LAUSR

February 1, 2019 • Volume 12 • Number 3 cases-anesthesia-analgesia.org 85 Copyright © 2018 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000870 An asymptomatic 50-year-old woman was known for a cardiac murmur since childhood. A transthoracic echocardiography (TTE) was performed after she received chemotherapy for breast cancer. TTE revealed a left ventricular ejection fraction of 65% and a doublechambered right ventricle (DCRV) with an intracavitary peak gradient of 127 mm Hg and a mean of 73 mm Hg. A perimembranous ventricular septal defect (VSD) with left to right shunt and mild aortic regurgitation was also noted (Supplemental Digital Content 1, Video 1, http://links.lww. com/AACR/A213). Preoperative cardiac catheterization revealed a 90% stenosis of the left anterior descending coronary artery and a peak systolic pressure gradient of 60 mm Hg from the right ventricular (RV) apex to the RV outflow tract (RVOT; RV apex pressure, 93 mm Hg, RVOT pressure, 33 mm Hg) with a pulmonary-to-systemic shunt ratio of 1.6. Written informed consent for publication was obtained from the patient. The patient was scheduled for elective resection of the obstructing muscular bundle in the RVOT, closure of the VSD, and coronary artery bypass grafting of the left anterior descending. An intraoperative transesophageal echocardiography (TEE) was performed. RVOT obstruction with notable thickening of the RV anterior and septal walls was clearly identified on midesophageal 4-chamber view and the RV inflow and outflow view (Figure 1). The upper esophageal aortic arch short-axis view demonstrated a normal functioning pulmonic valve with accelerated flow in the RVOT (Supplemental Digital Content 2, Video 2, http:// links.lww.com/AACR/A214). The peak and mean gradient across the RVOT obstruction was 108 and 68 mm Hg, respectively (Figure 2). An 8to 10-mm perimembranous VSD was also confirmed (Figure 3). RV was mildly hypertrophic with normal systolic function. There were mild tricuspid regurgitation and mild aortic insufficiency. After extensive muscular resection, no significant obstruction was seen across the RVOT despite some residual muscle thickening noted on the septal wall (Supplemental Digital Content 3, Video 3, http://links.lww.com/AACR/A215). Direct pressure measurement obtained with a transduced needle inserted into the RV, proximal to the obstruction, demonstrated a systolic pressure of 40 mm Hg which was significantly lower than the pressure obtained preoperatively by right heart catheterization (93 mm Hg). TEE Doppler measurement showed a peak and mean gradient across the RVOT of 14 and 9 mm Hg. The small VSD was repaired. It was located below the right coronary cusp of the aortic valve connecting to the proximal high-pressure RV chamber. The patient had an uneventful postoperative course with TTE done 4 months later showing no residual obstruction.