The clinical assessment of patients with respiratory and circulatory problems can be complex, time consuming and have a high incidence of error. Bedside transthoracic ultrasound (US) is a useful adjunctive test in the evaluation of acutely unstable patients. This case series describes the use of the Focus Assessed Transthoracic Echocardiography (FATE) protocol to diagnose unsuspected pleural collections of fluid and how drainage significantly contributes to the haemodynamic improvement seen in these patients.
A 31-year-old female who was 15 weeks postpartum developed an acute coronary syndrome due to a spontaneous coronary artery dissection and was managed conservatively. Three days later, she rapidly deteriorated with development of acute pulmonary edema and cardiogenic shock. She was intubated, and subsequent imaging revealed severe mitral valve regurgitation with papillary muscle rupture and preserved left ventricular ejection fraction. She was placed on venoarterial extracorporeal membrane oxygenator (VA-ECMO) shortly thereafter and stabilized with improvement in biochemistry. Surgery was planned following further stabilization.Transesophageal echo (TEE) performed, however, demonstrated an absence of forward flow through the aortic valve with serial imaging highly suggestive of aortic root thrombus (Figures 1, 2 and Movies S1, S2) with enlarging, non-uniform echo density within the aortic root. There was no associated spontaneous echo contrast or sludge surrounding this enlarging presumed aortic thrombus. On the basis of these findings, the patient underwent emergent surgery.The preoperative TEE in the operating room showed that the spontaneous echo contrast (SEC) had become more prominent and less mobile (Figures 3, 4 and Movies S3, S4). However, intraoperative TEE showed a typical swirling pattern with gentle manipulation of the aortic root and revealed that the suspected thrombus along the aortic valve was in fact SEC. As a result of the TEE findings, we Aortic root spontaneous echo contrast is a rare but significant finding. We report a 31-year-old female who was placed on venoarterial extracorporeal membrane oxygenation emergently for acute mitral regurgitation secondary to papillary muscle rupture. Following stabilization, subsequent transesophageal echocardiography suggested aortic root thrombus and prompted emergent surgery. However, further inspection with intraoperative transesophageal echocardiography revealed a spontaneous echo contrast which aided us in the intraoperative decision making. K E Y W O R D S extracorporeal membrane oxygenation, intraoperative transesophageal echocardiography, spontaneous echo contrast F I G U R E 1 Transesophageal echo performed in ICU. Midesophageal AV long axis view showing non-uniform echo dense lesion in the aortic root (arrow). Ao = aorta; LA = left atrium; LVOT = left ventricular outflow tract
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