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Echo Rounds

Answer/Explanation

Stephen M. McHugh, MD1; Robert H. Boretsky, MD2; Michael L. Boisen, MD1; Kathirvel Subramaniam, MD MPH3

  1. Clinical Assistant Professor, Department of Anesthesia and Critical Care, University of Pittsburgh, Pittsburgh, PA
  2. Clinical Associate Professor, Department of Anesthesia and Critical Care, University of Pittsburgh, Pittsburgh, PA
  3. Associate Professor, Department of Anesthesia and Critical Care, University of Pittsburgh, Pittsburgh, PA

Question 1. Answer d

Transthoracic echocardiogram (TTE) showed no pericardial effusion, a dilated left ventricle (LV) with severe LV systolic dysfunction (EF 25%–30%), apical and midventricular akinesis, preserved contractility at the base, and possible apical thrombus (Video 1). A patient with anxiety and acute stress with wall motion abnormality not confirming to any coronary artery distribution is suggestive of stress-induced cardiomyopathy.

Question 2. Answer b

It was promptly recognized by focused TTE by the anesthesiologists and it was decided to proceed with the emergent limb saving revascularization procedure. The anesthetic plan was modified to include preinduction placement of a radial artery catheter for continuous hemodynamic monitoring, preparation of vasoactive infusions for immediate administration, and transesophageal echocardiogram (TEE) to confirm the findings and evaluate for the suspected LV thrombus. After uneventful induction of general anesthesia, TEE confirmed the findings of midventricular and apical akinesis with adherent thrombus and preserved basal function. Left superficial femoral artery and tibial artery thrombectomies and four-compartment fasciotomies were completed without incident.

Question 3. Answer d

Postoperative cardiology consultation was obtained, and coronary angiography revealed no significant coronary artery disease (CAD). Absence of significant CAD, myocarditis and pheochromocytoma are prerequisites for the diagnosis of stress-induced cardiomyopathy. Unfortunately, below-the-knee amputation was subsequently required. Metoprolol, lisinopril, and enoxaparin were prescribed and the patient was discharged home after 3 weeks in the hospital.

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