TRANSESOPHAGEAL ECHOCARDIOGRAPHY PREDICTS MORTALITY IN CRITICALLY ILLPATIENTS WITH UNEXPLAINED HYPOTENSION

Objectives. This study sought to determine the prognostic yield and ut ility of transesophageal echocardiography in critically ill patients w ith unexplained hypotension. Background. Transesophageal echocardiogra phy is increasingly utilized in the intensive care setting and is part icularly suited for the evaluation of hypotension; however, the progno stic yield of transesophageal echocardiography in these patients is un known. Methods. We prospectively studied 61 adult patients in the inte nsive care unit with sustained (>60 min) unexplained hypotension. Both transthoracic and transesophageal echocardiography were performed, an d results were immediately disclosed to the primary physician, who rep orted any resulting changes in management. Patients were classified on the basis of transesophageal echocardiographic findings into one of t hree prognostic groups: 1) nonventricular (valvular, pericardial) card iac limitation to cardiac output; 2) ventricular failure; and 3) nonca rdiac systemic disease (hypovolemia or law systemic vascular resistanc e, or both). Primary end points were death or discharge from the inten sive care unit. Results. A transesophageal echocardiographic diagnosis of nonventricular limitation to cardiac output was associated with im proved survival; to discharge from the intensive care unit (81%) versu s a diagnosis of ventricular disease (41%) or hypovolemia/low systemic vascular resistance (44%, p = 0.03). Twenty nine (64%) of 45 transtho racic echocardiographic studies were inadequate compared with 2 (3%) o f 61 transesophageal echocardiographic studies (p < 0.001). Transesoph ageal echocardiography contributed new clinically significant diagnose s (not seen with transthoracic echocardiography) in 17 patients (28%), leading to operation in 12 (20%). Conclusions. Transesophageal echoca rdiography makes a clinically important contribution to the diagnosis and management of unexplained hypotension and predicts prognosis in th e critical care setting.