A 53-yr-old woman with a left ventricular assist device (LVAD), placed 4 mo before admission for idiopathic dilated cardiomyopathy, was awaiting heart transplantation. She was found unresponsive at home with low cardiac output from her LVAD. No signs of fractures or thoracic bruising were present and she did not require chest compressions for resuscitation. During transport to the hospital, she was tracheally intubated, started on inotropic drugs, and transferred directly to the operating room on arrival to the hospital for surgical evaluation.Transesophageal echocardiography (TEE) was performed in the operating room to evaluate the patient's critical condition. TEE demonstrated a fluid collection adjacent to the right ventricle (RV) in the midesophageal four-chamber view at 0°and midesophageal long axis view at 87°rotation (Fig. 1, video clip 1; please see video clip available at www.anesthesia-analgesia.org). The LVAD inflow cannula in the left ventricle did not show any signs of obstruction or malpositioning, the LVAD outflow cannula in the aorta was not visible on TEE, although TEE is an ideal technique for evaluating LVAD placement and function. 1 A drain was placed percutaneously via a subxiphoid approach under TEE guidance by visualizing the position of the paracentesis cannula in the fluid cavity. The patient remained hemodynamically unstable with continuing drainage of a large amount of blood. Further inspection on TEE with color flow Doppler revealed a communication between the fluid cavity and the RV (Fig. 2, top). Pulsed wave Doppler identified flow from the RV into the RV dissection cavity (Fig. 2, bottom). Cardiopulmonary bypass was initiated via cannulation of the femoral vessels. During surgical exploration, the RV was found to be dissected in a large portion, producing an intramural pocket. Therefore, the surgical finding confirmed the primary diagnosis made on TEE. The RV was considered irreparable by the surgeon because of the large ventricular dissection in conjunction with extremely friable myocardial tissue. The patient's overall detrimental condition before surgery in conjunction with an irreparable RV resulted in the decision to discontinue cardiopulmonary bypass and declare the patient dead. Postmortem autopsy confirmed the surgical finding of an intramural RV dissection.RV dissection is infrequent, and can result from myocardial infarction, coronary artery balloon angioplasty, thrombolytic therapy, cardiac operation, or chest trauma. 2,3 It may also occur spontaneously with unknown etiology. 4 The differential diagnosis for RV fluid collection includes pericardial hematoma, RV This article has supplementary material on the Web site:www.anesthesia-analgesia.org.

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Over the past decades, echocardiography has undergone a continuous evolution in technology that has promoted its clinical application and acceptance throughout perioperative medicine. These technological advances include improvements in transducer development that permit superior imaging quality and a wider selection of probes for epicardial, epiaortic, and surface echocardiography which can also be used in conjunction with multiplane transesophageal echocardiography. Moreover, the addition of Doppler technology and digital acquisition has secured the role of echocardiography as a valuable and relatively noninvasive diagnostic tool for the assessment of cardiovascular disease and hemodynamic monitoring throughout the perioperative period. Therefore, it has become increasingly important for perioperative physicians to understand the basic principles and underlying fundamental concepts pertaining to the technology and physics of echocardiography, as well as its inherent limitations. The current review outlines the modes and applications of different echocardiographic techniques used in perioperative echocardiography including M-mode, two-dimensional echocardiography, and Doppler assessment of blood flow. In addition, the limitations of these techniques and typical artifacts associated with the perioperative use of echocardiography are described.