A 64-year-old gentleman with severe aortic stenosis was admitted for surgical aortic valve replacement. A bioprosthetic valve was implanted. Intraoperative transesophageal echocardiogram (TEE) immediately after cardiopulmonary bypass showed a well-seated bioprosthetic aortic valve with trivial intravalvular aortic insufficiency and no perivalvular leaks. The other cardiac valves showed normal function. Normal left ventricular (LV) and right ventricular (RV) systolic functions were noted, with no regional wall motion abnormalities.The patient came off bypass uneventfully, and the chest was closed. At this time, TEE demonstrated interval development of a mass in the posterolateral part of the left atrium, adjacent to the left atrial appendage and left upper pulmonary vein and extending to the coronary sinus ( Figure 1, see online videos 1-3). Consequently, the patient went back on cardiopulmonary bypass for further exploration, during which the surgical team discovered an intramural hematoma with no active hemorrhage. The hematoma was thought to be secondary to surgical trauma. TEE showed that valvular and ventricular function was unchanged.Reports of left atrial intramural hematomas as a complication of cardiac valve surgery are exceedingly rare. The patient exhibited stable hemodynamics, and a conservative approach was deemed appropriate with planned future reassessment by echocardiography. The patient had a benign perioperative course and was discharged home. He was doing well at 4-month follow up. Transthoracic echocardiography at that time showed resolution of the hematoma.Keywords: cardiopulmonary bypass, thoracic surgical procedure, intraoperative complications, left atrium, aortic valve stenosis, transesophageal echocardiography, transthoracic echocardiography, hematoma

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We report persistent postoperative paraplegia on recovery from anesthesia after emergent exploratory laparotomy for large bowel obstruction in a cachectic patient with an abdominal aortic aneurysm. Postoperative cervical, thoracic, and lumbar spine magnetic resonance imaging revealed only cervical spinal stenosis. We hypothesize that intraoperative embolization possibly caused by manipulation of an atherosclerotic aorta, and a brief episode of intraoperative hypotension resulted in spinal cord ischemia. This report highlights the importance of maintaining intraoperative hemodynamic stability and careful handling of the abdominal aorta, especially in underweight patients with an abdominal aortic aneurysm.

We report a unique presentation of an epidural abscess following mild trauma in a patient with asplenia. The patient reported subjective fever and marked pain along the right hip and flank, which are atypical locations for epidural abscess pain. A subsequent urinalysis showed leukocytes, and the diagnosis of an epidural abscess was missed until the patient presented over two weeks later with fever, spinal pain, leg weakness, and urinary incontinence. This report highlights the importance of heightened clinical suspicion of pneumococcal infections in asplenic patients with unexplained subjective fever. Cost-effective yet sensitive tests such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can help guide further investigation of epidural abscesses in such patients. Blood and urine cultures may also be warranted. Early diagnosis of epidural abscesses is essential to ensure improved outcomes.

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