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 patents. 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.