Transesophageal echocardiography predicts mortality in critically ill patients with unexplained hypotension

Department of Medicine, University of California, San Francisco 94143-0214, USA.

OBJECTIVES. This study sought to determine the prognostic yield and utility of transesophageal echocardiography in critically ill patients with unexplained hypotension. BACKGROUND. Transesophageal echocardiography is increasingly utilized in the intensive care setting and is particularly suited for the evaluation of hypotension; however, the prognostic yield of transesophageal echocardiography in these patients is unknown. METHODS. We prospectively studied 61 adult patients in the intensive care unit with sustained (> 60 min) unexplained hypotension. Both transthoracic and transesophageal echocardiography were performed, and results were immediately disclosed to the primary physician, who reported any resulting changes in management. Patients were classified on the basis of transesophageal echocardiographic findings into one of three prognostic groups: 1) nonventricular (valvular, pericardial) cardiac limitation to cardiac output; 2) ventricular failure; and 3) noncardiac systemic disease (hypovolemia or low systemic vascular resistance, or both). Primary end points were death or discharge from the intensive care unit. RESULTS. A transesophageal echocardiographic diagnosis of nonventricular limitation to cardiac output was associated with improved survival to discharge from the intensive care unit (81%) versus a diagnosis of ventricular disease (41%) or hypovolemia/low systemic vascular resistance (44%, p = 0.03). Twenty-nine (64%) of 45 transthoracic echocardiographic studies were inadequate compared with 2 (3%) of 61 transesophageal echocardiographic studies (p < 0.001). Transesophageal echocardiography contributed new clinically significant diagnoses (not seen with transthoracic echocardiography) in 17 patients (28%), leading to operation in 12 (20%). CONCLUSIONS. Transesophageal echocardiography makes a clinically important contribution to the diagnosis and management of unexplained hypotension and predicts prognosis in the critical care setting.

This article has been cited by other articles:

				R. M. LE. Orme, M. P. Oram, and C. E. McKinstry Impact of echocardiography on patient management in the intensive care unit: an audit of district general hospital practice Br. J. Anaesth., March 1, 2009; 102(3): 340 - 344. [Abstract] [Full Text] [PDF]

				Y. Beaulieu and P. E. Marik Bedside Ultrasonography in the ICU: Part 2 Chest, September 1, 2005; 128(3): 1766 - 1781. [Abstract] [Full Text] [PDF]

				M. X. Joseph, P. J. S. Disney, R. Da Costa, and S. J. Hutchison Transthoracic Echocardiography To Identify or Exclude Cardiac Cause of Shock Chest, November 1, 2004; 126(5): 1592 - 1597. [Abstract] [Full Text] [PDF]

				E. Bossone, B. DiGiovine, S. Watts, P. A. Marcovitz, L. Carey, C. Watts, and W. F. Armstrong Range and Prevalence of Cardiac Abnormalities in Patients Hospitalized in a Medical ICU Chest, October 1, 2002; 122(4): 1370 - 1376. [Abstract] [Full Text] [PDF]

				H. S. Mueller, K. Chatterjee, K. B. Davis, M. A. Fifer, C. Franklin, M. A. Greenberg, A. J. Labovitz, P. K. Shah, K. J. Tuman, M. H. Weil, et al. Present use of bedside right heart catheterization in patients with cardiac disease J. Am. Coll. Cardiol., September 1, 1998; 32(3): 840 - 864. [Full Text] [PDF]

				M. D. Cheitlin, J. S. Alpert, W. F. Armstrong, G. P. Aurigemma, G. A. Beller, F. Z. Bierman, T. W. Davidson, J. L. Davis, P. S. Douglas, L. D. Gillam, et al. ACC/AHA Guidelines for the Clinical Application of Echocardiography : A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography) Developed in Collaboration With the American Society of Echocardiography Circulation, March 18, 1997; 95(6): 1686 - 1744. [Full Text]

				D. J. Roberts Transesophageal Echocardiography in the Critical Care Unit: Patient Management Impact Analysis Journal of Diagnostic Medical Sonography, November 1, 1996; 12(6): 295 - 298. [Abstract] [PDF]