When Can Transesophageal and Trans-Thoracic Echocardiography Be Useful in a Non-Cardiac Case?

Abstract

An 83-year-old man with a history of hypertension, hyperlipidemia, and previous transient ischemia attack without any residual neurological deficits is brought to the operating room from the emergency department for hip arthroplasty to repair a traumatic femoral neck fracture. He describes an exercise tolerance of 2–3 blocks that is limited by knee and back pain. His EKG shows sinus tachycardia at 105 beats per minute, left axis deviation, and left ventricular hypertrophy. His chest X-ray demonstrates mild pulmonary congestion, and laboratories reveal a hemoglobin concentration of 8.5 g/dl and normal electrolytes with elevated creatinine of 1.4 mg/dl. His vital signs in the operating room are HR 105, BP 179/80, RR 18, Sp02 of 96 % on 2 L of nasal cannula. After routine induction of anesthesia, the patient remains hypotensive despite aggressive fluid resuscitation of 2 L and frequent boluses of phenylephrine. An arterial line, another large bore IV, and a phenylephrine drip are started with marginally improved blood pressure. An arterial blood gas demonstrates a stable hemoglobin of 8.0 g/dl. The anesthesiologist, who is basic transesophageal echocardiography (TEE) certified, places a TEE probe to evaluate the cause of the persistent hypotension. The TEE examination demonstrates a dilated left atrium and global systolic hypokinesis of the left ventricle with estimated ejection fraction of 30–35 %. Inotropic support is initiated, patient is taken to the catheterization laboratory for coronary angiogram, and the surgery is postponed to after the optimization of his cardiac status.