An Unusual Indication for Precordial Thump: Acute Prosthetic Valve ObstructionTHE DELIVERY of a closed-fisted blow to the sternum has been described for more than 100 years as a resuscitative technique. In 1920, Schott reported the use of repetitive sternal blows (known as fist or percussion pacing) in the setting of asystole.1 Subsequent reports emerged in which a single precordial thump (PT) delivered to the middle or lower sternum was occasionally effective in terminating a ventricular tachyarrhythmia.2 Current life support guidelines continue to include PT, albeit accompanied by a weak recommendation and in the limited setting of a witnessed and monitored ventricular tachyarrhythmia when a defibrillator is not immediately ready for use.
Noninvasive Assessment With Transthoracic Echocardiography in End-Stage Heart FailureHeart failure is a common cardiac condition that carries a substantial risk of morbidity and mortality despite advances in management. Echocardiography plays a central role in its diagnosis, elucidation of mechanisms, and detailed hemodynamic analysis. In this E-Challenge, the authors review a few transthoracic echocardiographic findings that yield insights into the hemodynamics.
Rescue Transesophageal Echocardiography: A Narrative Review of Current Knowledge and PracticePerioperative transesophageal echocardiography (TEE) has been part of clinical activity for more than 40 years. During this period, TEE has evolved in terms of technology and clinical applications beyond the initial fields of cardiology and cardiac surgery. The benefits of TEE in the diagnosis and management of acute hemodynamic and respiratory collapse have been recognized in noncardiac surgery and by other specialties too. This natural progress led to the development of rescue TEE, a relatively recent clinical application that extends the use of TEE and makes it accessible to a large group of clinicians and patients requiring acute care.
Transesophageal Echocardiography for Plug Closure After Aortic Arch ReplacementManagement of the left subclavian artery during total arch replacement for acute aortic dissection can be challenging.1 Its deep location in the thorax is difficult to access, and bleeding from the left subclavian artery can be hard to control. Moreover, the left vertebral artery arises from the left subclavian artery and must also be considered. In some cases of dissection, the flap extends into the left subclavian artery, which may cause upper extremity malperfusion.2 In this case, direct ligation of the origin of the left subclavian artery after replacement is preferable; but if this is not possible, endovascular closure can be performed later.
Intracardiac Echogenicity During Cardiopulmonary Bypass in a Vasoplegic Patient Undergoing Coronary Artery Bypass Grafting: To Explore or To IgnoreIntracardiac thrombus formation during cardiopulmonary bypass with full heparinization and adequate activated clotting time is uncommon,1,2 but it can be catastrophic given the potential of intracardiac thrombus to embolize and cause stroke, end-organ infarction, and acute limb ischemia.3 Spontaneous left ventricular thrombus formation during cardiopulmonary bypass in coronary artery bypass grafting is rare. A 62-year-old man with a history of heart failure with progressively declining ejection fraction and multivessel coronary artery disease presented for an elective coronary artery bypass grafting.
Role of Rescue Transesophageal Echocardiography During Intraoperative Anaphylaxis Complicated by Dynamic Left Ventricular Outflow Tract ObstructionANAPHYLAXIS IS SUSPECTED when there is dysfunction in ≥2 organ systems after exposure to a suspected antigen.1 Findings may include urticaria, mucosal edema, gastrointestinal distress, bronchospasm, or hypotension. It also can be diagnosed in adults who have a sudden decrease in systolic blood pressure to <90 mmHg or a ≥30% decrease from baseline blood pressure after exposure to a known allergen. An elevated serum tryptase concentration helps to confirm the diagnosis, as it is a marker for mast cell degranulation.
A Worm in the Heart: One of a Kind!The presence of artifacts during transesophageal echocardiography (TEE) is well-described. The patient was a 21-year-old woman who had previously undergone tetralogy of Fallot repair as an infant and now presented for pulmonic valve replacement due to severe pulmonic regurgitation. She reported a chronic history of recurrent right pleural effusion that required intermittent drainage. Intraoperative TEE showed a slender, writhing structure lateral to the right atrium, which was attached to it at one point (Fig 1; Video 1).
An Additional Structure in the Left Atrium in a Patient Undergoing Aortic Valve Replacement: Artifact or Something Else?A 68-year-old, 42- kg, 149- cm woman presented with chief complaints of dyspnea and palpitations of 4 months' duration. Transthoracic echocardiography revealed severe aortic stenosis due to bicuspid aortic valve disease, with peak and mean gradients of 125 and 85 mmHg, respectively. Coronary angiography was normal. She denied a history of syncopal episodes, transient ischemic attack, or cerebrovascular accident. She was afebrile. Normal sinus rhythm was present. Transesophageal echocardiography (TEE) performed before cardiopulmonary bypass confirmed the preoperative diagnosis.
A Stepwise Approach to Locating the Antrum During Gastric UltrasoundTo the Editor:
D-Transposition of the Great Arteries, the Rastelli Procedure, and its Complications: Management of a Complex ReoperationDEXTRO-TRANSPOSITION OF the Great Arteries (D-TGA) is the second most common cyanotic heart disease,1 with an incidence of 20-to-30 cases per 100,000 live births, amounting to 5%-to-7% of all congenital heart diseases.2 Advances in surgical techniques now permit these patients to survive into adulthood and live a normal life.3 Before the advent of the modern arterial switch surgery and in some forms of complex D-TGA in the current era, these patients commonly undergo multiple surgeries and subsequent revisions due to anatomic limitations of these complex surgical procedures.
NobleStitch Patent Foramen Ovales Closure for Recurrent Strokes in a Patient with COVID-19 on Extracorporeal Membrane OxygenationSEVERE HYPOXEMIA, secondary to the SARS-COV-2 (COVID-19) pneumonia, is a significant contributor to morbidity and mortality.1 Patent foramen ovales (PFOs) can exacerbate hypoxemia through an intracardiac shunt, slowing recovery and worsening outcomes.2-4 Cryptogenic stroke is a complication commonly associated with PFOs; however, current guidelines do not address PFO management in COVID-19 patients who experience recurrent paradoxical emboli, especially in the setting of COVID-19 pneumonia, increased right-sided pressures, and a hypercoagulable state.
A Free-Access Online Interactive Simulator to Enhance Perioperative Transesophageal Echocardiography Training Using a High-Fidelity Human Heart 3D ModelThe clinical uses of perioperative transesophageal echocardiography have grown exponentially in recent years for both cardiac and noncardiac surgical patients. Yet, echocardiography is a complex skill that also requires an advanced understanding of human cardiac anatomy. Although simulation has changed the way echocardiography is taught, most available systems are still limited by investment costs, accessibility, and qualities of the input cardiac 3-dimensional models. In this report, the authors discuss the development of an online simulator using a high-resolution human heart scan that accurately represents real cardiac anatomies, and that should be accessible to a wide range of learners without space or time limitations.
Systolic Nonclosure of the Mitral Valve: Two Left Ventricular Assist Device Patients with Pan-Cardiac Cycle Mitral Valve Opening During Shock StatesLEFT VENTRICULAR assist devices (LVAD) are physiologically unique due to the emptying of the left ventricle (LV) during diastole and systole regardless of aortic valve opening. Echocardiography is, therefore, essential in the management and optimization of patients with LVAD support who are in shock states.1 A well-described and common cause of low flow in LVAD patients is left ventricular suction events. This occurs when the pump flow exceeds mitral inflow, causing a reduction in the size of the LV cavity to a point that the LVAD inflow cannula comes into contact with a ventricular wall, resulting in decreased inflow, ectopy, or sustained ventricular arrhythmias.
A High-Resolution Virtual Reality-Based Simulator to Enhance Perioperative Echocardiography TrainingPerioperative echocardiography requires an advanced understanding of the complex human cardiac anatomy. Currently, conventional training simulators rely on handcrafted heart models that lack accuracy and details and undermine the complexities of the cardiac anatomy, both actual and relative. These simulators are expensive and difficult to transport, creating barriers to widespread implementation. In this report, the authors describe a realistic, virtual reality simulator using high-resolution human heart scans that accurately represent the healthy and pathologic cardiac anatomies in ways that can be standardized and made accessible to a wide range of learners at the cost of a virtual reality headset.
Temporary Epicardial Pacing After Cardiac SurgeryTemporary epicardial pacing frequently is employed after cardiac surgery, and can have a significant impact on a patient's hemodynamics, arrhythmias, and valvulopathies. Given that anesthesiologists often are involved intimately in the initial programming and subsequent management of epicardial pacing in the operating room and intensive care unit, it is important for practitioners to have a detailed understanding of the modes, modifiable intervals, and potential complications that can occur after cardiac surgery.
A Rare ShuntA 12-DAY-OLD girl (weight: 3 kg; height: 50 cm) presented to the authors’ institution in respiratory distress. The child was tachypneic (70 breaths/min), with an arterial oxygen saturation of about 65%-to- 70% on 3 L/min oxygen flow through a nasal cannula, and had signs of severe heart failure (Fig 1). Transthoracic echocardiography revealed situs solitus, levocardia, atrioventricular and ventriculoarterial concordant connections, normal systemic and pulmonary venous drainage, membranous pulmonary atresia, and an intact ventricular septum.
Large Mass in the Left Atrium: The Usual Myxoma or Another Common Etiology?A 64-YEAR-OLD, 82-kg, 183-cm man with heart failure with reduced ejection fraction and a remote history of coronary artery bypass graft surgery, mitral valve replacement, left atrial appendage ligation, and chronic atrial fibrillation treated with warfarin presented to the authors’ institution with worsening dyspnea on exertion, fatigue, and orthopnea. He denied chest pain, fever, chills, and palpitations. The physical examination revealed tachycardia and bilateral pitting edema in the lower extremities.
Where Should We Leave the Wild “Raa Raa” During Cardiopulmonary Bypass?THE PULMONARY artery catheter (PAC), the Raa Raa, the noisy, wild lion in a British stop-motion animated children's television program1 (Fig 1), also known as the Swan-Ganz catheter, is used frequently during cardiac surgery. The PAC might provide clinicians with important information on the preload, afterload, and contractility through the measured and derived parameters for risks stratification and guide perioperative management, particularly in patients with advanced heart failure, pulmonary hypertension, cardiogenic shock, and those who undergo heart and lung transplantation and left ventricular assist device implantation.
A Five-Leaf Clover or an Exceptionally Rare Cause of Severe Aortic Insufficiency?A 56-YEAR-old, 68- kg, 165- cm woman with a history of Crohn's disease presented to the authors’ institution with dyspnea and exercise intolerance of several months’ duration. More recently, her symptoms had progressed to occasional dyspnea at rest. She denied fever, chills, chest pain or pressure, palpitations, orthopnea, paroxysmal nocturnal dyspnea, syncope, and peripheral swelling. The physical examination was notable for a grade III of VI holodiastolic murmur. The electrocardiogram and laboratory analysis were noncontributory.
Transesophageal Echocardiography-Guided Extracorporeal Membrane Oxygenation Cannulation in COVID-19 PatientsA paucity of data supports the use of transesophageal echocardiography (TEE) for bedside extracorporeal membrane oxygenation (ECMO) cannulation. Concerns have been raised about performing TEEs in patients with COVID-19. The authors describe the use and safety of TEE guidance for ECMO cannulation for COVID-19.
A New-Onset Mass in the Right-Sided Atrium in a Child After Cardiac Surgery: Unravelling the DiagnosisA 2-year-old girl (weight: 9 kg, height: 82 cm) underwent an intracardiac repair. Preoperative transthoracic echocardiography revealed situs solitus, levocardia, left atrial isomerism, common atrium due to a large atrial septal defect, absent coronary sinus, 2 separate atrioventricular valves with a trivial left atrioventricular valve regurgitation due to a cleft in the anterior leaflet, and a dilated right ventricle with flattening of the interventricular septum due to volume overload (Fig. 1).
Use of a Video Laryngoscope to Reduce Complications of Transesophageal Echocardiography Probe Insertion: A Multicenter Randomized StudyThe objective of this multicenter study was to test the hypothesis of whether the use of a video laryngoscope (VL) reduces complications related to transesophageal echocardiography (TEE) probe insertion.
Ascending Aortic Pseudoaneurysm Fistulating into the Right Atrium: Vital Diagnosis via Intraoperative Transesophageal EchocardiographyTHORACIC AORTIC PSEUDOANEURYSM is a rare complication after cardiovascular surgery, with an incidence <0.5%.1,2 A 54-year-old man presented with a large pseudoaneurysm (7.6 cm × 6.4 cm) of the proximal ascending aorta after undergoing an aortic valve replacement for bicuspid aortic valve disease (Fig 1). The patient complained of shortness of breath and fatigue. The patient was taken to the operating room for repair. An intraoperative transesophageal echocardiogram demonstrated a contained transmural rupture of the ascending aortic wall with continuous-flow jets from the aortic lumen toward the pseudoaneurysm in the upper esophageal ascending aortic short-axis view (Fig 2A, Video 1).
“Ripples in Water” Effect Detected by Ultrasound During Internal Jugular CatheterizationHerein, I describe an interesting “ripples in water” effect in the right internal jugular vein using ultrasound guidance before its catheterization. A 54-year-old male with severe mitral stenosis, tricuspid regurgitation, pulmonary artery hypertension, and atrial fibrillation, was scheduled for mitral valve replacement. After the induction of anesthesia, the patient was positioned and prepared for a right internal jugular vein catheterization under ultrasound guidance. An ultrasound assessment revealed stasis of blood in the vessel and a “ripples in water” effect in a cross-sectional view (Fig 1; Video 1).
Dilated Cardiomyopathy Phenotype-Associated Left Ventricular Noncompaction and Congenital Long QT Syndrome Type-2 in Infants With KCNH2 Gene Mutation: Anesthetic ConsiderationsLEFT VENTRICULAR noncompaction (LVNC) is encountered on rare occasions as an intrinsic part of an infantile cardiomyopathy.1 In the presence of an underlying genetic cause, LVNC may be associated with left ventricular dilation and ventricular dysfunction.1 MYH7, MYBPC3, TPM1, TAZ, TTN, and NONO genes are known to cause LVNC.2LVNC also may be associated with long QT syndrome (LQTS), torsade de pointes, ventricular fibrillation, etc, in the presence of a KCNH2 gene mutation.2 The incidence of a dilated cardiomyopathy in association with a familial LQTS type-1 caused by KCNQ1 (a voltage-gated potassium channel gene) mutation and an LQTS type-3 due to SCN5A (a sodium channel gene) mutation has been reported.