Unrecognized tamponade diagnosed pre-induction by focused echocardiography.

PURPOSE: We report a case of unrecognized cardiac tamponade diagnosed pre-induction by focused transthoracic echocardiography (TTE). The value of focused perioperative TTE, the anesthetic implications of Churg-Strauss syndrome, and the diagnosis of cardiac tamponade are discussed. CLINICAL FEATURES: A 58-yr-old man with a history of severe asymptomatic aortic stenosis presented for elective endoscopic sinus surgery for intractable nasal polyps with recurrent sinusitis. His cardiologist and cardiac surgeon had recommended proceeding with surgery, as aortic valve replacement was not indicated because he was asymptomatic. Prior to induction, a focused TTE was performed by anesthesia in order to document the degree of aortic stenosis, baseline ventricular function, and baseline volume status. This provided a baseline for comparison in case the patient's hemodynamic status should deteriorate intraoperatively. Unexpectedly, the TTE examination revealed cardiac tamponade. After confirmation of the diagnosis by cardiology, urgent pericardiocentesis was performed. A diagnosis of Churg-Strauss syndrome was ultimately made, and the patient was treated with high-dose prednisone therapy. CONCLUSION: Focused TTE has significant clinical utility for the diagnosis and assessment of hemodynamically significant cardiac conditions, particularly in the complex patient where clinical examination is challenging and echocardiographic findings can have immediate management implications.

Brief report: Focused transthoracic echocardiography training in a cohort of Canadian anesthesiology residents: a pilot study.

PURPOSE: Bedside transthoracic echocardiography (TTE) is useful for rapid assessment and treatment of hemodynamic disturbances. Transthoracic echocardiography is not standard in Canadian anesthesia training even though undifferentiated hemodynamic disturbances are common in the perioperative setting. The objectives of this pilot study were to determine 1) whether it is feasible to implement a focused bedside TTE curriculum within core anesthesiology training, 2) whether changes could be detected and quantified following the program of study, and 3) whether curriculum implementation might lead to a significant increase in anesthesiology residents' TTE knowledge-base. METHODS: In this single-centre cohort pilot investigation, anesthesiology residents at Queen's University received focused bedside TTE training during the winter of 2011. The curriculum consisted of four three-hour sessions with both didactic and practical components. Pre- and post-curriculum examinations were administered, and examination results were compared using non-parametric tests. The primary outcome was the difference in mean pre- and post-curriculum examination scores. RESULTS: Ten participants completed pre- and post-curriculum examinations. Four residents were unable to participate in the curriculum but served as controls. Mean pretest scores (out of 50) were similar between the two groups (participants 23.9 vs controls 23.5; P = 0.83, Mann-Whitney U). Mean scores improved by 13.0 points following intervention but improved by only 1.3 points for controls, (P = 0.009, Mann-Whitney U). CONCLUSION: This pilot investigation suggests that implementation of a focused bedside TTE curriculum within anesthesia training is feasible, quantifiable, and effective for increasing anesthesia residents' TTE knowledge-base. This pilot study suggests that further investigation is warranted to determine the impact of this perioperative TTE curriculum.

Transesophageal echocardiography of a dislodged left atrial appendage thrombus and its subsequent surgical removal during coronary artery bypass graft surgery.

Left atrial appendage (LAA) thrombus is a common finding in patients with atrial fibrillation and a major source of emboli that cause strokes. The incidental finding of an LAA thrombus during cardiac surgery is an infrequent finding during routine intraoperative echocardiography, and optimal management is not well defined. A case of a large, incidentally discovered LAA thrombus that became mobile on initiation of cardiopulmonary bypass in a patient undergoing coronary artery bypass graft surgery is presented. Intraoperative transesophageal echocardiography diagnosed the thrombus, discovered its dislodgement from the LAA, and very interestingly demonstrated its surgical removal. This case demonstrates the ability of intraoperative transesophageal echocardiography to alter surgical management and provides support for its routine use in cases in which LAA thrombi are likely.