TRANSCARDIAC ECHOCARDIOGRAPHY DURING INVASIVE INTRAMEDULLARY PROCEDURES

We performed transoesophageal echocardiography in 111 operations (110 patients) which included medullary reaming for fresh fractures of the femur and tibia, pathological lesions of the femur, and hemiarthroplas ty of the hip, Embolic events of varying intensity were seen in 97 pro cedures and measured pulmonary responses correlated with the severity of embolic phenomena. Twenty-four out of the 25 severe embolic respons es occurred while reaming pathological lesions or during cemented hemi arthroplasty of the hip and, overall, pathological lesions produced th e most severe responses. Paradoxical embolisation occurred in four pat ients, all with pathological lesions of the femur (21%); two died, In 12 patients large coagulative masses became trapped in the heart, Exte nsive pulmonary thromboembolism with reamed bone and immature clot was found at post-mortem in two patients; there was severe systemic embol isation of fat and marrow in one who had a patent foramen ovale and wi despread mild systemic fat embolisation in the other without associate d foraminal defect, Sequential analysis of blood from the right atrium in five patients showed considerable activation of clotting cascades during reaming.