Transesophageal echocardiography in critically ill patients

Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis

INTRODUCTION

The diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose myocardial damage. A cardiac contusion can be life-threatening if not diagnosed and treated promptly. Several diagnostic tests have been used to evaluate the risk of cardiac complications, but the challenge of identifying patients with contusions nevertheless remains.

AIM OF THE STUDY

To evaluate the accuracy of diagnostic tests for detecting blunt cardiac injury (BCI) and its complications, in patients with severe chest injuries, who are assessed in an emergency department or by any front-line emergency physician.

METHODS

A targeted search strategy was performed using Ovid MEDLINE and Embase databases from 1993 up to October 2022. Data on at least one of the following diagnostic tests: electrocardiogram (ECG), serum creatinine phosphokinase-MB level (CPK-MB), echocardiography (Echo), Cardiac troponin I (cTnI) or Cardiac troponin T (cTnT). Diagnostic tests for cardiac contusion were evaluated for their accuracy in meta-analysis. Heterogeneity was assessed using the I² and the QUADAS-2 tool was used to assess bias of the studies.

RESULTS

This systematic review yielded 51 studies (n = 5,359). The weighted mean incidence of myocardial injuries after sustaining a blunt force trauma stood at 18.3% of cases. Overall weighted mean mortality among patients with blunt cardiac injury was 7.6% (1.4-36.4%). Initial ECG, cTnI, cTnT and transthoracic echocardiography TTE all showed high specificity (> 80%), but lower sensitivity (< 70%). TEE had a specificity of 72.1% (range 35.8-98.2%) and sensitivity of 86.7% (range 40-99.2%) in diagnosing cardiac contusion. CK-MB had the lowest diagnostic odds ratio of 3.598 (95% CI: 1.832-7.068). Normal ECG accompanied by normal cTnI showed a high sensitivity of 85% in ruling out cardiac injuries.

CONCLUSION

Emergency physicians face great challenges in diagnosing cardiac injuries in patients following blunt trauma. In the majority of cases, joint use of ECG and cTnI was a pragmatic and cost-effective approach to rule out cardiac injuries. In addition, TEE may be highly accurate in identifying cardiac injuries in suspected cases.

Critical Care Echocardiography as a Routine Procedure for the Detection and Early Treatment of Cardiac Pathologies

Transthoracic and transesophageal echocardiography are important investigations in the intensive care unit (ICU) to diagnose acute cardiac pathologies and assess the haemodynamic status. Recommendations for critical care echocardiography (CCE) have been published recently, but these still lack an evidence-based foundation. It is not known if performing transthoracic echocardiography (TTE) on a routine basis instead of only when required in acute cases is feasible or clinically useful. In this single-centre prospective observational study, we routinely performed TTE on 111 consecutive non-cardiological, non-cardiothoracic surgical ICU patients in two surgical ICUs in a tertiary care facility. Significant cardiac pathologies were detected in 82 (76.6%) and critical cardiac pathologies in 33 (30.8%) of the 107 patients. The most common critical cardiac pathologies were sPAP > 50 mmHg (19.63%), tricuspid annular plane systolic excursion ≤ 13 mm (9.4%), grade III diastolic dysfunction (8.4%), severe tricuspid valve insufficiency (5.6%) and left ventricular ejection fraction (LV-EF) ˂ 30% (4.7%). Some of the most commonly found cardiac pathologies are not well emphasised in current recommendations and training programs. We observed a progression of the cardiac pathologies previously described in 41 of the patients (91.1%). Patients with echocardiographic abnormalities had a significant survival disadvantage in the ICU. By performing CCE routinely, we observed the range and prevalence of cardiac pathologies that can be detected by echocardiography in critically ill patients. We recommend routine transthoracic CCE in ICU patients for early detection of cardiac pathologies and to help inform early intervention regimens, since cardiac conditions carry a significant survival disadvantage for the ICU patient.

Role of Echocardiography in the Intensive Care Unit: Overview of the Most Common Clinical Scenarios

The intensive care unit (ICU) is among the more important settings in which echocardiography plays a pivotal role. The ease of use, speed of execution, and completeness of information on heart anatomy and function that echocardiography is able to provide makes this tool the perfect diagnostic technique in patients for whom exhaustive information must be quickly obtained by physicians who sometimes lack specific skills in cardiovascular imaging. However, the clinical entities encountered by ICU clinicians are often difficult to distinguish and patient symptoms may not be obvious. This brief review describes three common clinical scenarios that benefit from echocardiography in the ICU, based on symptoms frequently claimed by patients admitted to the ICU. For each symptom we describe the most likely clinical possibilities, underlining the fundamental role that echocardiography plays in the differential diagnosis, and the echocardiographic elements most relevant to obtain the correct diagnosis and to guide treatment.

Core review: physician-performed ultrasound: the time has come for routine use in acute care medicine

The use of ultrasound in the acute care specialties of anesthesiology, intensive care, emergency medicine, and surgery has evolved from discrete, office-based echocardiographic examinations to the real-time or point-of-care clinical assessment and interventions. "Goal-focused" transthoracic echocardiography is a limited scope (as compared with comprehensive examination) echocardiographic examination, performed by the treating clinician in acute care medical practice, and is aimed at addressing specific clinical concerns. In the future, the practice of surface ultrasound will be integrated into the everyday clinical practice as ultrasound-assisted examination and ultrasound-guided procedures. This evolution should start at the medical student level and be reinforced throughout specialist training. The key to making ultrasound available to every physician is through education programs designed to facilitate uptake, rather than to prevent access to this technology and education by specialist craft groups. There is evidence that diagnosis is improved with ultrasound examination, yet data showing change in management and improvement in patient outcome are few and an important area for future research.

Transesophageal Echocardiography–Guided Hemodynamic Assessment and Management

Hemodynamic instability (shock) poses a major challenge in intensive care and is associated with increased mortality, morbidity, length of stay, and costs. The purpose of hemodynamic assessment and management is to detect the cause of hemodynamic instability in a given patient, provide actionable information for the physician, and thus help guide the management and resolution of hemodynamic instability. Although transesophageal echocardiography (TEE) has been the gold standard for hemodynamic assessment and management in the cardiac operating room, the invasive nature of conventional TEE has limited its use as a management tool in intensive care. Instead, one has seen a variety of indirect hemodynamic monitors used, despite now well understood limitations as described in a previous Critical Conversation in the July 2011 issue of this journal. Here we describe the use of TEE in intensive care as well as a new TEE system (the ImaCor hTEE system, ImaCor, Garden City, NY) with a miniaturized (approximately nasogastric tube sized), indwelling probe designed specifically for TEE-guided hemodynamic assessment and management in intensive care (hemodynamic TEE).

Safety of transesophageal echocardiography

Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.

Transthoracic echocardiogram is a useful tool in the hemodynamic assessment of patients with chest trauma

INTRODUCTION

The utility of transthoracic echocardiogram (TTE) in patients on the trauma service is not well defined. The aim of this study was to evaluate the frequency of abnormal echocardiographic findings that would aid in the assessment and management of cardiovascular hemodynamics in patients with chest trauma.

METHODS

A retrospective analysis of all patients who had a TTE on the trauma service at a level 1 trauma center during a 12-month period was performed.

RESULTS

There were 94 patients in the study. TTE was performed after cardiac surgery in 5 patients. One of the 5 patients with prior cardiac surgery was excluded from the study because of poor quality images, and each of the remaining 4 patients showed significant TTE abnormalities. Of the 89 patients without prior cardiac surgery, 38 (43%) had significant TTE findings although 32 (84%) of them had no known history of cardiac abnormalities. A decreased left ventricular ejection fraction (<50%) was found in 18% of all patients, and half of them were hemodynamically unstable. Significant valvular regurgitation or stenosis was found in 31 patients, pulmonary hypertension in 25 patients, left ventricular wall motion abnormalities in 12 patients and pericardial effusion in 11 patients.

CONCLUSION

Significant echocardiographic abnormalities are detected by TTE in patients with chest trauma. Such findings can be used in the hemodynamic assessment and management of unstable patients during their hospitalization and in planning long-term follow-up and management of these patients after discharge from the hospital.

Transesophageal echocardiography and noncardiac surgery

The use of transesophageal echocardiography (TEE) for monitoring during cardiac and noncardiac surgery has increased exponentially over the past few decades. TEE has evolved from a diagnostic tool to a monitoring device and a procedural adjunct. The close proximity of the TEE transducer to the heart generates high-quality images of the intracardiac structures and their spatial orientation. The use of TEE in noncardiac and critical care settings is not well studied, and the evidence of the benefits of its use in these settings is lacking. Despite the widespread availability of TEE equipment in US hospitals, less than 30% of anesthesiologists are formally trained in the use of perioperative TEE. In this review, the safety and indications of TEE are reviewed and detailed analysis of the best available evidence in this regard is presented. Landmark trials evaluating the use of TEE and its therapeutic impact in noncardiac surgical setting are critically reviewed. This article details recommendations to familiarize anesthesiologists with TEE technology to exploit it to its fullest potential to achieve better patient monitoring standards and eventually improve outcome. Training of greater numbers of anesthesiologists in TEE is needed to increase awareness of the indications and contraindications. Until relatively inexpensive TEE equipment is available, the initial cost of equipment acquisition remains a significant prohibitive factor limiting its widespread use.

Importance of transesophageal echocardiography in the critically ill and injured patient

Echocardiography, particularly transesophageal echocardiography (TEE), is a vital diagnostic and monitoring imaging modality for the intensivist. The field of echocardiography spans different venues and pathologies, ranging from surface transthoracic echocardiography and portable hand-held echocardiography, to contrast echocardiography, stress echocardiography, and TEE, among others. Numerous investigations have proven the worth of echocardiography, especially TEE, in the critically ill and injured patient, changing lives with the identification of obvious and subtle cardiothoracic diseases. Because this powerful imaging tool is immediately available and portable, crucial delays in diagnosis are not commonplace; rather than echocardiography, TEE, specifically, should be (and is in some institutions) the standard of care and management in assisting the intensivist in diagnosis of a variety of maladies. The effect of TEE technology is quite formidable, and numerous investigations have borne this out. The therapeutic effect of TEE ranges from 10% to 69%, with the majority of investigations falling into the 60% to 65% range. The diagnostic yield of TEE is far greater, approaching 78%. This article will detail the importance of echocardiography, its efficacy, and its high-yield imaging capability, particularly when compared with other imaging modalities, even transthoracic echocardiography.

Echocardiography for management of hypotension in the intensive care unit

Hypotension is a common problem in critically ill patients. Rapid diagnosis and intervention may prevent this deterioration and improve eventual outcome. Echocardiography may make a critical difference in the rapid diagnosis of both common and uncommon but important causes of hypotension, such as pericardial tamponade. The differential diagnosis for hypotension differs between acutely admitted septic or trauma patients and the chronic patient in the intensive care unit. A better approach to patient evaluation is the performance of a comprehensive evaluation on every patient. A comprehensive examination is less likely to miss an unexpected diagnosis. With practice, a complete examination may be performed in minutes. Preload, contractility, systolic function (global and focal), and assessment of diastolic dysfunction (common cause of congestive heart failure) can be performed quickly. Specific situations like pericardial tamponade, pulmonary embolism, left ventricular outflow tract obstruction, unexplained hypoxemia, and aortic dissection, among others, can all be reliably performed using transesophageal echocardiography. Appropriate training and utilization of this technology will essentially help better manage hypotension in critically ill patients and thereby may improve their outcome. An algorithm to this effect has been suggested, although the same results can be achieved with different algorithms or approaches.

Bedside echocardiography in the assessment of the critically ill

Advances in ultrasound technology continue to enhance its diagnostic applications in daily medical practice. Bedside echocardiographic examination has become useful to properly trained cardiologists, anesthesiologists, intensivists, surgeons, and emergency room physicians. Cardiac ultrasound can permit rapid, accurate, and noninvasive diagnosis of a broad range of acute cardiovascular pathologies. Although transesophageal echocardiography was once the principal diagnostic approach using ultrasound to evaluate intensive care unit patients, advances in ultrasound imaging, including harmonic imaging, digital acquisition, and contrast for endocardial enhancement, has improved the diagnostic yield of transthoracic echocardiography. Ultrasound devices continue to become more portable, and hand-carried devices are now readily available for bedside applications. This article discusses the application of bedside echocardiography in the intensive care unit. The emphasis is on echocardiography and cardiovascular diagnostics, specifically on goal-directed bedside cardiac ultrasonography.

Bedside ultrasonography in the ICU: part 1

Ultrasonography has become an invaluable tool in the management of critically ill patients. Its safety and portability allow for use at the bedside to provide rapid, detailed information regarding the cardiovascular system and the function and anatomy of certain internal organs. Echocardiography can noninvasively elucidate cardiac function and structure. This information is vital in the management hemodynamically unstable patients in the ICU. In addition, ultrasonography has particular value for the assessment and safe drainage of pleural and intra-abdominal fluid and the placement of central venous catheters. A new generation of portable, battery-powered, inexpensive, hand-carried ultrasound devices have recently become available; these devices can provide immediate diagnostic information not assessable by physical examination alone and allow for ultrasound-guided thoracocentesis, paracentesis, and central venous cannulation. This two-part article reviews the application of bedside ultrasonography in the ICU.

Transthoracic echocardiography to identify or exclude cardiac cause of shock

BACKGROUND

Transesophageal echocardiography (TEE) is often still considered the echocardiographic test of choice in the general ICU patient population to establish the presence or absence of cardiac cause of shock, and is often requested and performed as the initial and only echocardiographic test. This premise is based on older studies in which transthoracic echocardiography (TTE) commonly offered inadequate images in ICU patients.

STUDY OBJECTIVES

We hypothesized that current TTE imaging alone is adequate to identify or exclude cardiac cause of shock in the great majority of cases.

METHODS

One hundred consecutive shock cases in which an echocardiogram was requested were prospectively analyzed by two blinded echocardiographers for image adequacy, and the absence or presence of cardiac cause of shock (defined as one or more of the following: severe left ventricular (LV) or right ventricular systolic dysfunction, tamponade, severe left-sided valve disease, or a postinfarction mechanical complication), and compared to a clinical standard of presence/absence of cardiac cause of shock as determined by autopsy, surgery, or objective testing. Shock was defined as systolic BP < 100 mm Hg or fall in BP >/= 25%, and inotrope use or evidence of low output or venous congestion. Cardiac output was determined by the LV outflow tract (LVOT) Doppler method.

RESULTS

Sixty-three percent of cases had a cardiac cause of shock. TTE image quality was adequate in 99% cases. Among the 99% of cases in which the imaging was adequate, the sensitivity of TTE for cardiac cause of shock was 100%, the specificity was 95%, the positive predictive value was 97%, and the negative predictive value was 100%. There were relative contraindications to TEE in 15% of cases. Stroke volume index (15 +/- 6 mL/m(2) vs 31 +/- 7 mL/m(2) [mean +/- 1 SD]; p < 0.001) and cardiac index (1.6 +/- 0.5 mL/min/m(2) vs 2.9 +/- 0.9 mL/min/m(2); p < 0.001) were significantly less in the group with a cardiac cause of shock than in the group with a noncardiac cause of shock.

CONCLUSIONS

In the general critical care population, current TTE imaging identifies the great majority of cardiac causes of shock. TTE should be considered not only the initial, but also the principal echocardiographic test in the critical care environment.

Real-time 3D transesophageal echocardiography

Transesophageal echocardiography (TEE) is an essential diagnostic tool in patients with poor transthoracic echocardiographic windows or when detailed imaging of structures distant from the chest wall is necessary. A real-time 3D TEE probe has been fabricated in our laboratory in order to increase the amount of information available during a transesophageal procedure. The 1 cm diameter esophageal probe utilizes a 2-dimensional, 5 MHz array at its tip with a 6.3 mm diameter aperture, including 504 active channels. The array has a periodic vernier geometry with an element pitch of 0.18 mm, built onto a multilayer flexible (MLF) interconnect circuit. In order to accommodate 504 channels within the device, a 1 m long Gore MicroFlat cable was utilized for wiring the MLF to the corresponding system connectors. Pulse-echo tests in a water tank have yielded a -6 dB bandwidth of 25.3%. Fully connected to the system through 3 m of cable, the probe shows an average 50 omega insertion loss of-85 dB with a standard deviation of 4 dB, as determined through pitch-catch measurements for a sampling of 10 elements. Using the completed 3D TEE probe with the Volumetrics Medical Imaging 3D scanner, real-time volumetric images of in vivo canine cardiac anatomy have been acquired, displaying atrial views, mitral valve function and interventional catheter guidance.

The use and safety of transoesophageal echocardiography in the general ICU -- a minireview

BACKGROUND

The efficacy of transoesophageal echocardiography (TEE) has been evaluated predominantly in medical and cardiac surgical ICUs. This article reviews the pertinent literature and evaluates the impact of TEE in a general surgical ICU.

METHODS

Twenty studies on TEE in the ICU were evaluated for complications, indications, diagnostic, therapeutic, and surgical impact on patient management. Diagnostic impact was defined as identification of the underlying cardiovascular pathology, therapeutic impact as changes in patient management and surgical impact as indication for operative procedures. In addition, we reviewed the TEE reports and patient charts of 216 critically ill patients in a 16-bed multidisciplinary surgical ICU at our university hospital, who underwent a TEE for differential diagnosis of hemodynamic instability from July 1995 to December 1998 to assess the impact of TEE on patient management in a general surgical ICU.

RESULTS

The diagnostic, therapeutic and surgical impact in a total of 2,508 patients ranged from 44 to 99% (weighted mean 67.2%), 10-69% (36.0%), and 2-29% (14.1%), respectively. The complication rate was 2.6%, with no examination related mortality. In our series in a general surgical ICU, a diagnostic, therapeutic and surgical impact was inferred in 191 (88.4%), 148 (68.5%) and 12 (5.6%) patients, respectively. Adverse effects were observed in 5.6%.

CONCLUSION

TEE is safe, well-tolerated and useful in the management of critically ill patients. This applies as well for hemodynamically unstable patients in a general surgical ICU.

Substernal epicardial echocardiography: A recommended examination sequence and clinical evaluation in patients undergoing cardiac surgery

BACKGROUND

Substernal epicardial echocardiography is a novel echocardiography window, utilizing a modified mediastinal drain incorporating a sleeve for the insertion of a transesophageal echocardiography probe.

METHODS

Forty-six patients undergoing cardiac surgery from two institutions were evaluated, and an examination sequence was developed.

RESULTS

An 11-view examination is presented as a consensus between the two institutions. In clinical usage, there were no major complications attributable to use of the device. Minor air leaks occurred in 6 patients, and 2 cases of sternal wound infection occurring in a cluster of infections are reported, but causation was not attributed to use of the device. There were no significant differences in measurements of the aortic valve area, pulmonary artery diameter, left ventricular outflow tract dimension, or the sinotubular junction between substernal and transesophageal examinations. All 16 wall-motion segments were well visualized in most patients with substernal epicardial echocardiography.

CONCLUSIONS

Substernal epicardial echocardiography is a safe device for use in the postoperative environment.

Diagnosing cardiac contusion: old wisdom and new insights

Cardiac contusion is usually caused by blunt chest trauma and therefore is frequently suspected in patients involved in car or motorcycle accidents. The diagnosis of a myocardial contusion is difficult because of non-specific symptoms and the lack of an ideal test to detect myocardial damage. Cardiac contusion can cause life threatening arrhythmias and cardiac failure. Many diagnostic methods, such as ECG, biochemical cardiac markers, transthoracic and transoesophageal echocardiography, and radionuclide imaging studies, have been investigated to determine their use in predicting such complications. Recently, cardiac troponin I and T were found to be highly sensitive for myocardial injury. Troponin I and T have also proved to be useful in the stratification of patients at risk for complications. Nevertheless, diagnosis of a cardiac contusion and identification of patients at risk remain a challenge. In this review the current diagnostic tests will be discussed. Also, based on these diagnostic tests, a screening strategy containing data from the latest studies is presented, with the intention of detecting patients at risk.

[Safety and usefulness of transesophageal echocardiography in the acute phase of myocardial infarction]

INTRODUCTION AND OBJECTIVES

The usefulness and safety of transesophageal echocardiography have been assessed in other studies but there is no report in which these factors have been evaluated in the acute phase of myocardial infarction. Patients and method. Transesophageal echocardiography was performed 56 times in 55 patients in the first week after a myocardial infarction.

RESULTS

The study was completed in 54 of 56 patients. The indications were a transthoracic acoustic window that did not provide an accurate diagnosis in 13 (23.2%), diagnosis of mechanical complications and severity assessment of mitral regurgitation in 35 (62.5%), exclusion of aortic dissection in 4 (7.1%), assessment of the severity of aortic stenosis in 1 (1.8%), exclusion of the presence of atrial thrombus in 1 (1.8%), evaluation of the left ventricular outflow tract gradient in 1 (1.8%), and evaluation of the presence of a left ventricular thrombus in 1 patient (1.8%). Two patients (3.6%) died while the study was being made, the first one 10 minutes after finishing the echocardiogram due to progression of a partial rupture of the papillary muscle and the second due to left ventricle free wall rupture. In both patients, the indication for transesophageal echography was the need for proper evaluation of a post-Acute Myocardial Infarction mechanical complication.

CONCLUSIONS

Transesophageal echocardiography is a very useful technique for evaluating patients during the acute phase of myocardial infarction but further studies are needed to establish its safety in these patients.

Range and prevalence of cardiac abnormalities in patients hospitalized in a medical ICU

BACKGROUND

Patients hospitalized in medical ICUs (MICUs) with acute noncardiac illnesses have an undefined prevalence of underlying cardiovascular abnormalities. Because of the acuteness of illness, the need for frequent concurrent mechanical ventilation, and the nature of the underlying diseases, routine cardiac examination may be suboptimal for identifying concurrent cardiac abnormalities.

PURPOSE

The purpose of this study was to utilize transthoracic echocardiography and Doppler echocardiography interrogation to identify the range and prevalence of occult cardiac abnormalities that may be present in patients admitted to an MICU.

METHODS

Over a 12-month period, 500 consecutive patients who had been admitted to the MICU of a large university tertiary care center underwent complete two-dimensional echocardiography and Doppler scanning within 18 h of admission. The final study population comprised 467 patients. No study subject had been admitted to the MICU for a primary cardiac diagnosis. Cardiovascular abnormalities were prospectively defined, and all echocardiograms were interpreted independently by blinded observers. Both MICU and overall mortality rates as well as length of stay were compared to the presence or absence of cardiac abnormalities.

RESULTS

One or more cardiac abnormalities was noted in 169 patients (36%). The average (+/-SD) age of patients in the study was 52 +/- 17 years (age range, 17 to 100 years), and the average age was 57 +/- 18 years (age range, 18 to 93 years) in patients with underlying cardiac abnormalities. A single cardiac abnormality was noted in 103 patients (22%), two cardiac abnormalities were noted in 34 patients (7.2%), and three or more cardiac abnormalities were noted in 32 patients (6.8%). Based on subsequent requests for cardiac diagnostic studies, 67 patients (14.3%) were clinically suspected of having significant cardiovascular abnormalities, 39 of whom (58%) had one or more cardiac abnormalities on seen on echocardiography. Cardiac abnormalities were unsuspected in 130 of 169 patients (77%) and were only noted at the time they underwent surveillance echocardiography. Although there was no correlation between the presence of cardiac abnormalities and mortality, both MICU and hospital length of stay were increased in patients with cardiac abnormalities.

CONCLUSION

A significant proportion of patients admitted to an MICU with noncardiac illness have underlying cardiac abnormalities, which can be detected with surveillance echocardiography at the time of admission. Cardiac abnormalities were associated with an increased length of stay but not with increased mortality.

Crossing atrial thrombus in a patient with recurrent pulmonary embolism

OBJECTIVES

To report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism.

DESIGN

Case report.

SETTING

Intensive care unit of a university hospital.

PATIENT

A 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy.

INTERVENTION

Systemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy.

MEASUREMENTS AND MAIN RESULTS

Transesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit.

CONCLUSIONS

Recurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.

The hemodynamically unstable patient in the intensive care unit: hemodynamic vs. transesophageal echocardiographic monitoring

OBJECTIVE

Transesophageal echocardiography is a diagnostic and monitoring modality. The objectives of our study were to compare the diagnoses obtained with continuous transesophageal echocardiography and hemodynamic monitoring in the intensive care unit, to determine interobserver variability of diagnosis obtained with both modalities, and to evaluate its impact.

DESIGN

Prospective cohort study.

SETTING

Surgical intensive care unit.

PATIENTS

Consecutive hemodynamically unstable patients after cardiac surgery.

INTERVENTIONS

At admission, unstable patients were monitored during 4 hrs with transesophageal echocardiography and standard hemodynamic monitoring. The critical care physician evaluated the patients based on all information except the transesophageal echocardiography at 0, 2, and 4 hrs and formulated a hypothesis on the most likely cause of hemodynamic instability. Transesophageal echocardiography information was provided after each evaluation. To evaluate interobserver variability, all the hemodynamic and echocardiographic information was gathered, randomized, and evaluated by five clinicians for the hemodynamic data and five echocardiographers for the transesophageal echocardiography data. The evaluators were blinded to all other information. Kappa statistics were used to evaluate agreement. Impact of transesophageal echocardiography was assessed retrospectively by using the Deutsch scale.

RESULTS

Twenty patients qualified for the study. The agreement between the hemodynamic and echocardiographic diagnosis showed a kappa at admission, 2 hrs, and 4 hrs of 0.33, 0.47, and 0.28. The interobserver agreement for the initial diagnosis (p =.014) and between all evaluators (p <.001) was significantly higher in the echocardiographic compared with the hemodynamic group. The transesophageal echocardiographic information was considered retrospectively to be essential in 34% and valuable in 34% of cases.

CONCLUSIONS

These observations support the belief that transesophageal echocardiographic monitoring in the intensive care unit is associated with higher interobserver agreement in diagnosing and excluding significant causes of hemodynamic instability for postoperative cardiac surgical patients.

Transesophageal echocardiography in critically ill patients

OBJECTIVE

To evaluate the safety and utility of transesophageal echocardiography performed by intensive care physicians in critically ill patients.

DESIGN

Retrospective chart review.

SETTING

A 24-bed multidisciplinary adult intensive care unit in a 692-bed tertiary referral teaching hospital.

PATIENTS

Two hundred fifty-five intensive care patients.

INTERVENTIONS

We studied 255 consecutive intensive care patients who underwent transesophageal echocardiography between January 1996 and January 2000.

MEASUREMENTS AND MAIN RESULTS

Three hundred eight transesophageal echocardiography studies were successfully performed; the probe could not be passed in one patient with a cervical fracture. The indications included unexplained hypotension (40%), known or suspected endocarditis (27%), assessment of ventricular function (15%), pulmonary edema (5%), source of embolus (4%), assessment of aorta (4%), and other (5%). In 67% of hypotensive patients, transesophageal echocardiography revealed the cause of hemodynamic instability, leading to a management change and improvement in blood pressure in 31%. This included surgery in 22% without the need for additional tests. Overall, transesophageal echocardiography findings led to a significant change in management in 32% of all studies performed. One patient receiving continuous positive airways pressure suffered pulmonary aspiration during tracheal intubation before transesophageal echocardiography, two patients had hypotension associated with sedative medication, and there was one case of oropharyngeal bleeding after probe insertion.

CONCLUSION

Transesophageal echocardiography when performed by intensive care physicians is a safe procedure and provides useful information for the evaluation and management of critically ill patients.

Diagnostic accuracy and cost-effectiveness of contrast echocardiography on evaluation of cardiac function in technically very difficult patients in the intensive care unit

Echocardiographic assessment of cardiac function can be quite difficult in the intensive care unit and may require transesophageal echocardiography (TEE). We therefore compared harmonic imaging alone or in combination with contrast to TEE in 32 consecutive patients in the intensive care units who were considered technically very difficult (> or =50% of the 16 segments not visualized from any view). Excellent or adequate endocardial visualization was achieved in 13% of segments with fundamental imaging, 34% with harmonic imaging, and 87% with contrast (p < 0.0001); the latter success rate was similar to TEE (87% vs 90%; p = NS). When TEE was used as the standard, agreement in exact interpretation of wall motion increased from 48% for fundamental imaging to 58% with harmonic imaging, and reached 70% with contrast (p <0.0001). Contrast had the best sensitivity (89%) for detecting wall motion abnormalities. Estimation of ejection fraction was possible in 31% with fundamental imaging, 50% with harmonic imaging, and in 97% with contrast. Ejection fraction quantitated by contrast enhancement correlated best with TEE (r = 0.91). Cost-effectiveness analysis revealed that contrast echo was cost-effective compared with TEE in determining regional and global ventricular function, with a cost saving of 3% and 17%, respectively. Thus, contrast echocardiography provides an accurate, safe, and cost-effective alternative to TEE for evaluating ventricular function in technically very difficult studies.

Perioperative use of transesophageal echocardiography by anesthesiologists: impact in noncardiac surgery and in the intensive care unit

BACKGROUND

The American Society of Anesthesiologists (ASA) has published practice guidelines for the use of perioperative transesophageal echocardiography (TEE) but the role and impact of TEE performed by anesthesiologists outside the cardiac operating room (OR) is still poorly explored. We report our experience in the use of TEE in the noncardiac OR, the recovery room and in the intensive care unit (ICU) in a university hospital, and analyze the impact of TEE on clinical decision making.

METHODS

Two hundred fourteen patients were included and TEE indications were classified prospectively according to the ASA guidelines. The examinations and data sheets were reviewed by two anesthesiologists with advanced training in TEE. For each examination, it was noted if TEE altered the management according to five groups: 1) changing medical therapy; 2) changing surgical therapy; 3) confirmation of a diagnosis; 4) positioning of an intravascular device; and 5) TEE used as a substitute to a pulmonary artery catheter.

RESULTS

Eighty-nine (37%), 67 (31%) and 58 (27%) patients had category I, II and III indications. The impact was more significant in category I where TEE altered therapy 60% of the time compared with 31% and 21% for categories II and III (P < 0.001). The most frequent reason for changing management was a modification in medical therapy in 53 instances (45%).

CONCLUSION

Our results confirm a greater impact of TEE performed by anesthesiologists on clinical management for category I compared to category II and III indications in the noncardiac OR surgical setting and in the ICU.

Transthoracic echocardiography is not cost-effective in critically ill surgical patients

BACKGROUND

Echocardiography has been shown to be valuable in critically ill surgical patients. Transthoracic echocardiography (TTE) often fails to provide adequate imaging in critically ill patients, necessitating subsequent transesophageal echocardiography (TEE). The objective of this study was to determine and quantify factors associated with failure of transthoracic echocardiography (TTE) in critically ill surgical patients, and to define a cost-effective strategy for echocardiography in these patients.

METHODS

Demographic and clinical data were collected retrospectively and evaluated to determine which factors were associated with failure of TTE to provide adequate imaging. In addition, models were developed to estimate costs for echocardiography in critically ill surgical patients.

RESULTS

TTE has a high failure rate in critically ill surgical patients. This failure rate increases significantly in patients who gain > 10% body weight from admission weight, who are supported with > or = 15 cm H(2)O positive end-expiratory pressure, and in those with chest tubes. As a result, the use of TTE in critically ill surgical patients is not cost-effective. TEE, however, is highly effective in this group of patients, and is more cost-effective than TTE in evaluating those critically ill surgical patients requiring echocardiography.

CONCLUSION

The routine use of TTE to initially evaluate all critically ill surgical patients who require echocardiography should be abandoned because it is not cost-effective. TEE appears to be the most cost-effective echocardiographic modality in the surgical intensive care unit.

Indications and impact of postoperative transesophageal echocardiography in cardiac surgical patients

OBJECTIVE

Transesophageal echocardiography (TEE) has gained widespread acceptance among intensivists as a tool to facilitate decision-making in the management of critically ill patients. This observational study analyzes the indications and impact of TEE and the outcome in patients following cardiac surgery.

DESIGN

Standardized reports containing indication, main diagnosis, and impact on patient management were completed during TEE.

SETTING

Intensive care unit in a university hospital.

PATIENTS

Postoperative cardiac surgery patients requiring TEE.

INTERVENTION

TEE in sedated and mechanically ventilated patients.

MEASUREMENTS AND RESULTS

Reports were obtained in 301 adult patients between June 1996 and June 2000. Indications were postoperative control of left ventricular function in 102 (34%) cases; unexplained, sudden hemodynamic deterioration in 89 (29%); suspicion of pericardial tamponade in 41 (14%); cardiac ischemia in 26 (9%); and "other" in 43 (14%). In 136 patients (45%), a new diagnosis was established or an important pathology was excluded. Pericardial tamponade was diagnosed in 34 cases (11%) and excluded in 36 cases (12%). Other diagnoses included severe left ventricular failure, large pleural effusion, and others. Therapeutic impact was found in 220 cases (73%): change of pharmacologic treatment and/or fluid therapy in 118 cases (40%), resternotomy in 43 (14%), no reoperation necessary in 39 (13%), and various in 20 (7%). No impact was found in 81 cases (27%). In a subgroup of patients in whom preoperative risk scores were evaluated, the indication for a postoperative TEE was significantly associated with a prolonged stay in the intensive care unit: 7 (5.6, 8.4) days vs. 1 (0.8, 1.2) day (median, [95% confidence interval]) (p <.0001), more neurologic complications (18/137 = 13.1% vs. 21/680 = 3.0%) (p <.0001), and increased mortality (34/153 = 22.2% vs. 18/709 = 2.5%) (p <.0001). Corrected for preoperative risk scores, these differences were still significant.

CONCLUSION

Although TEE provided important findings and therapeutic impact in postoperative cardiac surgical patients, patients with comparable preoperative risk who had postoperative TEE examinations had a significantly worse outcome than those without the need for postoperative TEE.

Myocardial dysfunction associated with brain death: clinical, echocardiographic, and pathologic features

BACKGROUND

The sequelae of severe brain injury include myocardial dysfunction. We sought to describe the prevalence and characteristics of myocardial dysfunction seen in the context of brain-injury-related brain death and to compare these abnormalities with myocardial pathologic changes.

METHODS

We examined the clinical course, electrocardiograms, head computed tomography scans, and echocardiographic data of 66 consecutive patients with brain death who were evaluated as heart donors. In a sub-group of patients, we compared echocardiographic findings with pathologic findings.

RESULTS

Echocardiographic systolic myocardial dysfunction was present in 28 (42%) of 66 patients and was not predicted by clinical, electrocardiographic, or head computed tomographic scan characteristics. Ventricular arrhythmias were more common in the patients with, compared to those without, myocardial dysfunction (32% vs 0%; p < 0.001). Myocardial dysfunction was segmental in all 8 patients with spontaneous subarachnoid or intracerebral hemorrhage. In these patients, the left ventricular apex was often spared. Myocardial dysfunction was either segmental or global in 17 patients who suffered head trauma and in 3 patients who died of other central nervous system illnesses. In 11 autopsied hearts, we found poor correlation between echocardiographic dysfunction and pathologic findings.

CONCLUSIONS

Systolic myocardial dysfunction is common after brain-injury-related brain death. After spontaneous subarachnoid or intracerebral hemorrhage, the pattern of dysfunction is segmental, whereas after head trauma, it may be either segmental or global. We found poor correlation between the echocardiographic distribution of dysfunction and light microscopic pathologic findings.

Transesophageal echocardiography (TEE) in the critical care patient

Critically ill patients often pose special diagnostic problems to the clinician, intensified by limited physical examination findings and difficulty in transportation to imaging suites. Mechanical ventilation and the limited ability to position the patient make transthoracic echocardiography difficult. Transesophageal echocardiographic (TEE) imaging, however, is well suited to the critical care patient and is frequently used to evaluate hemodynamic status, the presence of vegetations, a cardioembolic source, and an intracardiac cause of hypoxemia. Using proper precautions, TEE can be performed safely in unstable patients and frequently leads to important changes in management.

Ultrasound and other imaging technologies in the intensive care unit

As technology advances, more imaging and procedures are performed at the bedside on critically ill patients in ICUs, thereby eliminating the risks of transporting patients. These imaging techniques can serve as diagnostic and therapeutic tools in treating the acute and chronic consequences of injured, critically ill patients. One area of growth is ultrasonography. Critical care applications of ultrasonography are expanding, and the learning curve of surgeons and intensivists performing some of these studies is improving. Ultrasonography can supplement physical examination and provide useful "real-time" information on nearly every body cavity. Other imaging technology is also available in a portable form, enabling imaging directly at the bedside. Images are now becoming readily and easily available with the advancement of teleradiology. Some of the imaging modalities are still in development, and their clinical effectiveness is being studied. In the future, more uses of these various imaging technologies may become evident and cost-effective.

[Problems of clinical evaluation of hemodynamics at rest and during exercise in chronic heart disease. Value of cardiac catheterization and problems of clinical classification]

BACKGROUND

NYHA classification is mostly used for graduation of clinical limitation due to cardiac failure. Right heart catheterization is not generally used to evaluate hemodynamics and to define the effects of drugs in patients with chronic cardiac failure. Clinical data and results from echocardiography, stress tests or nuclear cardiology seem to be sufficient. Our aim was to demonstrate subjectivity of a classification system (NYHA) comparing the graduation done by physicians and by patients and to represent the difficulty to prognosticate hemodynamic data of patients with heart failure.

PATIENTS AND METHODS

Limitation of 53 patients with heart diseases was classified by physicians and patients using NYHA classification. Pulmonary capillary wedge pressure (PCWP), stroke volume (SV) and cardiac output were predicted by physicians; they were allowed to utilize all examination data they could get. Predicted hemodynamic data were compared with the results of measurement at rest and during exercise.

RESULTS

Patients classified themselves significantly worse than physicians did: 2.68 +/- 0.64 vs. 2.23 +/- 0.74 (p = 0.0012). Similarity in NYHA classification was found in 29/53 cases. Correlation of predicted and measured hemodynamic data was low: PCWP (at rest) r = 0.346; PCWP (during exercise) r = 0.232; SV (at rest) r = 0.476; SV (during exercise) r = 0.445; HMV (at rest) r = 0.412; HMV (during exercise) r = 0.538.

CONCLUSION

Clinical classification systems like NYHA are subjective, classification by physicians differs significantly from classification by patients. Prediction of hemodynamics is not possible despite all examination data had been available. Right heart catheterization is necessary to define hemodynamics at rest and during exercise.

Multicenter Experience Using a New Prototype Transnasal Transesophageal Echocardiography Probe

Transesophageal echocardiography (TEE) is an invaluable diagnostic tool, particularly in patients with inadequate transthoracic echocardiographic examinations. In addition, continuous TEE has been used to monitor ventricular and valvular performance in the intensive care unit and the operating room. However, current generation transesophageal probes have limitations in the critical care setting due to their size. Recently, a prototype miniaturized transesophageal probe was developed to overcome these limitations. This probe was used by five medical centers for 194 examinations. A large proportion of these patients were in the intensive care unit (43%), as well as mechanically ventilated (39%). Seventy percent (70%) of the subjects in this study were intubated nasally with the prototype probe, with a success rate of 88.5%. Oral intubation was successful in every case. Subject tolerance was good, and 25% of the patients were intubated for > 1 h. Nasal intubation with the probe was more likely in intensive care patients, ventilated subjects, and patients who were intubated for > 1 hour. TEE with this miniaturized probe is feasible and safe even in multi-instrumented critical care patients. This probe provides adequate diagnostic imaging capabilities and may allow imaging over prolonged periods of time, making it suitable for the serial monitoring of ventricular performance.

Assessment of ventricular function in critically ill patients: limitations of pulmonary artery catheterization. Institutions of the McSPI Research Group

OBJECTIVE

To determine the accuracy of conventional hemodynamic assessment using pulmonary artery catheter-derived data in critically ill patients.

DESIGN

Cohort study.

SETTING

Kaiser Permanente and Veterans Affairs Medical Centers.

PARTICIPANTS

Twenty-five consecutive patients who had undergone elective aortocoronary bypass surgery.

MEASUREMENTS AND MAIN RESULTS

In the intensive care unit, conventional assessment (CA) was performed hourly by clinicians using conventional (radial artery and pulmonary artery) hemodynamic measurements from which left ventricular (LV) function and intracardiac volume were estimated. Simultaneously, transesophageal echocardiography (TEE) data were recorded on videotape, blinded to the clinicians, and quantitatively analyzed off-line. TEE-determined LV function was classified as either normal (ejection fraction > or =40%) or abnormal (ejection fraction <40%) and intracardiac volume as normal (end-diastolic area = 8 to 22 cm2), low (end-diastolic area <8 cm2), or high (end-diastolic area >22 cm2).

CONCLUSION

Evaluable data included 130 of 150 (87%) observations of simultaneously collected CA and TEE data, averaging 5.6+/-4.4 observations per patient. The overall predictive probability for conventional clinical assessment of normal ventricular function was 98% (118/121), whereas for abnormal ventricular function it was 0% (0/9). For CA of volume, the overall predictive probabilities for hypovolemia, normovolemia, and hypervolemia were 50% (3/6), 60% (69/115), and 22% (2/9). Although conventional clinical assessment of normal LV function in the intensive care unit correlates well with echocardiographic assessment, both LV dysfunction and extremes of preload (hypovolemia or hypervolemia) are assessed poorly by clinicians using conventional clinical monitoring with pulmonary artery catheterization.

Changing Patterns of Transesophageal Echocardiography Use in the Intensive Care Unit

Since its advent, the use of transesophageal echocardiography (TEE) has grown rapidly. In patients undergoing TEE in the intensive care unit over two time periods (4 years apart), we evaluated whether TEE led to new/unsuspected findings or changes in patient management. Results showed that the indications for which patients underwent TEE changed considerably between the two time periods. Hemodynamic instability was an indication for TEE in 41% of the patients in the first interval and 56% of the patients in the second interval. TEE frequently established a new diagnosis (41%) and led to significant management changes (28%) in both time periods. These changes occurred despite the use of a pulmonary artery catheter in nearly 2/3 of the patients studied. Therefore, despite increasing and changing use, TEE frequently establishes unsuspected diagnosis and directly influences patient management when used in intensive care patients.

Cardiac complications in the intensive care unit

Advances in the care of critically ill patients has been startling, especially in patients with acute coronary syndromes. With new therapies and procedures, however, have come new complications. On balance, our patients are better off, but the stakes are now higher and the complications more serious. The need for constant vigilance has never been greater.

Complications of transesophageal echocardiography in the ED

The complication rate of transesophageal echocardiography (TEE) performed in clinical settings outside the emergency department (ED) has been reported to be 1% to 3%. The rate of complications of performing TEE in the ED has not been established. The purpose of this study was to determine the rate of complications associated TEE with carried out on ED patients, and to investigate parameters that might predict complications. A retrospective chart review was carried out on consecutive ED patients undergoing TEE at a major referral center. Complications were abstracted. Parameters to predict complications were assessed, including age, gender, vital signs, pulse oximetry values, serum bicarbonate level, and hematocrit level. A total of 142 patients underwent TEE in the ED during the study period; 88 of these were trauma patients. There were 18 (12.6%) complications: death (1), respiratory insufficiency/failure (7), hypotension (3), emesis (4), agitation (2), and cardiac dysrhythmia (1). None of the tested variables predicted a complication. TEE carried out in the ED has a higher complication rate than has been reported in other clinical settings.

Role of Echocardiography in Complications Associated with Partial or Complete Rupture of the Myocardium in Acute Myocardial Infarction

In this report, we focus on the specific complications of acute myocardial infarction that are associated with rupture of the myocardium and for which two-dimensional and Doppler color flow echocardiography expedites accurate diagnosis for prompt treatment, including surgical repair, which can be crucial to survival in such cases.

Transnasal transesophageal echocardiography: a modified application mode for cardiac examination in ventilated patients

In 42 endotracheally intubated patients, we examined the utility of a miniaturized monoplane probe for transnasal transesophageal echocardiography (TEE). Transnasal TEE was prospectively evaluated in 26 deeply and 16 mildly sedated patients receiving topical anesthesia with lidocaine jelly 2%. The patients with deep sedation were additionally examined with transoral monoplane and multiplane TEE. Transnasal esophageal insertion of the TEE probe was successfully performed in 90% of patients. Endotracheal malpositioning was corrected in two patients. Nasal bleeding required treatment in another patient. Topical anesthesia was adequate in 82% of mildly sedated patients. Left ventricular short- and four-chamber long-axis views of good quality were obtained with transnasal (transoral) monoplane TEE in 76% (81%) and 92% (96%) of patients (differences not significant). Compared with conventional multiplane TEE, transnasal monoplane TEE missed diagnoses in 19% of patients. The relative error (mean +/- SEM) of quantification with transnasal TEE was <9% +/- 2% for ventricular diameters and <7% +/- 2% for cross-sectional area measurements, with a bias of 0.5 +/- 3.8 cm2 and 0.1 +/- 2.4 cm2 (mean +/- 2 SD) for left ventricular end-diastolic and end-systolic short-axis areas. The relative error in measuring intracardiac flow velocities was >40%, but systolic to diastolic peak velocity ratios at the valvular site were determined with an error <4% +/- 3%. Transnasal monoplane TEE can be performed even in mildly sedated patients with an endotracheal tube without further need for analgesia or sedation. The technique is as useful as conventional transoral TEE to image standard tomographic planes for quantification, but it is less suited for comprehensive echocardiographic diagnosing.

IMPLICATIONS

Transnasal insertion of a miniaturized monoplane transesophageal echocardiography (TEE) probe was studied in endotracheally intubated patients. Nasal passage was well tolerated even by patients with only mild sedation. Imaging quality was similar to conventional transoral monoplane TEE with larger transducers, but technical restraints cause a deficit in complete cardiac diagnosing obtained with multiplane TEE.

Assessment of cardiovascular volume status by transoesophageal echocardiography and dye dilution during cardiac surgery

Conventional evaluation of cardiovascular volume status by filling pressures is unreliable in critically ill patients. Measurements of left ventricular end diastolic area index by transoesophageal echocardiography and of intrathoracic blood volume index by dye indicator dilution are new approaches to this problem. In this study, different indices of cardiovascular volume status were analysed to define their relation during the pronounced haemodynamic changes associated with systemic inflammation after cardiopulmonary bypass. Correlations were performed with left ventricular end diastolic area index, intrathoracic blood volume index, central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP). Data from 15 patients receiving coronary artery bypass grafts were compared after induction of anaesthesia and in the intensive care unit. Spearman's correlation coefficient for perioperative absolute changes in left ventricular end diastolic area index and intrathoracic blood volume index was 0.87 (P < 0.05). However, an increase in intrathoracic blood volume index by 125 mL m-2 was necessary to maintain a baseline left ventricular end diastolic area index. Absolute values of all variables varied widely, with the only significant correlation found between CVP and PCWP. Changes in CVP and PCWP did not correlate with changes in left ventricular end diastolic area index or intrathoracic blood volume index. Provided simultaneous baseline measurements are available and a supranormal intrathoracic blood volume index compensates for the haemodynamic changes in systemic inflammation, left ventricular end diastolic area index and intrathoracic blood volume index may substitute for each other during the evaluation of cardiovascular volume status in patients with stable cardiac function.

Role of emergency intraoperative transesophageal echocardiography

Transesophageal echocardiography (TEE) has a definitive role in the diagnosis and management of critically ill patients with cardiovascular disease and patients undergoing cardiac operations. The diagnostic role of emergency intraoperative TEE and the impact on clinical outcome have not been evaluated. We reviewed the indications, findings, and impact of emergency intraoperative TEE in 66 patients over a 4-year period. The indications for emergency TEE were unexplained hemodynamic instability (36 patients), preoperative evaluation of patients having emergency surgery (19 patients), cardiac evaluation of trauma cases (6 patients), and unexplained intraoperative hypoxemia (5 patients). New findings were disclosed in 53 (80%) patients, with an alteration of the planned surgical procedure in 15 (23%). Despite the therapeutic impact, 24 patients (36%) did not survive to hospital dismissal. We recommend that TEE be considered as the diagnostic tool of choice when surgical patients have unexplained hemodynamic instability, when time does not permit complete preoperative evaluation, when cardiovascular injury is suspected in a trauma patient, and to evaluate unexplained hypoxemia.