A man in his 80s with a history of chronic persistent atrial fibrillation treated with anticoagulation medication, stage II chronic kidney disease, hypertension, and diet-controlled diabetes mellitus presented to the hospital after several days of abdominal pain, constipation, and vomiting. Abdominal radiography demonstrated dilated loops of small bowel and paucity of gas in the colon. A computed tomographic scan of the abdomen confirmed a small-bowel obstruction. Results of basic laboratory testing were remarkable only for elevated levels of serum urea nitrogen and creatinine, which were consistent with the patient’s baseline and a therapeutic international normalized ratio. Chest radiography demonstrated no acute cardiopulmonary process, and an electrocardiogram demonstrated atrial fibrillation at a rate of 114 bpm. On hospital day 2, the patient’s cardiologist was consulted. An echocardiogram was ordered for preoperative evaluation. The echocardiogram was read as revealing moderate to severe left ventricular (LV) dysfunction and an ejection fraction of 30% to 35%, with multiple regional wall motion abnormalities. There was also concern for the possible development of a new LV thrombus. As a result, surgery for small-bowel obstruction was delayed.
Foy AJ, Ting JG. The Harms of an Unnecessary Preoperative EchocardiogramA Teachable Moment. JAMA Intern Med. 2014;174(6):853-854. doi:10.1001/jamainternmed.2014.379