Patient with posterior mediastinal mass requiring urgent cardiopulmonary bypass.

T HE literature on anesthetic concerns and perioperative care of patients with mediastinal masses has focused almost exclusively on anterior mediastinal masses. Posterior mediastinal masses traditionally have been suggested to carry a low risk of anesthetic implications. We present the case of a patient with a posterior mediastinal mass who experienced hemodynamic and respiratory decompensation upon induction of general anesthesia and required urgent transition to cardiopulmonary bypass (CPB). Our case illustrates the importance of real-time imaging provided by transesophageal echocardiography (TEE) in explaining the etiology of intractable hemodynamic instability and a new finding of significant pericardial and left pleural effusion not seen on preoperative imaging. TEE made clear the urgent need to initiate CPB because it revealed a near total compression of the left atrium, which was obstructing delivery of volume to the left ventricle. In addition, this case demonstrates the inadequacy of “stand-by” CPB and the need for every institution to establish an interdisciplinary team to develop, before surgery, a formal plan for the perioperative care of patients with mediastinal masses.