A Magic Bullet: Bullet Embolism From the Heart to the Femoral Artery

A case study a patient who was emergently evaluated with an intraoperative transesophageal echocardiography after suffering a gunshot wound to the back is provided. This diagnostic examination revealed a left atrium to aorta fistula, due to the path of the bullet through the body. Immediate postoperative imaging with computed tomography revealed that the bullet had embolized to the left femoral artery from which it was later surgically removed. This rare clinical phenomenon of bullet embolization, involving the heart and associated vasculature, is reviewed.

Learning Curve for the Acquisition of 20 Standard Two-Dimensional Images in Advanced Perioperative Transesophageal Echocardiography: A Prospective Observational Study

Background Learning to perform intraoperative transesophageal echocardiography takes time and practice. We aimed to determine the cumulative success rate in the first 20 intraoperative transesophageal echocardiography cases performed by trainee anesthesiologists with no transesophageal echocardiography experience. Methods This prospective observational study included nine anesthesiologists (four cardiovascular and thoracic anesthesia fellows and five short-course perioperative intraoperative transesophageal echocardiography trainees). Overall, 180 studies self-performed by the trainees were reviewed by certified reviewers. A study was considered successful when at least 15 qualified images were collected within 30 minutes. The cumulative success of each trainee was used as a surrogate of a basic two-dimensional intraoperative transesophageal echocardiography learning curve. Results The participants comprised three male and six female anesthesiologists aged 29–43 years with 2–13 years of work experience. Most studies (146/180, 81.11%) were completed within 30 minutes, and the cumulative success rate was 70–90% (average 82.78 ± 6.71%). The average cumulative success rate in the short-course group (85 ± 7.07%) was higher than that in the official cardiovascular and thoracic fellow trainee group (80 ± 7.07%). The recommended caseload for a 75–80% success rate was 14–18 cases (95% confidence interval, 0.675–0.969). Conclusions We recommended a 14–18 caseload for a target success rate of 75–80% in studies performed by trainees with no previous experience. Our findings will enable the development of programs to train anesthesiologists in intraoperative transesophageal echocardiography.

Intraoperative Transesophageal Echocardiography to Monitor for Pulmonary Emboli in a Pediatric Patient Undergoing Undifferentiated Embryonal Sarcoma of the Liver Resection

A minimally invasive monitoring technique, intraoperative transesophageal echocardiography (TEE), has been utilized to provide real-time data on volume status and ventricular function in patients undergoing liver transplantation. In this case, TEE was utilized in an 8-year-old female undergoing undifferentiated embryonal sarcoma of the liver resection to monitor for pulmonary emboli, particularly a saddle embolus. In addition to visualization of cardiac structures, TEE can also be utilized to monitor the liver, lungs, spleen, and kidneys. Monitoring for echocardiographic findings of pulmonary embolism in this high-risk patient was an integral part of effective intraoperative management.

Endovascular rescue for malpositioned frozen elephant trunk into the false lumen

We describe a case of frozen elephant trunk deployment unintentionally malpositioned into the false lumen. An 83-year-old man underwent total arch repair with a frozen elephant trunk for type A acute aortic dissection complicated by mesenteric malperfusion. However, intraoperative transesophageal echocardiography showed expansion of the false lumen in the descending aorta, suggesting a malpositioned frozen elephant trunk into the false lumen. Endovascular fenestration of the dissecting flap and subsequent endograft deployment from the inside of the malpositioned frozen elephant trunk graft to the true lumen of the descending aorta was successfully performed under intravascular ultrasound guidance.