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MINERVA ANESTESIOL 2006;72:891-913

Transoesophageal echocardiography in critical care


E. HTTEMANN

Echocardiography has evolved to become one


of the most versatile modalities for diagnosing
and guiding treatment of critically ill patients.
Both transthoracic (TTE) and transesophageal
echocardiography (TEE) provide real-time bedside information about a variety of structural
and functional abnormalities of the heart as
well as contractility, filling status and cardiac
output, rendering it the method of choice for
the assessment of cardiac function in the intensive care unit (ICU). Both approaches have its
benefits and limitations. Although TTE remains
the approach of choice, TEE has been shown to
be of additional value in many instances in critically ill patients due to its ability to provide
excellent visualisation of cardiac structures,
its impact on patient management, and its low
complication rate (2.6%). The present status
of TEE in adult critical care is reviewed with
special emphasis on its role as a diagnostic tool
in several clinical scenarios, underlining its
effects on clinical decision making but also as
a monitoring adjunct. Conditions and settings
in which TEE provides the most definitive diagnosis in the critically ill and injured are hemodynamically unstable patients with suboptimal
TTE images or if mechanically ventilated,
patients with suspected aortic dissection or
aortic injury and other conditions in which
TEE is superior to TTE (such as suspected endocarditis, cardiac or aortic source of emboli. The
diagnostic, therapeutic and surgical impact on
patient management in critically ill patients

Address reprint requests to: E. Httemann MD, PhD, DEAA,


EDIC, Department of Anaesthesiology and Intensive Care
Medicine, University Hospital, Friedrich-Schiller-University
Jena, Erlanger Allee 101, D-07740 Jena, Germany.
E-mail: Egbert.Huettemann@med.uni-jena.de

Vol. 72, N. 11

Department of Anaesthesiology and


Intensive Care Medicine
University Hospital
Friedrich-Schiller-University Jena
Jena, Germany

ranged from 44% to 99% (weighted mean


67.2%), 10% to 69% (weighted mean 36%), and
2% to 29% (weighted mean 14.1%), respectively, depending on patients and type of ICU.
Since echocardiography provides different
information than other devices for hemodynamic monitoring such as the pulmonary
artery catheter the methods are therefore not
competitive but rather complementary. The
present body of evidence supporting the use of
TEE in critically ill patients lacks prospective,
randomized controlled studies focusing on endpoints like cost-effectiveness, morbidity or
mortality. However, present evidence as well as
experience, points to the significant benefits
which may be gained by the availability of
echocardiography and especially TEE in ICUs,
as well the necessity for a training of intensive
care physicians.
Key words: Echocardiography, transesophageal - Critical care - Intensive care unit.

ransoesophageal echocardiography (TEE)


has evolved to become one of the most
versatile modalities for diagnosing and guiding treatment of critically ill patients. The reasons for this development include its ease of
use at patient bedside, the high quality imaging due to improved imaging technology

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TABLE I.Studies evaluating impact of TEE on patient management in the ICU. With permission from Httemann
Author

Design

Year

Study
period
(month)

TEE (N)

ICU-type (%)

Mortality
(%)

Patients
studied
(% of ICU
admissions)

Ventilated
patients
(%)

Feasibility

Alam 2
Bruch 3

R
R

1996
2003

48
12

121
117

N/A
N/A

N/A
N/A

22
N/A

98 1
100

Chenzbrraun 4

1994

39

113

N/A

N/A

65

N/A 2

Colreavy 5

2002

48

308

38

4.2

99

99 3

Font 6
Foster 7

R
R

1991
1992

26
30

112
83

N/A
N/A

N/A
N/A

40
N/A

N/A
N/A

Harris 8
Heidenreich 9
Httemann 10
Hwang 11

R
P
R
R

1999
1995
2004
1993

18
14
42
24

206
61
216
78

23
48
44
N/A

N/A
N/A
6,6
N/A

N/A
91
98
21

N/A
97 4
100
98 5

Khoury 12

1994

41

77

N/A

N/A

47

100 6

McLean 13
Oh 14

R
R

1998
1990

24
12

53
51

N/A
N/A

3,2
N/A

N/A
59

100
98

Pearson 15

1990

10

62

N/A

N/A

36

98 7

Poelaert 16
Puybasset 17

R
P

1995
1993

7
10

103
32

51
61

11
N/A

56
100

N/A
100

Schmidlin 18
Slama 19

R
R

2001
1996

48
18

22
39

8,2
9,1

100
66

100
100

Sohn 20

Vignon 21

P
R

1995
1994
2001

78
12
36

301
61
127
96
130

CICU
M (52%)
CT-SICU (48%)
CT-SICU (52%)
MICU (34%)
CCU (13%)
MICU (68%)
CT-SICU (32%)
CICU
GICU (50%)
CCU (47%)
M (3%)
CICU
CICU
SICU
GICU (60%)
ER (40%)
SICU (48%)
CCU (24%)
MICU (19%)
NICU (7%)
GICU
CCU (49%)
SICU (29,4%)
MICU (21,5%)
CCU (49%)
CT-SICU (21%)
MICU (19%)
SICU (11%)
GICU
MICU (53%)
CT-SICU (34%)
SICU (13%)
CT-SICU
MICU (52%)
CT-SICU (48%)
MICU (56%)
CT-SICU (44%)
MICU (57%)
CT-SICU (43%)
CT-SICU

51
N/A
24

N/A
N/A
2,1

81
86
100

98
100
100

Wake 22
Total

(weighted
mean)

2508

* Non-surgical: (pharmacological treatment, fluid therapy).


Legends: Explanations (number of patients in paraphrases): (1) Unco-operativeness (2); (2) Probe could not be advanced more than 30 cm
(1); (3) Probe could not be passed in one patient with a cervical fracture (1); (4) Laryngoscopic guidance employed in 7%; (5) Failed insertion (2); (6) Difficult insertion (5); (7) Failed insertion (patient with large aneurysm of the thoracic aorta compressing the esophagus) (1).
Abbreviations: CICU: ICUs with a high proportion of coronary and/or cardiac surgical patients, but not further specified; CT-SICU:
Cardiothoracic-Surgical ICU; MICU: Medical ICU; SICU: Surgical ICU; CCU: Coronary Care Unit; GICU: General ICU (General adult ICU
(critical illness, trauma, major elective surgery); NICU: Neurologic-neurosurgical ICU; ER: Emergency room; M: Miscellaneous.

(multiplane probes), the rapid availability of


diagnostic information, and its low complication rates. Furthermore, impaired cardiac

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performance is one of the most frequent causes of hemodynamic instability and circulatory failure in critically ill patients.1 Differential

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et al.10
Impact
Complications
(%)

Diagnostic

Overall
therapeutic

Nonsurgical*

Surgical

0
2

58
43

25
43

7
33

19
10

45

26

18

55

33

20

13

0
0

99
77

16
32

4
13

12
19

HTTEMANN

septic cardiomyopathy, inflammatory responses, right ventricular (RV) failure in conjunction with pulmonary hypertension and the
fact that an aging population presents with
more concurrent cardiac comorbidities. This
paper reviews the present status of TEE in
adult critical care with special emphasis on its
role as a diagnostic tool in several clinical
scenarios, underlining its effects on clinical
decision making but also as a monitoring
adjunct.
Technique

N/A
5
6
0

47
97
88
85

32
61
69
N/A

19
41
63
N/A

13
20
6
26

64

48

19

29

N/A
4

45
59

10
N/A

8
N/A

2
24

44

N/A

N/A

1
0

74
78

44
N/A

30
N/A

14
N/A

4
20

73
45

60
20

46
12

14
8

52

N/A

N/A

21

97

41

33

91

58

43

15

(weighted
mean)

67.2

36

14.1

diagnosis may be rather complex and may be


highlighted by the wide array of entities
encountered in critical care such as ischemia,

Vol. 72, N. 11

The performance of TEE is more difficult in


critically ill patients, because of concomitant
mechanical ventilation, nasogastric tube use
and tenuous hemodynamic and respiratory
status. Nevertheless the feasibility of TEE in
a total of 2 508 critically ill patients in various
settings varied between 97% and 100% (Table
I).2-22 In mechanically ventilated patients,
esophageal intubation may be facilitated by
removal of the nasogastric tube, if present,
temporary deflation of the endotracheal tube
cuff, forward jaw thrust, probe placement
under direct laryngoscopic view and application of paralyzing agents.9, 12
Safety
TEE is a semi-invasive procedure that is
not without risk to the patient. Because the
probe is passed blindly, there is potential for
injuring the hypopharynx and esophagus,
the latter in particular from undetected
tumors, diverticula and strictures. New
insights in hypopharyngeal complications
due to the blind passage of a TEE probe transorally were provided by a recent study.23 In
this randomized, prospective clinical study
in 159 consciously sedated adults, TEE was
performed either blindly or with concomitant transnasal videoendoscopic monitoring
of the hypopharynx. Hypopharyngeal lacerations or hematomas occurred in 19 of 80
(23.8%) patients with blind passage of the
probe (11 superficial lacerations of pyriform
sinus, 1 laceration of pharynx, 12 arytenoid

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TABLE II.Complications of TEE in the ICU (21 studies with n=2 508 examinations). With permission from
Httemann et al.10
Category

Details

N.

Displacement of tracheostomy tube (1), pulmonary aspiration during tracheal


intubation before TEE (1)
Respiratory failure (1), transient hypoxia (4)
Ventilation
Hypotension (15), hypertension (4), increase in pulmonary artery pressure (1)
Circulation
Atrial flutter, atrial fibrillation (5), VES (1)
Arrhythmias
Circumstances not further specified (1), due to abruptly discontinued inotropic
Cardiac arrest
support but successful resuscitation - not related to TEE study (1)
Grand mal seizure (1)
Seizures
(1)
Vomitus
(7)
Coughing
Oropharyngeal mucosal lesions Superficial mucous lesion (1), self-terminating oral blood suffusion (15),
oropharyngeal bleeding (1)
Airway

5
20
6
2
1
1
7
17

61
(2.6%)

Total

hematomas, 2 vocal fold hematomas, and 1


pyriform hematoma) in contrast to 1 of 79
patients (1.3%) with the optical guided technique (1 superficial pyriform laceration).
These findings warrant a cautious passage
and a proper training of esophageal intubation given the comorbidities of critically ill
patients such as coagulation abnormalities.
In a nonfasting patient, emesis is in particular a concern, especially when the trachea is not protected by an endotracheal
tube. Although the risk for aspiration is lessened if an endotracheal tube is in place with
distended cuff, gastric suction, fasting or discontinuation of tube feedings for a minimum
of 4 h is recommended before an elective
TEE study.
Frequently used sedative agents include
midazolam, opioids and propofol. Dosing is
highly variable, and depends on the hemodynamic stability of the patient, ongoing preprocedural sedation of the patient, and the
ventilatory status of the patient. Sedative
induced hypotension is a frequent problem
in patients with depressed cardiac function or
decreased systemic vascular resistance (SVR)
thus necessitating transient vasopressor support. Topical lidocaine use may aid the suppression of the gag reflex. However, since
the gag reflex is rarely eliminated completely, there is often a mild increase in blood
pressure and heart rate associated with agitation at the time of probe insertion. In

894

patients with significant respiratory distress,


transient sedation and intubation along with
mechanical ventilation is an option to perform a TEE safely if the information is
required urgently and cannot be obtained
transthoracically.
Although hypopharyngeal and esophageal
perforations after TEE examination are very
rare yet, owing to the increased use of TEE for
intraoperative monitoring, the occurrence of
these life-threatening complications is increasing. If there is any suspicion of perforation of
the upper airways and/or upper digestive
tract, immediate diagnostic and therapeutic
procedures are indicated. Clinical symptoms
may initially be unspecific and recognition
may thus be delayed by days or more than 1
week.24, 25 Thus, a high level of alertness is
warranted, particularly in critically ill patients.
The reported complications of 2 508 TEE
studies in critically ill patients are listed in
Table II.10 The most frequent reported complications were circulatory disturbances such
as transient hypo- or hypertension, superficial
mucous lesions, hypoxemia, arrhythmias,
and dislodgement of nasogastric or nasojejunal tubes. Given the high severity of illness
in critically ill patients, TEE was associated
with surprisingly few complications (overall
complication rate of 61/2 508 - 2.6%) with
no examination related mortality (Table II).10
This is in accordance with a previous
European multicenter study reporting an

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HTTEMANN

TABLE III.Indications of transthoracic and transesophageal echocardiography in critically ill patients (in addition to the usual indications for TEE such as endocarditis, source of embolus and suspected aortic dissection).
TTE

TEE

General screening - overall evaluation


Hemodynamic evaluation

Inadequate visualization by TTE


Hemodynamic instability
Unexplained hypoxemia
Prone position
Tamponade (local)
Post cardiac surgery - complications of cardiothoracic surgery
Acute RV overload with hypoxemia; or hemodynamic instability, pulmonary emboli
Thoracic trauma (in a ventilated patient) and suspected aortic injury
Diagnosis/exclusion of thoracic aortic dissection, endocarditis, cardiac or aortic source of embolus
Guidance of placement of central lines, PAC; cannulae

Exclusion of tamponade

Acute RV overload (pulmonary embolism)


Thoracic trauma (patient not ventilated)
Contraindications for TEE

Depending on quality of visualization:


Mechanically ventilated patient
Complications of myocardial infarction
Evaluation of potential transplant donor

overall complication rate of 2.5% with 1 case


of fatal haematemesis due to a malignant
tumour (1/10 218 examinations, 88.7% being
conscious in- or outpatients).26 However,
complication rates of TEE undertaken in the
emergency department have been found to
be much higher than for TEEs undertaken in
intensive care units (ICUs). In one series of
142 TEEs, there were 18 complications
(12.6%): death (1), respiratory insufficiency/failure (7), hypotension (3), emesis (4),
agitation (2), and cardiac dysrhythmia (1).27
The issue of antibiotic prophylaxis before
TEE in view of the high risk of bacteremia in
ICU patients due to colonization of the upper
gastrointestinal tract and mucosal injury is
controversial. The reported incidence of postTEE bacteremia varies considerably. In a
prospective study involving 139 TEE procedures in an ICU, the frequency of bacteremia
attributable to TEE did not differ significantly between patients who received antibiotic
prophylaxis prior to TEE (1 of 83 patients;
[1.2%]) and those who did not (1 of 56
patients; [1.8%]).28 Other investigations documented in non ICU settings rates of post-TEE
bacteremia between 1% and 17%.29-32 Though
routine antibiotic prophylaxis before TEE is
not advocated, however, given the lack of

Vol. 72, N. 11

data on risk factors for developing post-TEE


endocarditis, it should be recommended in
high-risk patients such as those with prosthetic valves, multivalvular involvement or
those with a past history of infective endocarditis.
Indications
The updated guidelines of the ACC/
AHA/ASE for the clinical application of
echocardiography (2003) have delineated the
following conditions and settings in which
TEE provides the most definitive diagnosis
in the critically ill and injured (Table III):33
the hemodynamically unstable patient
with suboptimal TTE images;
the hemodynamically unstable patient
on a ventilator;
major trauma or postoperative patients
(unable to be positioned for adequate TTE);
suspected aortic dissection;
suspected aortic injury;
other conditions in which TEE is superior (such as suspected endocarditis, cardiac
or aortic source of emboli).
In a series of 2 508 TEE studies in critically ill patients published over the last 15

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Pericardial disease (3%)

Chest trauma (1%)

Valvular assesment (including prosthetic 6%)


Possible embolic source (7%)

Hemodynamic
instability (39%)

Miscellaneous (8%)

Aortic pathology (8%)

Ventricular function (9%)

Possible endocarditis (19%)

Legend: The pie chart illustrates the indications for performing a TEE for 2 508 studies in the ICU.
Figure 1.Specific indications for TEE in the ICU. With permission from Httermann et al.10

years,10 hemodynamic instability constituted


the by farleading indication, making up 39%
of indications, followed by suspected endocarditis (19%), assessment of ventricular function (9%), suspected aortic disease (8%), miscellaneus indications (8%), suspected cardiac
source of emboli (7%), valvular assessment
including prothetic valves (6%), suspected
pericardial tamponade (3%) and chest trauma
(1%) (Figure 1).
Endocarditis
Suspected infective endocarditis constitutes a rather common indication for a TEE
examination in the ICU and is the second
most frequent indication among centers
reporting their experience (Figure 1). Several
studies have demonstrated the role of TEE
in the detection of native and prosthetic valve
vegetation due to endocarditis. The sensitivity of TEE for vegetation on native valves in
patients with endocarditis is 82% to 100%,
compared to 60% for TTE 34-36 with specificities of 88% to 100%. In patients with prosthetic valve endocarditis, TEE has become
an essential diagnostic tool since the sensi-

896

tivity of TTE is a mere 36% compared to 77%


to 94% for TEE.37, 38 False-positive findings,
however, may occur from erroneous diagnosis attributable to lesions that resemble
vegetations such as Lambls excrescences,
valvular fibrin strands, ruptured or redundant chordae, nonspecific valvular thickening,
or calcification. In patients with prosthetic
valves, erroneous interpretation of artifactual phantoms, sewing ring sutures, surgically
severed or retained chordae tendinae, fibrin
strands, or periprosthetic material may occur.
TEE is a crucial diagnostic aide to identify
complications such as myocardial abscesses, fistulas, mycotic aneurysms, valvular
aneurysms or perforations, flail leaflets, or
prosthetic valve dehiscences. These serious
complications are harbingers of significant
morbidity and mortality, and may warrant
urgent surgical intervention.39-41 If a clinical
suspicion for endocarditis persists after a negative TEE, a repeat TEE should be performed
in 7 to 10 days. The negative predictive value of TEE is reported to be 98%.34 TEE - without transthoracic imaging - is cost effective in
ICU patients in comparison with other modal-

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ities when the probability of endocarditis


exceeds 2%.42 False negative studies are usually caused by vegetations that are smaller
than the resolution limits, vegetations that
have embolized, or artifacts from prosthetic
acoustic shadowing. Given the sensitivity and
according to the guidelines of the AHA, TEE
is the primary imaging modality of choice,
especially in patients with artificial valves, in
patients with intermediate or high clinical
suspicion of infective endocarditis and in
patients with high risk of infective endocarditis related complications such as Staphylococcus aureus bacteremia, fungemia, systemic-to-pulmonary shunts, cyanotic congenital heart disease, and prior IE.33 TEEguided therapy has been recommended to
determine duration of antibiotic therapy in
patients with catheterassociated Staphylococcus aureus.43
Pulmonary embolism
Transthoracic echocardiography (TTE) is
routinely used to screen patients with suspected pulmonary embolism. Acute cor pulmonale may be identified by the criteria of
acute RV pressure overload such as RV dilatation with right ventricle appearing larger than
left, paradoxical septal motion, loss of inspiratory collaps to inferior vena cava and tricuspid regurgitation (jet velocity >2.5 m/s2).44
TTE rarely visualises right cardiac thrombemboli. TEE is indicated if TTE is nondiagnostic, hemodynamic instability is present or
RV overload is identified (to confirm central
pulmonary or intracardiac thrombemboli).
TEE holds the promise of diagnosing pulmonary embolism by direct visualization of a
thrombus rather than by relying on indirect
signs, such as RV enlargement and hypokinesis. In patients with shock central thrombemboli are frequently demonstrated. In these
patients, TEE has a sensitivity of 80-92% and
a specificity of almost 100%.45, 46 The examination assesses the extent of thromboembolism as well as its surgical accessibility. In
general, the main pulmonary artery and then
the right pulmonary artery are first visualized. The right pulmonary artery can be followed until it branches to the right lobar pul-

Vol. 72, N. 11

HTTEMANN

monary arteries. However, due to interference of the left main bronchus, thromboembolism is more difficult to detect in the left
pulmonary artery.
PATENT FORAMEN OVALE
In patients with major pulmonary
embolism, detection of a patent foramen
ovale signifies a particularly high risk for
death and arterial thromboembolic complications. In a case series of 139 consecutive
patients with pulmonary embolism, the presence of a patent foramen ovale was associated with a mortality rate more than twice
as high as in patients without evidence of
right-to-left shunt.47 Multivariate analysis indicated a greater than ten-fold increase in the
risk for death and a five-fold increase in the
risk for major adverse events among patients
with pulmonary embolism and a patent foramen ovale. Therefore, in patients with pulmonary embolism and elevated right atrial
pressure, a patent foramen ovale should be
sought on echocardiography with color-flow
Doppler imaging or agitated saline contrast.
UNEXPLAINED SUDDEN CARDIAC ARREST AND PULSELESS ELECTRICAL ACTIVITY
TEE may have a uniquely valuable role in
patients who present with unexplained sudden cardiac arrest and pulseless electrical
activity. In a recent study, TEE was performed
in 25 patients who presented with pulseless
electrical activity.48 Eleven patients did not
have isolated RV enlargement. In 14, however, RV enlargement without left ventricular
(LV) enlargement was found. Of these 14, 5
had no pulmonary embolism (cardiac contusion; RV infarction; cor pulmonale; ventricular hypertrophy). The remaining 9
patients had pulmonary embolism. One case
of pulmonary embolism was missed during
TEE but was subsequently diagnosed at
autopsy. For the remaining 8 patients, pulmonary embolism was diagnosed during cardiac arrest. Two survived to hospital discharge: one received thrombolysis and the
other underwent emergent surgical embolectomy. Occult pulmonary embolism may thus
be considered a possible cause of cardiac

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arrest in patients with pulseless electrical


activity. If feasible, TEE should be done as
quickly as possible in appropriate patients
during resuscitative efforts.

effect of flow. Various authors have reported significant aortic atheroma in up to 50% to 60% of
patients with unexplained stroke.56
Aortic dissection

Systemic embolism
TEE constitutes the most sensitive and specific technique in determining the sources and
potential mechanisms for systemic embolism in
patients with stroke, transient ischemic attack
and peripheral and visceral infarction.49-51 TEE
can identify the cardiac source of cerebral
embolism in up to 57% of patients with cryptogenic stroke.50 Overall, TEE increases the
likelihood of finding a cardiac source of
embolism by between two- to fourfold.
Findings may include left atrial spontaneous
contrast, atrial and ventricular thrombi, vegetations, tumors, atrial septal aneurysm, rightto-left shunting through a patent foramen
ovale, and atheromatous disease of the aorta
as potential causes of embolism. In critically ill
patients with atrial fibrillation, TEE is often
necessary to rule out the presence of thrombi before cardioversion when a long period
anticoagulation is not possible. It has been
demonstrated that a TEE-guided cardioversion strategy produces a similar rate of stroke
(i.e., <1%) as that for the more traditional
method of anticoagulation therapy for 3 weeks
prior to the performance of elective direct current cardioversion.52 As such, a negative TEE
can replace moderate-term anticoagulation in
patients with recent onset atrial fibrillation prior to direct current cardioversion.
AORTA
TEE is of particular value for the evaluation
of the aorta, in particular the entities atheromatous disease, penetrating aortic ulcers, aortic intramural hematoma, dissection, and traumatic aortic injury.53-55 Aortography provides
only an inexact view of the aortic lumen, without clear identification of the endothelial surface.
CT scanning and MRI can provide an enhanced
evaluation; however, the imaging is not performed in real time. TEE is ideally suited to
providing high resolution real-time imaging,
which also provides atherosclerotic plaque morphology and mobility, as well as the dynamic

898

In addition to the previous gold standard


of aortography for the diagnosis of dissection, TTE, TEE, CT scanning, and MRI have
defined roles in the diagnosis of dissection.
Although each of these modalities has certain
advantages and limitations, the accuracy,
speed, relatively low cost, portability, and
capability to comprehensively evaluate the
heart, aorta, and its branches for complications of dissection have made TEE an attractive first choice for the evaluation of suspected aortic dissection in both the emergency department and in critical care settings.53, 55 In particular, TEE allows differentiation of dissection from intramural
hematoma and penetrating ulcers, localizing
primary and secondary entry sites, differentiation of the true and false lumen, evaluation
of the aortic valve for regurgitation, establishing involvement of the coronary arteries
and ruling out of associated conditions such
as pericardial effusions and tamponade.
Unexplained hypoxemia
In patients in whom the degree of hypoxemia appears disproportionate to the severity of their illness, TEE can diagnose or rule
out specific cardiac causes of hypoxemia
such as poor ventricular function, mitral
regurgitation, pleural effusions, pulmonary
emboli, intracardiac shunts (patent foramen
ovale, septal defects) and extracardiac shunts
such as intrapulmonary shunting associated
with a hepatopulmonary syndrome or orthopnoe tachypnoe syndrome.
Postoperative cardiac surgery patients
TEE is particularly valuable in hypotensive
postoperative cardiac surgery patient to detect
treatable conditions.57, 58 Entities encountered
are localized pericardial effusions and tamponade, perivalvular leakage, valvular dysfunction, right or LV dysfunction. The superiority of TEE results from the superior visualization in the postoperative setting with its

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many limitations regarding proper transthoracic imaging.


Myocardial infarction
In patients with myocardial infarction, particularly patients with cardiogenic shock, TEE
can provide useful additional information regarding the extent of myocardial
involvement and suspected complications.
Acute valvular insufficiency, secondary to
either chordal or papillary muscle ruptur and
the presence of mural thrombi, are best evalutated by TEE. Other complications such as
ventricular septal defect, free wall rupture,
dynamic LV outflow obstruction or ventricular pseudoaneurysm may be diagnosed by
TTE as well. Limitations of TEE in respect of
the ventricular apex should be remembered.

more complete assessment of the cardiac


structures than TTE.62 In this study, echocardiography eliminated 9 (30%) potential
donors on the basis of heart dysfunction,
regional wall motion abnormalities, and, in 1
patient, a bicuspid aortic valve. Of these 9, 7,
including the bicuspid aortic valve, were
eliminated on the basis of TEE findings (i.e.,
TTE was not adequate).
Furthermore, in addition to donor screening, given the incidence of 6.5-22.5% of LV
dysfunction in patients with lethal severe
brain injury or brain-dead patients,63 TEE may
have a significant impact on patient management, particularly by therapeutic interventions to optimize organ function ultimately
leading to improved organ procurement
rates.63
Hepatopulmonary syndrome

Chest trauma
Myocardial contusion or rupture, pericardial effusion, tamponade, major vascular disruption, septal defects or fistulae, and valvular
regurgitation may all result from either blunt or
penetrating trauma.59 Both TTE or TEE methods have been found to be useful in the severely injured patient in whom cardiac, pericardial, mediastinal, or major intrathoracic vascular injury has occurred. However, TEE has been
shown to be clearly superior to TTE in the
recognition and management of cardiovascular injuries after blunt chest trauma. In one
study, an adequate visualization by TTE was
achieved in only 38% of patients compared to
98% by TEE. TEE was far more sensitive in the
diagnosis of myocardial contusion (11% vs
34%), hemomediastinum (4% vs 25%) and aortic ruptur (2% vs 10%).60 In patients with suspected traumatic aortic injury TEE may be used
as first-line evaluation of such patients, particularly if hemodynamic instability.61 Recent
excellent reviews comprehensively cover the
use of TEE in traumatized patients and in the
emergency room setting.61
Management and assessment of potential
organ donors
TEE has been shown to provide high-quality imaging of cardiac donor hearts and a

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HTTEMANN

Contrast-enhanced TEE is superior to TTE


for detecting an intrapulmonary shunt (IPS)
in patients with severe liver disease. In recent
studies, the overall detection rate of an IPS
was significantly higher with TEE (42% and
51%) than with TTE (28% and 32%).64, 65
Quality of imaging was poor in 22% with
TTE and 0% with TEE. A paO2 <80 mmHg or
dyspnea was associated with an IPS in 56%
and 50% of patients with TEE and in 33%
and 25% with TTE, respectively. Because of
the high sensitivity of TEE in the diagnosis
and grading of pulmonary vasodilatation in
cirrhotic patients, and its better correlation
with gas-exchange abnormalities, all patients
suspected of a hepatopulmonary syndrome
should undergo TEE in search of an IPS if
TTE is normal.
Transthoracic versus transesophageal
echocardiography
Previous comparative analyses have shown
that limited diagnostic capabilities of TTE in
the ICU due to inadequate or inconclusive
imaging in the majority of patients 6, 7, 11, 14-16, 20
(Table IV).6, 7, 9, 11, 12, 14-16, 20 The improved cardiac evaluation by TEE is clearly evidenced
by the fact that TEE provided new diagnosis

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TABLE IV.Echocardiography in critical care: TTE versus TEE.


Author

Design Year

Study
period
(month)

ICU-type
(%)

Ventilated
patients
(%)

% patients TTE (N) TEE (N) Adequate


with
visualisation
TTE and
TEE

TTE
comment

% TEE
diagnosis
not available

Font6

1991

26

CICU

40

100

112

112

68

Fair to poor
image

27

Foster7

1992

30

GICU (50%)
CCU (47%)
M (3%)

N/A

34

28

83

N/A

4 studies
technically
very
poor

89

Heidenreich9

1995

14

CICU

91

75

45

61

36

28

Hwang11

1993

24

GICU (60%)
ER (40%)
SICU (48%)

21

100

78

78

N/A

50

Khoury12

1994

41

CCU (24%)
MICU (19%)
NICU (7%)

41

100

77

77

Technically
poor or
inconclusive
in all patients

80

Oh14

1990

12

59

100

51

51

N/A

TTE non-diagnostic,
suboptimal
or impossible

59

Pearson15

1990

10

36

100

62

62

N/A

Suboptimal
in most

44

Poelaert16

1995

CCU (49%)
SICU
(29.4%)
MICU
(21.5%)
CCU (49%)
CT-SICU
(21%)
MICU (19%)
SICU (11%)
GICU

56

N/A

N/A

103

N/A

27

Sohn20

1995

78

MICU (56%)
CT-SICU
(44%)

81

100

127

127

TEE only in
pts with
inadequate
TTE
Suboptimal
TTE reason
for TEE

98

Abbreviations: CICU: ICUs with a high proportion of coronary and/or cardiac surgical patients, but not further specified; CT-SICU:
Cardiothoracic-Surgical ICU; MICU: Medical ICU; SICU: Surgical ICU, CCU: Coronary Care Unit; GICU: General ICU (General adult ICU
(critical illness, trauma, major elective surgery); NICU: Neurologic-neurosurgical ICU; ER: Emergency room; M: Miscellaneous.

in 27% to 98% of patients. Even more important, changes in treatment management were
in a high percentage 80% solely due to
TEE findings.12
Two factors account for this high percentage of inadequate studies of TTE in critical-

900

ly ill patients: technical factors and patient


characteristics. In critically ill patients proper imaging is frequently limited due to surgical dressings, tapes, or tubings, air distribution due to mechanical ventilation, the presence of pneumothorax, pneumomediastinum,

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TABELLA I. Vie anatomiche del dolore nelle lom


Comment (numbers in
phrases denotes
number of patients)

Sensitivity of TTE compared


to TEE for different
entities in %
(number of patients
in brackets)

By TEE 131 new lesions com- Significant regurgitation (50):


pared to 95 by TTE: TTE/TEE 76
Thrombus (8): 75
= 73% overall:
Vegetation (26) : 73
LV visualization (20): 65
Aortic pathology (12): 67
25 new findings by TEE in 22 N/A
pts with previous TTE;
TEE prompted cardiac surgery in 19% of patients
28% (17) new diagnosis by N/A
TEE not observed by TTE
48% of changes in
management due to TEE
Aortic dissection (27): 44

Hemodynamic instability
(20): 55
Embolic source (11): 0
Mitral regurgitation (7): 56
Vegetation (3) : 0
80% (37) of changes in mana- Vegetation /Abscess (14): 36
gement were due solely to Cardiac source of embolism
TEE findings; TEE prompted (3): 0
surgery in 22 patients (29%) Hypovolemia (7): 0
Mitral regurgitation (8): 25
N/A
59%

44

N/A

TEE excluded abnormalities N/A


in 27%

98%

N/A

HTTEMANN

inadequate studies in such critically ill


patients. Recently, weight gain >10%, PEEP >
15 cm H2O, chest tube thoracostomy, inotropes, or vasopressors have been identified as
factors indicating a significantly higher rate of
failure of TTE to provide adequate imaging in
critically ill surgical patients.66
When assessing the role of TTE and TEE in
the ICU, it should be kept in mind that the
studies cited above date from the last decade.
New modalities such as harmonic imaging
and contrast injection may considerably
improve the usefulness of TTE in critically
ill patients. Two studies have shown that wall
motion scoring and ejection fraction calculation can be improved to over 80% of such
patients with contrast imaging.67, 68 Recently,
employing current TTE equipment with harmonic imaging and digital imaging technology, TTE image quality was adequate in 99%
of cases.69 In this study, in a general critical
care population, the sensitivity of TTE for
the detection of cardiac cause of shock shock
(defined as severe LV or RV systolic dysfunction, tamponade, severe left-sided valve
disease, or a postinfarction mechanical complication), was 100% and the specificity was
95%.69
Because of the highly variable nature of
critical care patients, the differing clinical settings, the ongoing technical improvements
of both TTE or TEE techniques, the relative
merit and recommendations may vary among
institutions. In any case, TTE can be extremely useful in critically ill patients, despite its
technical limitations. Whether or not TTE
studies should precede TEE, depends on the
critical care setting and the experience of the
attending physicians.
Impact on patient management

or subcutaneous emphysema, edemas, obesity and chronic obstructive disease. In addition, lack of patient cooperation, as well as
the impossibility of moving some patients
into the left lateral decubitus position, contributes to a high prevalence of technically

Vol. 72, N. 11

Over the last decade, the efficacy of TEE


has been evaluated in different populations
of critically ill patients, as well as in various
types of ICU.2, 4, 6-22 Twenty-one studies have
been published so far evaluating the impact of
TEE on patient management in a total of 2
508 critically ill patients (Table I). The majority of these investigations were retrospective

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Cardiac source of emboli (4%)

RWMA (4%)

Aortic pathology (8%)

Left ventricular
disfunction (27%)

Pericardial disease (10%)

Vegetations/abscess (11%)
Valve disfunction (14%)

Hypovolemia (11%)
Right ventricular disfunction (11%)

Legend: Diagnosis established by TEE in the ICU based on 2 508 studies.


Figure 2.Most frequent diagnosis by TEE in the ICU. With permission from Httermann et al.10

in design (18/21). The investigations differ


considerably in study design, size, setting (type
of ICU), percentage of ventilated patients (21100%), and indications for performing a TEE
study. By far the most experience in the use of
TEE in ICUs stems from critical care settings
with a high proportion of cardiac, including
coronary and/or cardiac surgical patients
(53%). Given this heterogenity of settings and
indications, it is not surprising that the reported findings, as well as therapeutic and surgical impact, vary considerably (Figure 2).10 LV
dysfunction comprised 27% (1-31), valve dysfunction 14% (1-32), RV dysfunction 11% (122), hypovolaemia 11% (1-14), endocarditis, as
evidenced by vegetations or paravalvular
abscess, 11% (2-19), pericardial tamponade
10% (2-13), aortic pathology 8% (1-40), a cardiac source of emboli 4% (3-8), and regional
wall motion abnormalities 4% (5-30) of the
main diagnoses established in 2 508 patients
(values in parentheses denote range of values in different studies). In 2 studies, miscellaneous conditions such as low SVR (21%)
and congenital heart disease (6%) were reported as findings. The efficacy of TEE has been

902

adressed by the evaluation of the impact on


patient management. Diagnostic, therapeutic
and surgical impact have been defined as identification of the underlying cardiovascular
pathology, changes in acute care (application
of antibiotics, inotropic or vasopressor drugs,
fluids) and surgical interventions resulting from
TEE findings, respectively. The diagnostic,
overall therapeutic and surgical impact
described in these studies ranged from 44% to
99% (weighted mean 67.2%), 10% to 69%
(weighted mean 36%), and 2% to 29% (weighted mean 14.1%), respectively (Table IV). In
summary, the majority of studies points to a
high diagnostic and therapeutic impact in critically ill patients.
Hemodynamic instability
Both TTE and TEE are now considered as
the methods of choice in hemodynamic unstable critically ill patients. In particular, TEE is not
only feasible and safe in greater than 97% of
patients, but also is a technology that can be
performed quickly at the bedside. In one study

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HTTEMANN

TABLE V.Basic echocardiographic characteristics of the most common clinical conditions of acute circulatory
failure - differential diagnosis of hypotension.
Etiology

Hypovolemia
Left ventricular dysfunction

LVEDA

FAC

Doppler

RVEDA

Additional findings

MR

Respiratory variation of aortic VTI


Regional wall motion abnormalities;
diastolic dysfunction
SVR

Vasodilatation (f.e. septic or ()


anaphylactic shock)
Valvular dysfunction (severe
[acute] mitral or aortic regurgitation)
Ventricular septal defect
Pulmonary embolism

Right ventricular dysfunction

Tamponade

E<A
(preload )
MR, AR

VSD
TR, PR
TR

Valve morphology

(>> 0.6 EDA)


(>0.6 EDA)

Intracardiac thrombi; PAP


Pericardial effusion; (early) diastolic
collaps of free right atrial or ventricular wall

EDA ventricular end-diastolic area LVEDA left ventricular end-diastolic area, RVEDA right ventricular end-diastolic area, FAC fractional area change, MR mitral regurgitation, AR aortic regurgitation, TR tricuspid regurgitation, PR pulmonary regurgitation, VSD ventricular septal defect, SVR systemic vascular resistance, PAP pulmonary artery pressure, E E wave (maximal velocity of early diastolic filling), A A wave (maximal velocity of atrial diastolic filling), VTI velocity time integral, decrease, increase, normal.

the TEE assessment required 19 min to perform compared to 63 min to set up for and
evaluate by a pulmonary artery catheter (PAC).70
Echocardiography may help to define pathophysiological abnormalities in patients even
when there is continuous invasive monitoring by a PAC. In several series echocardiography was found to be more reliable than the
PAC in determining the cause of hypotension.9, 57, 58, 71, 72 In the setting of hypotension,
TEE has changed management in as many as
63% of patients with a PAC in place, resulting
in an improvement in hemodynamics.9
Concordance between TEE and PAC in critically ill patients has been good for patients
with normal cardiopulmonary function and
in patients with low ventricular volumes.9, 72
However, in patients with abnormal cardiopulmonary function, agreement has been
variable, ranging from 0% to 71%.70-72 In a
recent study on hemodynamically unstable
patients after cardiac surgery monitored with
PAC, hemodynamic and TEE monitoring
showed only a fair agreement on the hemodynamic diagnosis (such as hypovolemia, left
or RV dysfunction, or tamponade).73
The differential diagnosis of the most common clinical conditions of acute circulatory
failure by echocardiography is illustrated by
Table V. Due to its diagnostic power, echocar-

Vol. 72, N. 11

diography permits a rational step by step


approach to the problem of hemodynamic
instability, which is illustrated in Figure 3. Based
on the echocardiographic findings, treatment
can be started and its effects assessed by repeated TTE or short-term TEE monitoring. If necessary, because of persistent hemodynamic
instability or treatment failure, an advanced
hemodynamic monitoring such as PAC or
transpulmonary indicator dilution technique
(PiCCO) can be tailored to the patients need.
TEE and other devices for an advanced
hemodynamic monitoring
As a diagnostic tool, TEE provides a wide
array of information. However, as a continuous monitor for a prolonged period of time
(>12-24 h), it is limited by both the current
technology and the ability of the caregiver
to continuously interpret on-line images.
Newer technology, such as smaller TEE
probes, may make it more feasible to place a
probe for prolonged periods of time. The
continuous on-line interpretation of images
would still be limited by the abilities and
availability of those clinicians performing and
interpreting the exam.
Measurement of cardiac output by TEE on

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TRANSOESOPHAGEAL ECHOCARDIOGRAPHY IN CRITICAL CARE

Hemodynamic instability
Unexplained hypotension

Cardiac function?

Initial clinical assessment and general measures

Evident cause

Transthoracic
Transesophageal echocardiography

Treatment

Therapeutic failure

Specific problems:
Pericardial effusion
Valvular dysfunction
New regional wall motion
abnormalities
Emboli

Specific therapeutic
Interventions:
(PTCA, thrombolysis, surgery etc.)

Hyperdynamic
LV (end-systolic
obliteration of LV)

LV and/or RV
dysfunction
(low perfusion
state, low blood
pressure)

RV overload
(PHT)

Optimalization of filling (RASPV/RV of VTI)

Persistent low cardiac output


Re-evaluation by echocardiography

Indication for continuous advanced hemodynamic


monitoring (f.e. PAC or PiCCO) based on TEE and
patient characteristics and differentiated pharmacological
therapy (inotropes, vasopressors and fluid)

Legend:
This figure illustrates the diagnostic approach to a critically ill patient presenting with acute hemodynamic instability
RASPV: respiratory arterial systolic pressure variation

Figure 3.Assessment of cardiac function in the critically ill patient - Diagnostic approach.

a continuous basis is not yet available.


However, in instances such as severe tricuspid regurgitation, where thermodilution cardiac outputs can be misleading, the cardiac
output can be checked by a Doppler-derived
cardiac output.
Echocardiography provides different
information than other currently available
devices for an advanced hemodynamic monitoring such as the PAC and the PiCCO system, and the methods are therefore not com-

904

petitive but rather complementary. An


overview of the parameters, that can be
obtained by each technique, and its advantages and disadvantages is provided in Table
VI.
Assessment and monitoring of cardiac
function
In the critical care setting, heart failure

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HTTEMANN

TABLE VI.Hemodynamic assessment by echocardiography compared to pulmonary artery catheterization (PAC)


and double indicator dilution technique (PiCCO).
Device

Parameters
Preload
Fluid responsiveness
Afterload
Contractility

Pulmonary artery
catheterization
(PAC)

Double indicator
dilution technique
(PiCCO)

ITBVI/GEDVI

CVP, PAOP, RVEDV

CO

SVR
LVSWI, RVSWI
RVEF (RVEF-PAC)
CO/CCO (thermo-dilution)

PAP
Miscellaneous

PAP (continuously)
SvO2

Advantage

Continuous (CCO, SvO2,


RVEDV)
hemodynamic
monitoring
PAP (pulmonary hypertension)

Disadvantage

Invasive
Filling pressures (CVP,
PAOP) do not correlate well
with SV
Beneficial effect on clinical
outcome not documented

SVV
SVR
CFI

(Transesophageal)
Echocardiography

LVEDA, LVEDV;
RVEDA, RVEDV
Respiratory variation of VTI
Wall stress
EF, FAC, PAMP

CO/CCO (thermo-dilution, pul- CO (Doppler flow)


se contour analysis)
PAP (intermittent)

Regional wall motion


EVLW
Diastolic function
Valvular function
Continuous hemodynamic Bedsided, comprehensive
evaluation of cardiac funcmonitoring (CO)
tion (see above)
ITBVI better preload parameter than filling pressures Inexpensive (TTE)
Assessment of fluid res-ponsiveness by SVV
EVLW may aid management
of ARDS
Technically limited images
Invasive
in majority of patients (TTE)
No information on PAP
Beneficial effect on clinical Semi-invasive (TEE)
outcome not documented Repeated studies longer
than several hours are
impractical
Requires training
Data intermittent
High fixed costs

CFI cardiac function index, CVP central venous pressure, PAOP pulmonary artery occlusion pressure, TTE transthoracic echocardiography, TEE transesophageal echocardiography, PAP pulmonary artery pressure, SVV stroke volume variation, EVLW extravascular
lung water, CO cardiac output, CCO continuous cardiac output, ARDS acute respiratory distress syndrome, SvO2 mixed venous oxygen saturation, LVEDV left ventricular end-diastolic volume, RVEDV right ventricular end-diastolic volume, ITBVI intrathoracic blood
volume index, PAC pulmonary artery catheter, RVEDV right ventricular end-diastolic volume, GEDVI global end-diastolic volume index,
LVEDA left ventricular end-diastolic area, RVEDA right ventricular end-diastolic area, FAC fractional area change, SVR systemic vascular resistance, PAP pulmonary artery pressure, VTI velocity time integral, LVSWI left ventricular stroke work index, RVSWI right ventricular stroke work index, RVEF right ventricular ejection fraction, EF ejection fraction, FAC fractional area change, PAMP preload adjusted maximal power.

is commonly defined as an alteration of cardiac pumping preventing an adequate systemic oxygen delivery at a rate commensurable with aerobic requirements of the
metabolizing tissues. Many factors can result
in the heart failing as a pump, and the complexity of these factors requires to differentiate contractile performance of the
myocardium from those related to hydraulic
loading.
This is especially important since a rational therapeutic approach requires a sound
understanding of the underlying patho-

Vol. 72, N. 11

physiology. Echocardiography allows the


examiner not only to obtain data on the
physiologically relevant determinants of
ventricular function, namely contractility,
preload and afterload, but also on the diastolic function and cardiac output. Although
alteration in LV diastolic function may result
form systolic dysfunction, as may as 40%
of patients with congestive heart failure may
present with normal systolic function and
have diastolic dysfunction as primary cause.
Recent excellent reviews comprehensively
cover the issue of hemodynamic monitoring

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by TEE.74, 75
Preload
TEE permits qualitative and quantitative estimation of preload in patients with either normal
ventricular function as well as dysfunction. In
adequately sedated critically ill patients the
presence of a hyperdynamic ventricle may indicate hypovolemia in the absence of inotropic
drugs. Furthermore, lv end-systolic cavity obliteration, referred to as kissing walls or kissing
papillary muscles, is very suggestive of a low filling status.76 Three-dimensional assessment of LV
volume can be done by tracing the end-diastolic
border in a mid-esophageal long-axis view in
a longitudinal plane. A quantitative estimation
can be performed in different ways using twodimensional echocardiography. The left ventricular end-diastolic area (LVEDA), measured
at as imaged in the transgastric short axis view
at the level of papillary muscles, correlates well
with volumetric analogues and has been shown
to directly reflect changes in left ventricular
end-diastolic volume (LVEDV).77 In cardiosurgical patients with normal as well as abnormal
LV function a linear decline in LVEDA of 0.3
cm2/ % blood loss was described during graded blood loss.78, 79 An indexed LVEDA measured at the midpapillary level of the left ventricle of smaller than 5.5 cm2/m2 body surface
area is very suggestive for a low filling status of
the LV.80 A good correlation (r = 0.84 and 0.87
respectively) was found between cardiac output and changes in the LVEDA index and
intrathoracic blood volume index measured
with the dye dilution technique in patients with
septic shock and in postoperative cardiac surgical patients, although neither parameter correlated with central venous pressure (CVP) or
pulmonary capillary wedge pressure (PCWP).81,
82 In critically ill patients, no correlation between
PCWP and stroke volume (SV) was found,
while end-diastolic area (EDA), measured by
TEE, correlated well with measured SV.83
Further, changes in PCWP after a fluid bolus did
not correlate with changes in SV or EDA. In
this study, a large percentage of patients were
receiving inotropic therapy. Baseline PCWP or
EDA did not adequately predict a response to
volume therapy; however, patients with lower

906

EDA were more likely to increase SV after fluid administration.


However, if fluid management is to be
guided by LVEDA, several shortcomings and
limitations must be appreciated. The presence of regional wall motion abnormalities
may limit the correct use of LVEDA as a preload parameter. Furthermore, the apical
region of the LV is more prone to regional
wall motion abnormalities than the base of
the heart. Single data seldom provide conclusive information about the filling status,
especially in septic patients with increased
LVEDA. In patients with RV dysfunction,
bulging of the interventricular septum towards the left decreases LVEDA. Guiding fluid management by LVEDA in these patients
will lead to inappropiate therapeutic interventions.
In order to circumvent the limitations of
static parameters such as EDA or end-diastolic
volume (EDV) in predicting response of volume therapy, the term fluid responsiveness
has been proposed as an important estimate
of the optimization of preload. Using methods that are analogous to systolic respiratory pressure variation 84 and SV variation 85
which have been shown to correlate well
with a positive fluid responsiveness, the value of flow measurements across the aortic
valve in the assessment of flow velocity variation with cyclic altering of intrathoracic pressures has been demonstrated recently.86 The
velocity time integral (VTI) at that level
decreased progressively, in close relationship with a graded and controlled blood loss
performed in an animal experimental setting.
Thus, respiratory variations of VTI are a sensitive index of fluid responsiveness.
Filling pressures
Although multiple studies have demonstrated that central pressures can be assessed
using echocardiography, it is important to
realize that these pressures are estimated and
not directly measured.
LEFT-SIDED FILLING PRESSURES
Echocardiography permits the indirect
estimation of LV filling pressures in various

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ways, utilizing both two-dimensional echocardiography and Doppler echocardiography.


The curvature of the interatrial septum
reflects the relationship between right and left
atrial pressures (LAP).87 At low or normal LAP
the interatrial septum briefly reverses its normal rightward curvature during the exhalation phase of positive pressure ventilation because for just this moment, the right atrial
pressure (RAP) exceeds the LAP - absence of
this reversal has a positive predictive value of
0.97 for a LAP >15 mmHg.87 In patients with
hypovolemia, the movement of the interatrial
septum during the cardiac cycle is increased.
However, pressure or preload estimation by
means of the position of the interatrial septum is not applicable in patients with valvular
disease such as tricuspid regurgitation and in
severe LV failure.
Doppler echocardiography allows estimation of left-sided filling pressures by various
methods. The transmitral flow pattern, using
pulsed-wave Doppler, consisting of an E and
A wave (the E wave represents the early rapid
filling phase, whereas the A wave is secondary to late filling as a result of atrial contraction), provides insight as well to the LAP
as well as to the LV diastolic function. LAP can
be determined by looking at the deceleration time of early diastolic filling of mitral
inflow. This method correlates well with
PCWP in those patients with LV ejection fractions of less than 35%.88 The shorter the DCTE, the higher is the PCWP. An DCT-E of <120
ms and >150 ms indicated a high and a low
PCWP, respectively. A DCT-E >150 ms had a
positive predictive value of 100% that the
PCWP is >10 mmHg.88
When present, mitral regurgitation can also
be used to estimate LV filling. Doppler
echocardiography permits the estimation of
the LAP using the modified Bernoulli equation, as described in the following formula
LAP: SAP - 4 V2, in which SAP is the systolic
aortic pressure, and V2 is the transmitral peak
regurgitant flow velocity. This method is
based on the assumption there is no pressure gradient between the LV and the ascending aorta.
The regurgitant jet of aortic regurgitation
can be used to determine the left ventricular

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HTTEMANN

end diastolic pressure (LVEDP) as shown by


the following formula: LVEDP = DBP - 4
(ARED) 2 (DBP = diastolic blood pressure;
ARED = end diastolic velocity of the aortic
regurgitant jet).
The pulmonary venous flow pattern is a
another possibility for estimating left-sided
filling pressures.89 A strong negative correlation exists between the systolic fraction of
pulmonary vein flow and LAP. A systolic fraction of less than 55% was a sensitive indicator and specific indicator of LAP >15 mmHg.
As qualitative assessment of LAP is possible
by determination of the dominating peak
velocities: if systolic peak velocity dominates,
LAP is low; if diastolic peak velocities predominates with blunting of systolic peak,
LAP is high.90 A ratio of the systolic and diastolic flow wave velocities of <0.4 is suggestive of an increased LVEDP.91 The systolic
forward flow wave in the pulmonary vein
Doppler pattern is preceded by a small
reverse atrial contraction wave. Another
important feature is the ratio of the duration
of the atrial reverse flow wave at the level of
the pulmonary veins and the atrial contraction
wave at the level of the mitral valve. The difference between the duration of the atrial
reversal flow and the duration of the atrial
inflow wave is independent of age and thus
may be used as a reliable index of LVEDP,
even in elderly patients. A reverse A wave
duration that exceeds the duration of the atrial inflow wave predicts an LVEDP of >15
mmHg.92 PCWP correlates best with the atrial reverse flow wave velocity (r=0.81).89
Recently, tissue doppler myocardial imaging (TDI) has been demonstrated to allow
an fairly accurate estimation of left-sided filling pressures.93, 94 Whereas the E wave of the
transmitral flow pattern is load-sensitive, the
early diastolic velocity measured with TDI, Ea,
behaves as a relatively load-independent
index of ventricular relaxation. The ratio of
the E wave to Ea showed the strongest relation to PCWP (r=0.86), irrespective of the
pattern and the ejection fraction,94 although
this has not been confirmed.95
COLOR DOPPLER M-MODE

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A new approach to describe left myocardial


relaxation and assess preload is the measurement of flow propagation velocity (FPV),
the rate at which the transmitral flow is propagated into the ventricle, by color Doppler mmode. This index depends on the relaxation
rate of the ventricle and seems to be independent of preload.96 The ratio of peak E
wave velocity/FPV can be used to estimate
pulmonary artery occlusion pressures (PAOP).
In 45 patients in intensive care, estimated
PAOP showed good agreement with measured PAOP, overreading by 16.2 mmHg
(bias2 SD) at a mean PAOP of 15 mmHg.96
In summary, TEE cannot estimate LAP precisely, but can reliably identify clinically significant elevations in most patients.
RIGHT ATRIAL PRESSURE
Measurement of the vena cava diameter
and its variation during the respiratory cycle
allows estimation of RAP.97 A dilated vena
cava (>2 cm) without significant respiratory
variation (<50%) is consistent with RAP >15
mmHg.
Diastolic function
Doppler echocardiography allows a comprehensive evaluation and grading of diastolic
function. Normal diastolic function allows
adequate filling of the ventricles during rest
and exercise without abnormal increase in
diastolic filling pressures. Diastolic dysfunction encompasses a continuum of abnormal
filling patterns due to abnormal relaxation
and compliance. Based on the information
obtained from transmitral and pulmonary
venous flow patterns, the following grades of
diastolic dysfunction can be differentiated by
echocardiography: impaired relaxation and
compliance, pseudo-normalization, and
restriction, either reversible or irreversible.
Particularly in the critical care setting, however, one should be aware that the data
obtained are the resulting effect not just of
myocardial factors (ischemia, inotropic stimulation) affecting compliance and relaxation
but as well as external factors such as
mechanical ventilation with high positive
end-expiratory pressure, stiffness of the peri-

908

cardium and thrombi in the pericardial sac.


Recently, new techniques such as TDI and
color doppler M-mode have been shown to
provide less load, sensitive indices of diastolic
dysfunction.98 For a detailed discussion of
the evaluation of diastolic function by
echocardiography the reader is referred to
the literature.
Assessment of global ventricular function
Global ventricular function may be
assessed by both load-dependent and load
independent parameters. Ejection fraction or
fractional area change (the two-dimensional
parameter) are the classical load-dependent
indices of global ventricular function. Another
flow derived load dependent parameter to
describe global LV function is dP/dtmax, the
mean rate of pressure rise, which requires
some degree of mitral regurgitation.99
A clinically appealing afterload independent parameter is preload adjusted maximal
power (PWRmax = PAo x VAomax x AVA x 1.333
x 10-4 (PAo instantaneous aortic pressure,
VAomax instantaneous maximum aortic blood
flow velocity, AVA time-averaged aortic valve
area, and PWRmax the maximum PWR [in
watts]).100 In clinical conditions, instantaneous
aortic pressure is arterial blood pressure at the
time point at which the product of pressure
and flow becomes is at the maximum.
Preload adjustment may be done by correction of the PWR with the square of the LVEDV
or the LVEDA. This method however cannot
be used in patients with severe mitral regurgitation or aortic valve disease.
Cardiac output
Cardiac output can be measured in a number of ways by echocardiography that can
be divided into volumetric and Dopplerbased methods. Using measurements made at
end systole and end diastole, the SV (and
hence cardiac output) can be estimated. The
2 main limitations of volumetric methods are
resolution and geometry. Resolution of 2
dimensional echocardiography ranges from
0.3 to 1.5 mm, depending on the frequency
used and number of cycles per pulse. In a
comparison of echocardiography-derived SV

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with thermodilution, a 10% change in SV corresponded to only a 0.7-mm change in ventricular radius.101 Geometric assumptions rely
on smooth circular or elliptical shapes. The
ventricle is assumed to contract uniformly,
which may not occur, even without regional
wall motion abnormalities. Extrapolation from
areas to volumes adds further errors.
Volumetric cardiac output methods may be
sufficient for tracking trends, but for absolute
values, agreement with thermodilution was
relatively poor.102-104
By using Doppler echocardiography, cardiac output can be computed by multiplying flow velocity time integral over LV outflow
tract, aortic, mitral, or pulmonary valve, valve
opening area and heart frequency.105-108 In
general, the measurement of flow velocity at
the aortic valve is the preferred site for determining cardiac output. Compared with the
standard thermodilution technique for cardiac output estimation, studies using aortic
valve flow have shown good agreement with
thermodilution, especially if the aortic valve
area is estimated by using a triangular model.105-107
Afterload
Physiologically, afterload is defined as
the force opposing ventricular fiber shortening during contraction or the impedance
to ejection. Although it is influenced to a
high degree by the arterial pressure, it is
not synonymous with peripheral arterial
pressure, peripheral vascular tone or SVR.
Afterload is determined by peripheral loading conditions as reflected by the SVR as
well as intrinsic cardiac properties such as
ventricular dimensions and wall thickness.
Thus it is not surprising that SVR has been
shown to be an unreliable index of LV afterload.109 (End-systolic)- meridional wall stress
( = 1.35 P ESD / 4 h (1 + h / ESD) [P
LV end-systolic pressure; ESD LV end-systolic diameter; h end-systolic LV wall thickness]), which can be measured by echocardiography, reflects all these factors and is a
better index of afterload than SVR alone.
According to Laplaces law LV wall stress
is directly proportional to chamber radius

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and pressure and inversely proportional to


wall thickness. While SVR is a function of
cardiac output and arterial pressure, afterload is a function of ventricular size and
arterial pressure. This explains, why in a
critically ill patient wall stress may be elevated due to a dilated ventricle while SVR
may be significantly reduced. This differentiation is important, since afterload,
besides the heart rate and contractile state,
is a major determinant of myocardial oxygen
consumption.
Conclusions
In summary, echocardiography offers a
unique way for a comprehensive assessment
of cardiac function. Both TTE and TEE provide real-time bedside information about a
variety of structural and functional abnormalities of the heart as well as contractility,
filling status and cardiac output. Both
approaches have its benefits and limitations.
Although TTE may remains the approach of
choice, TEE has been shown to be of additional value in many instances in critically ill
patients due to its ability to provide excellent visualisation of cardiac structures.
Advances in technology such as miniaturized probe size, 3-D-ultrasound, automatic
blood flow measurement, will expand the
role of TEE in critical care. Echocardiography
is the method of choice for the assessment of
cardiac function, but cannot simply replace
other technologies of advanced hemodynamic
monitoring
in
the
ICU.
Echocardiography provides different information than the PAC or the transpulmonary
indicator technique, and the methods are
therefore not competitive but rather complementary.
Similarly to devices such as the PAC, the
present body of evidence supporting the use
of TEE in critically ill patients lacks prospective, randomized controlled studies focusing
on end-points like cost-effectiveness, morbidity or mortality. However, present evidence as well as experience, points to the
significant benefits which may be gained by
the availability of echocardiography and espe-

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TRANSOESOPHAGEAL ECHOCARDIOGRAPHY IN CRITICAL CARE

cially TEE in ICUs, as well the necessity for a


training of intensive care physicians.
Riassunto
Ecocardiografia transesofagea in Terapia Intensiva
Lecocardiografia si evoluta sino a divenire una
delle modalit pi versatili per la diagnosi e per la guida del trattamento di pazienti critici. Sia lecocardiografia transtoracica (TTE) sia quella transesofagea
(TEE) sono in grado di fornire al letto del paziente
informazioni in tempo reale su una variet di anomalie cardiache strutturali e funzionali cos come sulla
contrattilit, sullo status ventricolare e sulla gittata
cardiaca, e sono diventate il metodo di scelta per la
valutazione della funzionalit cardiaca nelle unit di
terapia intensiva. Entrambi gli approcci presentano
vantaggi e svantaggi. Sebbene la TTE rimanga lapproccio di scelta, la TEE si dimostrata in grado di
fornire un valore aggiunto in molti casi di pazienti critici grazie alla sua capacit di fornire una visualizzazione eccellente delle strutture cardiache, al suo
impatto sulla gestione del paziente e al suo basso
tasso di complicanze (2,6%). Viene qui rivisto lo stato dellarte della TEE nel paziente adulto critico, con
particolare attenzione circa il suo ruolo diagnostico in
diversi scenari clinici, sottolineandone i suoi effetti
sulle decisioni cliniche che dovranno essere prese
ma anche sul suo ruolo circa il monitoraggio. Le condizioni nelle quali la TEE fornisce le migliori indicazioni diagnostiche definitive nei pazienti critici e nel
caso in cui siano presenti lesioni cardiache sono rappresentate dai pazienti emodinamicamente instabili
con reperti TTE sub-ottimali o sottoposti a ventilazione meccanica, dai pazienti con sospetta dissezione aortica o con lesioni aortiche e da altre situazioni nelle quali la TEE si dimostra essere superiore
alla TTE (come nel caso di sospetta endocardite, di
possibile embolia a partenza cardiaca o aortica).
Limpatto diagnostico, terapeutico e chirurgico sulla
gestione del paziente critico varia dal 44% al 99%
(media ponderata 67,2%), dal 10% al 69% (media
ponderata 36%) e dal 2% al 29% (media ponderata
14,1%), rispettivamente, a seconda dei pazienti e del
tipo di terapia intensiva. Dal momento che lecocardiografia fornisce informazioni diverse rispetto ad
altri strumenti per il monitoraggio emodinamico, quali
il cateterismo arterioso polmonare, i diversi metodi
non sono in competizione tra loro ma piuttosto complementari. I dati attuali che supportano lutilizzo della TEE nei pazienti critici necessitano di studi prospettici, randomizzati e controllati focalizzati su obiettivi
quali il rapporto costo-beneficio, la morbidit o la
mortalit. In ogni caso, levidenza attuale cos come
lesperienza, evidenziano i significativi benefici che
possono essere ottenuti dalla disponibilit dellecocardiografia, specialmente quella TEE, nelle unit di

910

terapia intensiva, cos come la necessit di un adeguato addestramento dei medici operanti in tali tipi di
unit.
Parole chiave: Ecocardiogramma transesofageo Paziente critico - Terapia intensiva.

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