UNINTENTIONAL FOREIGN BODIES, like surgical sponges, left within the pericardial cavity during cardiac surgery may be associated with morbidity and mortality. A surgical sponge placed posterior to the heart may remain undetected and be the source of persistent hemodynamic instability. The authors report an incident wherein a surgical sponge placed posterior to the heart during cardiopulmonary bypass (CPB) was detected by intraoperative transesophageal echocardiography (TEE) to be the cause of unstable hemodynamics in the post-CPB period.
