Multimedia Library
An Unusual Indication for Precordial Thump: Acute Prosthetic Valve Obstruction
THE 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 Failure
Heart 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 Practice
Perioperative 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 Replacement
Management 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 Ignore
Intracardiac 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 Obstruction
ANAPHYLAXIS 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.D-Transposition of the Great Arteries, the Rastelli Procedure, and its Complications: Management of a Complex Reoperation
DEXTRO-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 Oxygenation
SEVERE 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 Model
The 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.
