What Transesophageal Echocardiography Reveals About Intraoperative Iatrogenic Aortic Dissection

Intraoperative iatrogenic aortic dissection is a rare but potentially catastrophic complication of cardiovascular surgery. Although transoesophageal echocardiography (TEE) is considered a key diagnostic tool, its practical value and limitations are not fully appreciated. From the perspective of a TEE observer with more than 30 years of experience, only 7 cases of intraoperative iatrogenic aortic dissection were encountered. Review of these cases yielded 3 practical observations: conventional monitoring modalities may fail to detect developing dissection; the mere presence of a TEE probe does not guarantee recognition; and some forms of aortic wall injury may challenge conventional interpretations. Representative cases demonstrated that dissection can progress without immediate changes in haemodynamic variables or surgical findings, and that clinically important pathology may extend beyond the visible operative field. Additional observations suggested that intraoperative aortic wall injury may present with diverse morphologic appearances depending on the involved layer of the aortic wall. These experiences support considering proactive TEE surveillance during initiation of arterial perfusion and suggest that recognition of otherwise occult pathology may facilitate timely intervention and improve situational awareness during cardiovascular surgery.