Two year experience and clinical impact of echocardiography in the cardiothoracic intensive care unit: 093

Introduction: Evaluation of acute, persistent and life-threatening haemodynamic disturbances is a class I indication for echocardiography according to the 2003 guideline update for the clinical application of echocardiograhy [¹].

Method: Retrospective analysis of all cardiac surgical patients in the intensive care unit (ICU) who received urgent echocardiography done by two anaesthesiologists with advanced training. Indications were classified into four groups:

1. haemodynamic instability
2. exclusion of valvular pathology
3. exclusion of vegetation or thrombus
4. exclusion of aortic dissection

The changes in treatment resulting from echocardiography findings were classified into medical (A) and surgical (B) interventions:

A1: volume management; A2: inotrope therapy; A3: early coronary angiography because of severe regional wall motion abnormalities; A4: cardioversion; B1: evacuation of haemopericardium; B2: mitral valve replacement; B3: insertion of an intra-aortic balloon pump; B4: coronary revascularization.

Results: From 01/2002 to 12/2003 2157 patients were treated in our cardiac surgical ICU. We surveyed a total of 61 patients (3%) with 67 echocardiographic examinations in the ICU. 19 were transthoracic (TTE) and 48 were transoesophageal echocardiographic studies (TOE). Six patients could not be adequately imaged by TTE. TOE was required to make the diagnosis.

Table: Table. Indications (n of patients)/changes in treatment (n).

In 32 (52.5%) of our patients, medical management was changed, most commonly by an alteration in inotrope therapy and/or iv. fluid load but also by immediate coronary angiography. In two cases systolic anterior motion of the mitral valve was detected triggering a complete change in haemodynamic management. 15 (24.6%) patients had a surgical intervention. 13 returned to the operating room mostly because of cardiac tamponade. There were two mitral valve replacements and one case with coronary revascularization plus intra-aortic balloon pump. In 14 patients TOE findings were considered lifesaving.

Discussion: In our cardiac surgical ICU echocardiographic findings had a significant clinical impact, especially in the haemodynamically unstable patient. TOE often provides the most definitive diagnosis and may improve survival.