Background: 86 year-old male with extensive medical history who had undergone elective CABG several hours earlier. In the CTICU, the patient was tachycardic and hypotensive (80–110 mm Hg) while on Levophed. SVO₂ was 32% and CVP was 25 mm Hg. 

 

Method: Attending ICU physician ordered a transthoracic echo (TTE) and a transesophageal echo (TEE) with the ClariTEE™ probe (ImaCor Inc, Uniondale, NY). Both studies were performed at the bedside simultaneously in the ICU.

Results: An echo technologist performed the TTE from the patient’s left side and was unable to assess the right atrium. The attending ICU physician, performing the TEE exam from the right side of the bed easily placed the probe without complication and was quickly able to obtain a four-chamber view of the heart.

From this view, the physician noticed a large blood clot pressing on the right atrium and concluded that localized tamponade was the cause of the patient’s deterioration. Based on this new information, the patient was taken directly back to the operating room for an immediate reoperation and the clot was removed. The patient’s status immediately stabilized, and he returned to the ICU. Shortly after the patient’s return, the physician performed a second assessment with the ClariTEE™ probe and determined that the right atrium was filling normally. The patient’s blood pressure was no longer labile (140-150 mm Hg), Levophed was discontinued, and the patient was hemodynamically stable (HR: 70 beats/minute and CVP: 8 mm Hg).

Discussion: The published incidence of tamponade following cardiac surgeries is 0.5%-5.8% (Russo et al., 1993), and re-operation due to tamponade is costly and associated with increased mortality and prolonged hospital stay.   While the use of TEE is well documented as an effective tool in the cardiac O.R. for monitoring patients, there is currently no effective method of monitoring these patients outside the O.R. where serious complications often occurs. In this specific case, as often occurs in the ICU, the TTE was unable to provide the critical information required to make this diagnosis. 

Conclusion: The ClariTEE™ probe can be an effective and useful tool in diagnosing tamponade in post-cardiac surgery cases. Moreover, the ClariTEE™ probe allows physicians to establish a continuity of care in the ICU that heretofore has not been available.