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A woman in her 50s presenting for emergent intracranial surgery was discovered to have a large incongruity in blood pressure between her right arm and her other extremities. Intraoperative rescue transoesophageal echocardiography (TOE) revealed a large thromboatheromatous burden in her descending aorta resulting in a functional coarctation. Usually diagnosed via CT imaging, we present what we believe to be the first published case diagnosed intraoperatively using TOE. After the diagnosis was made, blood pressure goals were adjusted to provide sufficient perfusion distally and her surgery was completed otherwise uneventfully.

A 67-year-old man with a history of non-ischaemic cardiomyopathy (ejection fraction 15%–20%) and previous mechanical aortic valve replacement presented for HeartMate II left ventricular assist device (LVAD) implantation due to worsening heart failure symptoms (New York Heart Association III–IV). After redo sternotomy, the aortic valve was closed with a prefashioned occluder device (figure 1). After occluder placement, the aortic cross-clamp was removed and the valve assessed with transoesophageal echocardiography (TOE) to ensure proper closure (figures 2–4, videos 1–3). Once satisfactory closure was confirmed, a HeartMate II LVAD was inserted. Figure 1 Mechanical aortic valve prosthesis occluder constructed of felt, braided polyester sutures, and vascular clips prior to implantation. Figure 2 The mid-oesophageal aortic valve long-axis view confirming complete occlusion/closure of the aortic valve without leaflet motion. Ao, aorta; AV, aortic valve; LA, left atrium; LV, left ventricle. Figure 3 Colour flow Doppler across the left ventricular outflow tract (LVOT) in the mid-oesophageal aortic valve long-axis view confirmed a lack of flow across the LVOT and complete closure of the mechanical valve. Ao, aorta; AV, aortic valve; LA, left atrium; LV, left ventricle. …