Harnessing the heart

Do you “professionally put people to sleep”? Are you an anesthetist, or do you perform TEE studies and you are often confronted with the question “how good is LVF”? Well here is a lesson for you:

A common story

Ludwig a 78 years old retired locomotive engineer had a minor stroke. Since he also had a history of atrial fibrillation he was sent to our TEE lab to exclude a cardiac source of embolism. It is our policy to always perform a standard transthoracic exam before every TEE. So this is what we did:.

A boring echo



Four and two chamber view showing the typical features of hypertensive heart disease





A different patient?

We prepared the patient for the study and gave him midazolam and lidocaine spray.Unfortunately Ludwig was not so happy that we were pushing the probe down his throat. He was very restless so we added an extra dose of midazolam to calm him down. Everything went smooth from then on. So here is the 4 and 2 Chamber view during the TEE study. Is there anything special?







TEE study demonstrating globally impaired left ventricular function


We did not find a thrombus but look at left ventricular function. Only 30 min after we performed the transthoracic echo! What has happened? The patient does not have coronary artery disease so this is not the result of ischemia.







A simple explanation

Sedation and anesthesia definitely affects contractility! Even though Midazolam is relatively benign it too can cause impairment of LVF. Certainly this is a reversible effect and dose dependant (we gave a dose of 7mg). But it is important to know - especially if you are monitoring function during procedures or surgery. I have encountered numerous situations where it is important to consider this fact.

The key message: TEE and TTE go hand in hand and ejection fraction is a parameter that can be highly variable. What are your thoughts? Any experience? Let us know and post your comment below.
Thomas and the 123Sonography team