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From the *Department of Anesthesiology, Rush University Medical Center, Chicago, IL; †Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL; ‡Hospital of the University of Pennsylvania, Philadelphia, PA; and §Department of Anesthesiology Montefiore Medical Center, Bronx, NY. Address reprint requests to Kimberly L. Kesner, MD, Department of Anesthesiology, Rush University Medical Center, 1653 W. Congress Parkway, #739, Chicago, IL 60637. E-mail: kim.taub@gmail.com © 2016 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 MITRAL VALVE REPLACEMENT is a commonly performed operation with good success rates. The St. Jude Medical (SJM) prosthesis (St. Jude Medical, St. Paul, MN) has a long record of safety and very low incidence (0.06%) of mechanical failure. While failure of a mechanical valve is rare, most reports occur years after the initial surgery, usually involving an obstruction preventing the valve from fully closing. The authors present a case of immediate intraoperative mechanical mitral valve failure in which a robotically inserted valve did not open upon weaning from cardiopulmonary bypass (CPB).

Transesophageal echocardiography (TEE) assists in the intraoperative decision-making process during cardiac anesthesia and cardiac surgery. Mechanical ventricular support may be necessary to support the circulatory system temporarily or serve as a bridge to heart transplantation. A left ventricular assist device (LVAD) is most commonly used.1 Biventricular failure necessitates the use of an LVAD along with a right ventricular assist device (RVAD) to form a biventricular assist device (BIVAD) (Fig 1). TEE plays a vital role in evaluating effective mechanical assistance of the circulation.1-3 This case describes a BIVAD placement in a patient and shows the roles and limitations of TEE in this scenario.

Objective: To investigate the influence of cardiopulmonary bypass (CPB) and fraction of inspired oxygen (F I O 2 ) on the contrast effect of Optison, a second-generation ultrasound contrast agent, in humans during coronary artery bypass graft (CABG) surgery with transesophageal echocardiography (TEE). Design: Prospective, observational, repeated-measures design. Setting: A single university hospital. Participants: Ten patients who underwent elective CABG surgery. Interventions: A transgastric, midpapillary, short-axis view of the left ventricle was obtained with TEE in the conventional imaging mode. A central injection of 0.3 mL of Optison was administered at 4 stages: after induction of anesthesia at F I O 2 = 1.0 and F I O 2 = 0.43 ± 0.02 and after protamine administration at F I O 2 = 1.0 and F I O 2 = 0.52 ± 0.09. Background-corrected maximal pixel intensity (PImax corr ) in the left ventricle was determined with videodensitometry. To estimate the magnitude of change in pixel intensities, point estimates of differences in PImax corr and their 95% and 99% confidence intervals were calculated after repeated measures analysis of variance. Measurements and Main Results: Decreasing the F I O 2 from 1.0 to corr significantly before or after CPB (mean change = −4.2 and 0.8; SE = 2.0 and 1.9; p = 0.06 and 0.68). Values for PImax corr before and after CPB were not significantly different at either F I O 2 = 1.0 or F I O 2 p = 0.26 and 0.54). Mean differences from initial values ranged from a 10% decrease to a 5% increase. Conclusion: In patients who undergo CABG surgery, the contrast opacification of Optison in the left ventricle is not changed by CPB or alterations in F I O 2 during intraoperative TEE. The application of Optison for enhancement of the endocardial border is not limited during cardiac surgery.

To determine factors that improve intraoperative myocardial perfusion assessment with conventional ultrasound imaging and intravenous ultrasound agents.Prospective cohort study with repeated interventions on each patient.Single university hospital.Fourteen patients scheduled for elective coronary artery bypass graft surgery.Myocardial perfusion was evaluated with contrast transesophageal echocardiography during conventional imaging after central venous injections of the contrast agent Optison (0.3 mL) before cardiopulmonary bypass. Eight patients received the injection during continuous sampling at each of 4 transducer frequency settings (3.5, 5.0, 6.0, 7.0 MHz). In another 6 patients, injections were administered during continuous and intermittent sampling (electrocardiogram-gated) at 3.5 and 5.0 MHz. Generalized estimating equations were used to compare mean responses, with por = 0.05 considered significant.All recorded images were analyzed with off-line videodensitometry. Background-corrected peak pixel intensity (PPI(corr)) and rate of change in pixel intensity (PPI(corr)/T(PPI)) were determined for each injection. PPI(corr) was greater at 3.5 MHz than at 5.0, 6.0, and 7.0 MHz (p0.001). PPI(corr)/T(PPI) was greater at 3.5 MHz than at 5.0 (p0.001), 6.0 (p = 0.003), and 7.0 MHz (p0.001). PPI(corr) was greater for gated than for nongated sampling conditions at 3.5 (p0.05) and 5.0 MHz (p0.05).To optimize myocardial contrast opacification, intraoperative transesophageal echocardiography should be performed with intermittent sampling at a transducer frequency close to the intrinsic frequency of the contrast agent.

A 52-YEAR-OLD African-American woman with coronary artery disease and a past medical history of hypertension and abuse of cocaine and heroin was scheduled for elective coronary artery bypass graft surgery. The coronary angiogram showed severe 2-vessel disease: occlusion of the proximal left anterior descending coronary artery and subtotal occlusion of the mid right coronary artery. Left ventricular systolic function was reported as normal with an ejection fraction of 73% and no regional wall motion abnormalities. The left ventricular end-diastolic pressure was elevated at 27 mmHg. A recent electrocardiogram showed normal sinus rhythm, and an inferior Q-wave myocardial infarction, also noticed on a previous electrocardiogram, could not be ruled out. After uneventful induction of general anesthesia and insertion of a pulmonary artery catheter, transesophageal echocardiography detected a left ventricular outpouching (Figs 1 and 2). Heart rate was 81 beats/min, blood pressure was 133/88 mmHg, and pulmonary artery pressure was 25/12 mmHg. What is the differential diagnosis?