the same echocardiography views used prebypass are used to evaluate new prosthetic valves for valve malfunction, perivalvular leak, valve stenosis, and patient prosthesis mismatch.

Heavily calcified AVs and annuli present many surgical challenges and must be meticulously debrided to ensure that there is no source of emboli and to secure a properly seated valve. Shapira et al. reported a perivalvular leak incidence of 2.2% after mechanical valve replacement in the aortic position requiring return to CPB.2 However, overly aggressive debridement puts patients at risk for supraventricular arrhythmias and heart block.

The echodensity, mobility, and its presence post-CPB in this case made the mass suspicious for calcium arising from the native AV or mitral valve. The ascending aortic arch plaques, although mobile, did not have the same echodense appearance as the mass, making it less likely the source of the embolus. However, calcification at the aortic sinotubular ridge was significant and may have been the origin of the debris. As stated in a previous Echo Rounds by Stechert and London, these calcifications are histologically similar to AV calcifications.3 Mitral annular calcification is a chronic degenerative process of the mitral support structure, and calcified debris from this location was also a possible source. Although mitral annular calcification doubles the risk of a spontaneous stroke, the cause of that association remains uncertain.4 Any manipulation of the mitral annulus during AVR logically increases the risk of embolism.

TEE can help identify potential embolic debris and allow for an intervention to avoid devastating complications. Stroke rate in an AVR is typically <2%; however, the concern for an embolic event increases significantly when a mobile mass is identified on the left side of the heart. Proper evaluation of the LV for any mass requires filling of the heart before removing the aortic cross-clamp and thorough echocardiographic visualization. Although retrieval of the mass may increase bypass time, stroke avoidance is believed to be worth the risk.5


Name: Tara R. Brakke, MD, FASE.

Contribution: This author helped write the manuscript and conduct the study.

Attestation: Tara R. Brakke approved the final manuscript.

Name: Ankit Agrawal.

Contribution: This author helped write the manuscript.

Attestation: Ankit Agrawal approved the final manuscript.

Name: Kimberly S. Harden, MD.

Contribution: This author helped write the manuscript and conduct the study.

Attestation: Kimberly S. Harden approved the final manuscript.

Name: Sasha K. Shillcutt, MD, FASE.

Contribution: This author helped write the manuscript.

Attestation: Sasha K. Shillcutt approved the final manuscript.

Name: Candice R. Montzingo, MD.

Contribution: This author helped write the manuscript.

Attestation: Candice R. Montzingo approved the final manuscript.

This manuscript was handled by: Martin J. London, MD.


Video 1. Midesophageal short- and long-axis views of the aortic valve and midesophageal 4-chamber view obtained before CPB. Moderate mitral annular calcification noted with no intracardiac masses identified.

Video 2. Mobile filamentous debris in ascending aorta. AAo = ascending aorta.

Video 3. Modified midesophageal 2-chamber view and mid-commissural view revealing free-floating intracardiac echodense mass.


1. Katz ES, Tunick PA, Rusinek H, Ribakove G, Spencer FC, Kronzon I. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol 1992;20:70–7
2. Shapira Y, Vaturi M, Weisenberg DE, Raanani E, Sahar G, Snir E, Battler A, Vidne BA, Sagie A. Impact of intraoperative transesophageal echocardiography in patients undergoing valve replacement. Ann Thorac Surg 2004;78:579–84
3. Stechert MM, London MJ. Aortic sinotubular ridge calcification: a common transesophageal echocardiography finding with uncertain implications. Anesth Analg 2009;109:32–4
4. Benjamin E, Plehn J, D'Agostino, Belanger A, Cornai K, Fuller D, Wolf P, Levy D. Mitral annular calcification and the risk of stroke in an elderly cohort. N Engl J Med 1992;327:374–9
5. Maslow A, Lowenstein E, Steriti J, Leckie R, Cohn W, Haering M. Left ventricular thrombi: intraoperative detection by transesophageal echocardiography and recognition of a source of post CABG embolic stroke: a case series. Anesthesiology 1998;89:1257–62
Clinician's Key Teaching Points By Martin M. Stechert, M.D., Kent H. Rehfeldt, M.D., and Martin J. London, M.D.
  • Although infrequently encountered, detection of mobile, intracardiac or intraaortic debris during aortic valve replacement increases the risk of a cerebral embolic event. Such debris can be mobilized from a degenerative valve apparatus or it can be displaced from the aorta and ejected into the systemic circulation once the aortic cross-clamp is removed and circulation restored.
  • The differential diagnosis of a free-floating intracardiac mass includes dislodged valvular or aortic debris, retained surgical materials, and imaging artifact. The echocardiographic features of the mass together with knowledge of preexisting valvular or aortic pathology may aid in correctly identifying the origin of the mass. For example, the presence of acoustic shadowing distal to the mass suggests calcified valvular debris while the disappearance of the mass when viewed in orthogonal planes indicates imaging artifact.
  • In this case, transesophageal echocardiography identified a free-floating mass in the left ventricle after aortic valve replacement. Potential origin of the mass included the aortic valve, the mitral leaflets and annulus, or the aortic sinotubular ridge, all of which were significantly calcified. The echo texture of the mass more closely resembled the degenerative calcification of the aortic and mitral valves, as opposed to the mobile atheromatous plaque or plaque-associated thrombus previously noted in the ascending aorta which displayed a softer tissue reflectance.
  • The echocardiographic finding of a free-floating intracardiac mass in the left heart after cardiopulmonary (CBP) increases the risk of stroke and should prompt surgical removal even if resumption of CPB is required. While this complication may potentially occur during any type of cardiac or aortic instrumentation, the incidence is increased if surgery included manipulation of calcified mitral and aortic valves or an atherosclerotic aorta.
© 2011 International Anesthesia Research Society