Unnecessary Echo

I don't know how it is in your echo lab or where you work, but we are pretty busy. We are “flooded” with referrals - sometimes more than we can handle. To be honest we often ask ourselves whether some of these referrals are really necessary. However, here is an example that might make you think differently. This is a true story.

The village of Hallstatt in the Austrian Alps (Dachstein)
- the place where it all happened.
The friend of a colleague
It was one of those days in the lab when the beeper never ceases to go off, patients complain as to why they have to wait, and one case is more complex than the next. Suddenly a famous professor of maxillofacial surgery from our hospital walked into the lab. “A friend of mine is outside the lab and he needs a medical check-up, can you perform a quick echo?” he asked. This was quite clearly no emergency. When I asked the colleague why he needed an echo he told me the following story: his friend Hans (55-years old) likes to go hiking in the Alps together with a group of friends. On one such occasion he witnessed a companion who died suddenly while on the Dachstein mountain. It shocked him so much that he wanted to know whether he was at risk as well. And whom did he contact? His best friend, the maxillofacial surgeon, who brought him straight to me. I never found out why the echo was first on his list. I have the greatest admiration for what surgeons do, but honestly, why should he refer someone directly to an echo without a cardiologist or a physician even seeing him first? But then sometimes it takes more time to argue than to just perform the test. I simply performed the study.
The unexpected
Here is what we found:

The heart itself was normal but when I increased the depth to look at the surrounding entities, I saw a large circular structure posterior to the left atrium. The atrium was somehow compressed. I am sure many of you know what the structure is. But first let me show you a two-chamber view:

Two-chamber view. The dilated aorta is seen posterior
to the left atrium.
The structure can be seen here as well. Its diameter is almost 6 cm. This, quite clearly is the descending aorta. It is apparent that this is an aneurysm.
Looking at the abdominal aorta
We used our 3.25-mHz cardiology transducer to visualize the abdominal aorta as well. The aneurysm extended into the abdominal aorta. Here it measured 5.1 cm. Note that the aneurysm is full of thrombi and atherosclerotic debris.

Cross-section of the abdominal aorta.  

What an incidental finding! I am glad I did the study. Certainly, Hans needed further evaluation. As it turned out, he had many risk factors he was not aware of: hypertension, hyperlipidemia, and type II diabetes. Sure, he might have been referred to echocardiography sooner or later, but I was glad I didn't refuse to perform the study. Further testing revealed his risk factors: hypertension, hyperlipidemia, and a family history. I still believe we have to be rather selective in our referrals, but echo - a universal and important tool - occasionally reveals things that we didn’t look for in the first place.
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