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Table of Contents
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Year : 2015  |  Volume : 18  |  Issue : 2  |  Page : 225-226
Rational interpretation of transesophageal echocardiography hemodynamics in the Intensive Care Unit, post aortic valve replacement


1 Indraprastha Apollo Hospital, New Delhi, India
2 Department of Cardiology and echocardiography, Indraprastha Apollo Hospital, New Delhi, India

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Date of Web Publication2-Apr-2015
 

How to cite this article:
Kapur K K, Garg N. Rational interpretation of transesophageal echocardiography hemodynamics in the Intensive Care Unit, post aortic valve replacement. Ann Card Anaesth 2015;18:225-6

How to cite this URL:
Kapur K K, Garg N. Rational interpretation of transesophageal echocardiography hemodynamics in the Intensive Care Unit, post aortic valve replacement. Ann Card Anaesth [serial online] 2015 [cited 2019 Jul 20];18:225-6. Available from: http://www.annals.in/text.asp?2015/18/2/225/154477



   Case History Top


A 6-year-old male underwent tissue-aortic valve replacement (AVR). Postoperative, he required high inotropic support and high antibiotic support - his heart rate (HR) was 120/min and blood pressure was 90/60 mmHg. His transesophageal echocardiography - Echo report reveals:


   Observatiobs on Tee Top


The patient postoperatively showed the following:

  • Significant mitral regurgitation (MR) due to unrecognized mitral valve pathology [Figure 1] and [Figure 2]
    Figure 1: Mitral regurgitation

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    Figure 2: Mitral inflow pattern

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  • High ante grade trans-mitral velocity due to MR [Figure 3]
    Figure 3: High gradient across tissue aortic valve (transgastric view) Vmax: 390cm/s, VTI: 54.6 cm, MaxPG: 61 mmHg; Mean PG: 35.9 mmHg

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  • High left ventricular outflow tract (LVOT) velocity due to LVOT obstruction precipitated by inotropes [Figure 4]
    Figure 4: Left ventricular outflow tract gradients transgastric view

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  • Stiffened tissue aortic leaflets with high gradients [Figure 3] and [Figure 5]
    Figure 5: Transesophageal echocardiography long axis view showing transprosthetic flow

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  • High cardiac output (CO) resulting from Septicemia.


What does these parameters convey?

Hemodynamic calculations from transesophageal echocardiography parameters

  • Stroke volume (SV) = LVOT area × LVOT velocity time integral (VTI) =3.46 × 28 = 96.88 ml
  • CO = HR × SV = 120 × 96.88 = 11.6 l/min
  • Systemic vascular resistance (SVR) = 80 × (MAP-5)/CO = 448.3 dyne × s/cm 5
    • Clues 1 - Why so high a cardiac output?
    • Clues 2 - Why such a low SVR?


Dilemma in postoperative period
"What is the most likely explanation of high CO with low SVR in immediate Postoperative period?"


   Discussion Top


  • Patient did not have transprosthetic obstruction because of the VTI ratio - LVOT/AO = 28/54.6 = 0.51. Significant transprosthetic obstruction is likely only if this VTI ratio is <0.30
  • Significant mitral pathology (either regurgitation or obstructive) is unlikely; since high flow velocities are observed across both mitral and aortic valves. These finding can easily be explained by high CO state
  • As depicted in [Figure 5] the LVOT is wide open; thus significant LVOT narrowing can be excluded
  • Therefore, the most logical explanation is that the patient has SEPSIS, which could be due exacerbation of preexisting and unrecognized infection or acquired intraoperatively
  • The classical hemodynamics of septicemia are high CO with low SVR and failure to maintain adequate arterial pressure without the use of inotropes
  • Therefore colistin 2 million units were added to the existing antibiotic regimen (meropenam and targocid) - to which patient responded.


Postoperative course in ICU

His blood reports later shows:

High TLC: 18,000/dl (which later increased to 25,000). N-86 L-12 E-2.

High ESR: 60 mm/h.

Blood culture - Sterile (probably due to the preoperative use of antibiotics).

Patient was discharged after 2 weeks of hospital stay with normal pressure gradients across the tissue-AVR and normal velocities across the all cardiac valves.


   Conclusion Top


Thus, the intelligent interpretation of noninvasively derived hemodynamic by transesophageal echocardiography could be extremely useful in the appropriate diagnosis and management of critically ill patients.

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Correspondence Address:
Dr. K K Kapur
Indraprastha Apollo Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.154477

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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