Authors: Nikhil Kamath, MD – Baptist Health Medical Center, Little Rock AR and Destiny F. Chau, MD - Arkansas Children’s Hospital/University of Arkansas for Medical Sciences, Little Rock, AR


A 16-year-old, 50 kg adolescent male with a history of subvalvular aortic stenosis repaired as a child presents for laparoscopic appendectomy due to perforated appendicitis. Following rapid sequence induction with propofol and succinylcholine, the blood pressure decreases to 64/32 with new onset ST-segment depressions unresponsive to a fluid bolus and epinephrine. Transesophageal echocardiography demonstrates hyperdynamic ventricular contractility along with the following findings shown in the image below. (Image source credit: authors). What is the MOST LIKELY factor contributing to refractory hypotension in this patient?


Figure 1- Deep Transgastric Long Axis View