Clinical and echocardiographic diagnoses disagree in patients with unexplained hemodynamic instability after cardiac surgery

Purpose: To investigate 1) if clinical indications match diagnostic finding s from urgent transesophageal echocardiography (TEE) in hemodynamically uns table patients after cardiac surgery and 2) the clinical impact of the TEE findings. Methods: Retrospective review of all postcardiac surgical intensive care pa tients who received an urgent TEE over a three-year period from July 1(st) 1997 until June 30(th) 2000. The clinician's presumed diagnosis based on he modynamic and clinical evaluation was compared to TEE diagnosis. Surgical a nd medical interventions based on TEE results and the associated mortality were correlated. Results: A hundred and thirty TEEs were performed for hemodynamic instabili ty or suspected intracardiac vegetation or thrombus, all category I indicat ions according to ASA guidelines. In 41.5% of patients the echocardiographi c finding matched the presumed diagnosis. Patient management was significan tly changed as a result of TEE findings in 58.5% Of patients; 43.3% had cha nges in pharmacological therapy and 15.3% had a surgical intervention. Mort ality was significantly lower in those who received a surgical intervention when compared to those who had changes in drug treatment (P < 0.05). Conclusions: The results of urgent TEE in hemodynamically unstable patients or patients with thromboembolic phenomena in the postcardiac surgical inte nsive care unit are unpredictable in over half of cases, Inappropriate mana gement decisions may result without the information obtained from TEE exami nation. Clinical management is often modified as a result of TEE findings. TEE is essential in the management of hemodynamically unstable postcardiac surgical patients.