Background-Neurobehavioral impairment is a common complication of coronary bypass surgery. Cerebral microemboli during cardiopulmonary bypass (CPB) are a principal mechanism of cognitive injury. The aim of this work was to study the occurrence of cerebral embolism during CPB and to evaluate the effectiveness of evidence-based CPB circuit component and process changes on the exposure of the patient to emboli. Methods and Results-M-Mode

The use of transesophageal echocardiography (TEE) for monitoring during cardiac and noncardiac surgery has increased exponentially over the past few decades. TEE has evolved from a diagnostic tool to a monitoring device and a procedural adjunct. The close proximity of the TEE transducer to the heart generates high-quality images of the intracardiac structures and their spatial orientation. The use of TEE in noncardiac and critical care settings is not well studied, and the evidence of the benefits of its use in these settings is lacking. Despite the widespread availability of TEE equipment in US hospitals, less than 30% of anesthesiologists are formally trained in the use of perioperative TEE. In this review, the safety and indications of TEE are reviewed and detailed analysis of the best available evidence in this regard is presented. Landmark trials evaluating the use of TEE and its therapeutic impact in noncardiac surgical setting are critically reviewed. This article details recommendations to familiarize anesthesiologists with TEE technology to exploit it to its fullest potential to achieve better patient monitoring standards and eventually improve outcome. Training of greater numbers of anesthesiologists in TEE is needed to increase awareness of the indications and contraindications. Until relatively inexpensive TEE equipment is available, the initial cost of equipment acquisition remains a significant prohibitive factor limiting its widespread use.

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The authors report the case of a patient with symptomatic early bioprosthetic mitral valve deterioration in the setting of calcium supplementation. This was further complicated by a large left atrial thrombus despite supratherapeutic anticoagulation and a previously oversewn left atrial appendage. As mechanical valves are less predisposed to calcification in comparison with bioprosthetic implants, the patient underwent a mechanical mitral valve replacement in addition to a left atrial thrombectomy.