Episodic Monoplane Transesophageal Echocardiography Impacts Postoperative Management of the Cardiac Surgery Patient

Simon Maltais, MD, PhD,* William T. Costello, MD, Frederic T. Billings IV, MD, MSc, Julian S. Bick, MD, John G. Byrne, MD,* Rashid M. Ahmad, MD,* and Chad E. Wagner, MD
Objective: A new slender, exible, and miniaturized disposable monoplane transesophageal TEE probe has been approved for episodic hemodynamic transesophageal echocardiographic monitoring. The authors hypothesized that episodic monoplane TEE with a limited examination would help guide the postoperative management of high-risk cardiac surgery patients. Design: The authors analyzed the initial consecutive observational experience with the miniaturized transesophageal echocardiography monitoring system (ClariTEE, ImaCor, Uniondale, New York). Setting: Single institution in a university setting. Participants: Unstable cardiac surgery patients. Interventions: The authors assessed uid responsiveness, echocardiographic data, and concordance among hemodynamic data. Measurements and Main Results: From June 2010 to February 2011, 21 unstable cardiac surgery patients with postoperative instability were identied. Two patients (10%) required reoperation for bleeding and tamponade physiology. Right ventricular dysfunction was diagnosed by episodic TEE monitoring in 7 patients (33%), while hypovolemia was documented in 12 patients (57%). Volume responsiveness was documented in 11 patients. In this observational study, discordance between hemodynamic monitoring and episodic TEE was qualitatively observed in 14 patients (66%). Conclusion: The authors demonstrated the ability of episodic monoplane TEE to identify discordance between hemodynamic monitoring to better dene clinical scenarios in unstable cardiac surgery patients. For these challenging patients, limited episodic TEE assessment has become a cornerstone of ICU care in this institution. & 2013 Elsevier Inc. All rights reserved. KEY WORDS: cardiac surgery, transesophageal echocardiography, hemodynamic monitoring

ULTIPLANE TRANSESOPHAGEAL echocardiography (TEE) is used intraoperatively during most cardiac surgical procedures.1 TEE is used to quantify myocardial dysfunction, identify valvular abnormalities, and conrm placement of cannulae for patients implanted with a left ventricular assist device (LVAD).210 Transthoracic echocardiography is becoming increasingly useful in the diagnosis and management of the critically ill, but its use can be limited in the immediate postoperative cardiac surgery patient.1113 Extending the use of traditional multiplane TEE probes can be difcult secondary to the expense in allocating machines, probes, sterilization requirements, large probe diameter, and its inability to be left in place for an extended period of time.1416 A new slender, exible, and miniaturized disposable transesophageal TEE probe has been approved by the United States Food and Drug Administration to remain in situ for 72 hours, enabling episodic hemodynamic monitoring.17 The probes provide the opportunity to perform frequent direct qualitative and semi-quantitative assessment of myocardial function and lling in the setting of rapidly changing conditions common to the postoperative cardiac surgery patient. Though several case studies have shown examples of the utility of monoplane TEE and episodic monitoring, no larger studies have dened which groups of patients could benet from this technology.1719 The authors cardiovascular intensive care unit (CVICU) has placed more than 200 miniaturized monoplane probes in postoperative cardiac surgery patients, and, therefore, this institution is in the position of having substantial experience with this new technology. The authors hypothesized that episodic monoplane TEE guides assessment of intravascular/myocardial volume, inotrope need, vasopressor use, and assessment of pericardial effusions in critically ill cardiac surgery patients.
METHODS Institutional review board approval was obtained with an exception granted for obtaining study-specic consent secondary to the policy

that entry criteria in the study follow the clinical CVICU protocol for monoplane TEE evaluation. This study was a prospectively enrolled descriptive case series of unstable cardiac surgery patients and included the institutions consecutive experience with the miniaturized transesophageal echocardiography monitoring system in cardiac surgery patients (ClariTEE, ImaCor, Uniondale, NY). All cardiac surgery patients at this institution have an intraoperative TEE unless contraindicated. All patients received a pulmonary artery catheter intraoperatively. Patients received a monoplane TEE if they became hemodynamically unstable at any time in the ICU, dened as persistent systolic BP o100 mmHg, cardiac index o2.2 L/min/m2, SvO2 o 60%, suspected pericardial effusion with tamponade physiology, base decit 48 mEq/L, or lactate 45 mg/dL despite persistent inotropic, vasopressor, and/or volume resuscitation, and concern for or known right ventricular failure. Right ventricular (RV) failure was dened by a combination of features, including elevation in central venous pressure (418 mmHg), a normal or lower pulmonary capillary wedge pressure caused by poor left atrial lling, a diminished cardiac index (o2 L/min/m2), assessed with right-sided thermodilution techniques, a newly decreased or changed right ventricular function (free wall assessment in the ME4chx/TgSax, o2 cm tricuspid annular plane excursion) by the echo examination, and an associated dilated right ventricle.2022 Volume responsiveness was assessed in all patients. Qualitative assessment such as kissing papillary muscles in the TgSax view were used to assess, quantitatively, an LVEDA measured in the

From the *Division of Cardiovascular Surgery; and yDivision of Anesthesiology and Critical Care, Vanderbilt Heart, Vanderbilt University Medical Center, Nashville, Tennessee. $ Drs. Bick, Costello, and Wagner taught echocardiography workshops for ImaCor Inc. in 2012. Address reprint requests to Chad E Wagner, MD, Division of Anesthesiology, Vanderbilt Heart, 1215 21st Avenue South MCE 5th Floor, Nashville, TN 37232-8808. E-mail: chad.e.wagner@vanderbilt.edu & 2013 Elsevier Inc. All rights reserved. 1053-0770/2605-0031$36.00/0 http://dx.doi.org/10.1053/j.jvca.2013.02.012
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TgSax view less than 12 cm2 and/or an increase in LVEDA greater than 2 cm2 after performing passive leg raise maneuvers with a RASS 3 were considered to be potentially volume responsive.2325 The authors systematically performed a monoplane TEE imaging session every 2-3 hours for the initial 6 hours post-enrollment and as needed until the patient reached hemodynamic stability or reached 72 hours after surgery. The 72-hour cut-off was determined by a safety mechanism built into the software of the device to prevent long-term intubation and perceived infection risk (http://imacorinc.com). Imaging sessions were performed by 4 board-certied or -eligible anesthesiologists on service in the ICU and 1 anesthesia critical care fellow who received 2 months of education and oversight before being allowed to clip images. The fellows examinations always were reviewed quickly by the attending intensivist. The authors sought to obtain the midesophageal four-chamber (ME4C) and transgastric short-axis (TGSAX) views to assess left ventricular end-diastolic area (LVEDA), left ventricular fractional area change (LVFAC), right ventricular function, intravascular volume status and associated qualitative response to uid resuscitation, and pericardial effusion with tamponade physiology. Hemodynamic discordance was dened as the point at which the echocardiography examination ndings convinced the intensivist to change management direction from what was thought before the echocardiography imaging session. The examiner systematically collected bedside echo information. Echocardiographers were not blinded to other available hemodynamic monitors. For all patients, the echocardiographer recorded whether information obtained during imaging sessions inuenced hemodynamic management. Additional hemodynamic data were recorded by the bedside nurse and collected from the electronic medical record. Descriptive statistics for categoric variables are reported as frequency and percentage, and continuous variables are reported as mean (standard deviation) or median (range) as appropriate. RESULTS

valve endocarditis who arrived in septic shock for surgical evaluation. Episodic echocardiographic studies were completed in all of the 21 patients and discontinued when patients reached hemodynamic stability or 72 hours after intervention. Patients, interventions, and hemodynamic ndings are detailed in Table 1. A total of 512 loops were recorded from imaging sessions involving 21 unstable cardiac surgery patients. The average number of imaging sessions was 3.28, while the median was 3 per patient. Within this group, 2 patients (10%) required reoperation for bleeding and tamponade physiology. The average ICU length of stay was 8.8 6.9 days, and the observed in-hospital or 30-day mortality was 14%. Both the ME4C and TGSAX views were obtained for 96% of patients. Mean LVEDA was 17.1 6.3 cm2, while average LVFAC was 48.7% 16.6%. Right ventricular dysfunction was diagnosed by episodic TEE monitoring in 7 patients (33%). Hypovolemia was documented in 12 patients (57%) (Fig 1). Volume responsiveness was documented in 11 patients. Figure 1 summarizes uid management interventions for these patients. The group that was determined to be volume responsive (n 11) by echocardiography was 826 mL (1597 mL) net uid positive over the subsequent 6 hours compared to 78 mL (405 mL) in the same period in the group not determined to be volume responsive (p 0.013). In this observational study, discordance between standard hemodynamic monitoring and episodic limited TEE was observed qualitatively in 14 patients (66%).
DISCUSSION

Between June 2010 and February 2011, the authors performed episodic monoplane TEE in 20 cardiac surgery patients with postoperative instability and 1 patient with mitral

In this case series, key areas for which direct visualization added more information than achieved from clinical assessment and hemodynamic monitors included hypovolemia despite high lling pressures, assessment of RV function, biventricular

Table 1. Hemodynamic Data of Subjects

Patients n 21 Apache score Intervention CVPXPAPs-PAPdXCI Major TEE ndings Discordance

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

25 24 20 27 24 22 22 32 20 31 20 27 30 28 24 27 27 29 25 22 29

AVR MVR/CAB RAA AVR MVR CABG Pulmonary endarterectomy Pulmonary embolectomy CABG MVR-TVR Type-A dissection repair Double-lung transplant MVR-TV repair CABG Cardiogenic shock/ECMO Mitral regurgitation/endocarditis/sepsis AVR/CAB CABG Double-lung transplant AVR/MVR Pulmonary embolectomy

9X45-26X1.9 8X37-20X1.5 10X42-22X3.2 20X45-23X3.3 12X48-20X2.9 9X23-14X1.34 16X40-23X3.1 16X28-20X1.74 12X32-21X3 ND 16X45-28X1.45 15X40-24X3.46 12XND 15X52-43X1.89 4X36-18X4 16XND 4X27-12X2.6 15XND 9X24-13X2.08 14X27-15X2.24 17X27-23X3.32

Tamponade Hypovolemia Hypovolemia Hypovolemia Hypovolemia Hypovolemia Hypovolemia Hypovolemia Hypovolemia RV dysfunction Hypovolemia RV dysfunction RV dysfunction Tamponade RV dysfunction Hypovolemia RV dysfunction Hypovolemia RV dysfunction RV dysfunction Hypovolemia

yes no yes yes no no yes yes yes NXA yes no yes yes yes yes yes no yes no yes

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Fig 1. TEE identied pathology in unstable post cardiac surgery patients.

lling in the presence of RV failure, pericardial effusion/ tamponade, myocardial recovery, and weaning from mechanical ventricular support. Management of cardiac surgery patients in the ICU is challenging given that intravascular volume, pericardial uid collections, and myocardial function are often dynamic processes. Standard hemodynamic monitoring using CVP, left-sided lling pressures, and calculated cardiac index frequently are not predictive of the need for intravascular resuscitation.2628 These results conrm these ndings as the authors observed discordance between hemodynamic monitoring and TEE observations in 14 patients (66%). Despite lling pressure data, patients considered to be uid responsive by echocardiography were more likely to be appropriately resuscitated 6 hours after initiation of imaging (Fig 2). This study did not correlate uid response and resuscitation to patient outcomes. The validity of LVEDA as a surrogate for uid responsiveness has been studied in other works.23,29 Pulse-pressure variation also could have been used, but this method can be difcult to interpret in the postoperative cardiac surgery population secondary to a high incidence of arrhythmias/pacing, RV dysfunction, pericardial effusion/tamponade, and lack of paralysis with spontaneous breathing. The impact of episodic monoplane TEE in the cardiac surgery ICU upon patient outcomes is yet to be determined; however, in the authors clinical experience, episodic monoplane TEE monitoring did help elucidate physiologic derangement and guide therapy. More importantly, episodic assessment of changes in uid status, uid responsiveness, or ventricular size provided clinical guidance in assessing the timing of uid resuscitation. CVP has been shown to be a poor surrogate of RV function, especially in the acute postoperative setting.30 A number of factors, including tricuspid regurgitation, level of sedation, or line calibration potentially can alter the observed CVP value and subsequently inuence treatment. In the current high-risk cardiac surgery group, the authors observed little CVP variation during episodes of acute postoperative instability as dened in the Methods section. In fact, only 2 patients (8%) had a

signicant rise in CVP coincident with RV failure. In contrast, episodic observations found RV failure in 7 patients (33%). Episodic monoplane TEE monitoring allows direct semiquantitative assessment of acute myocardial function changes. Stunned myocardium undergoes recovery over time that easily can be visualized by echocardiography. Cardiac index is a poor surrogate for myocardial recovery and, if used alone in clinical decision-making, can leave the clinician ying blind. The authors easily can extrapolate this use to weaning balloon pumps and other modes of temporary mechanical support. In 2 cases, return to the OR was guided by episodic monitoring. Monitoring and diagnosing the evolution of diastolic collapse of the LA, RA, and, possibly, RV is a key advantage of episodic echocardiography. The key difference between diagnostic echocardiography and episodic echocardiography is that with diagnostic echocardiography a problem (tamponade) may be diagnosed but the development of an effusion over time may be missed. The authors refer to it as the AH-HA moment. Sometimes this occurs on probe placement, but other times it could be hours to days (especially in mechanical device management). Furthermore, much of the information in a diagnostic echocardiographic exam such as spectral Doppler interrogation of valves, diastolic dysfunction, detailed two-dimensional valve interrogation, and color-ow Doppler valve assessment are redundant given preprocedure studies and postprocedure intraoperative TEE. Using episodic monoplane TEE does not preclude obtaining a full multiplane TEE examination if it is believed by the intensivist or surgeon to be indicated. While the cost of these probes is not insignicant, this group of ill patients already has had a signicant nancial investment in their initial surgery, and if they are unstable, clinicians are making decisions (such as return to the operating room) that have profound clinical and nancial implications. At this stage in the ICU, the monoplane TEE examination is performed as an adjunct monitor to the pulmonary artery catheter, and in the clinical practice, the data are used in conjunction with other clinical inputs. Decisions to treat are not solely made by echocardiography (for example, just because the patient might be uid responsive does not mean the

Fig 2. Net uid balance 6 hours after initial TEE exam, separated into subjects judged responsive and unresponsive to a uid bolus.

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authors would give uid). Clinicians must not forget that this monitor is episodic and not continuous, and, therefore, as clinicians, it must be established when to image and be able to do so 24 hours a day. Education for this type of technology is in development at many institutions. The question of how to categorize the limited examination is being debated on the national stage. Does an intensivist have to be board certied in perioperative echocardiography to perform a limited episodic monoplane TEE exam? Half of the institutions CVICU intensivist faculty are board certied perioperative echocardiographers; the other half are not. The authors have held workshops for faculty and fellows on monoplane TEE, and local experts have been available to mentor and oversee/over-read exams. The medical director of the CVICU assesses competency. After 3 years, all faculty working in the CVICU are competent to perform monoplane TEE. In the CVICU, there are 18 hours of inhouse attending coverage, and the call attending has the expectation to continue episodic examinations overnight if clinically indicated. While the debate rages on the national stage, it is important to appreciate the complexity of postoperative cardiac surgery patients, and echocardiography of this patient population requires substantive knowledge that cannot be gained in 1-2 courses or 1-2 months. Limitations This was an observational nonblinded case series, which leaves the results open to observer bias. This probe allowed a semi-quantitative postoperative evaluation and should not replace standard formal TEE when indicated. Thus, the persons performing this examination and the cardiac surgeons must

have profound knowledge of the limitations of monoplane echocardiography to know what abnormalities might be missed by not performing a complete examination. This study was not designed to provide outcome data, but rather to elucidate the impact of episodic monoplane TEE on patient management. No study has ever proven that any monitoring device can improve clinical outcome. Future work assessing impact of uid responsiveness as seen by echo on outcomes will be extremely important. While the safety prole has not been published, the probe is the size of a nasogastric tube with 5 cm of very exible tip, which would lead to the belief it would be safer than a conventional probe. The authors have used more than 200 probes in the CVICU and more than 50 elsewhere with no complications to date. As the rate of complications is low with a standard TEE, it will obviously take a larger cohort of patients to dene the safety prole.
CONCLUSION

The miniaturized monoplane disposable probe is specically designed for easy assessment of myocardial function and lling in the critically ill. In this study, the authors demonstrated its ability to change the clinical management of unstable cardiac surgery patients. On the basis of these observations, hemodynamic monoplane TEE assessment has become a useful adjunct in this institution, extending the hemodynamic assessment capabilities of TEE from the operating room to the ICU. Randomized clinical trials are needed to assess the impact of episodic TEE monitoring on postoperative morbidity and mortality.

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