Observational Prospective Transesophageal Myocardial Ultrasound Survey

The gold standard in hemodynamic evaluation has been the combined use of echocardiography and right heart catheterization. Fall backs to echocardiography are its time consumption and requirement for specialist interpretation while the Swan-Ganz® catheter shows a poor correlation of central venous pressure to volume status and provides indirect and difficult to interpret measurements in patients with unique pathophysiological states.

Next generation continuous hemodynamic transesophageal echocardiography (hTEE®) is being increasingly utilized to assist with complex resuscitations and to monitor the hemodynamic profiles of critically ill patients. hTEE is proving to be an essential diagnostic, therapeutic and monitoring tool for the rapid evaluation of the hemodynamic state in the critically ill patient and or hemodynamically compromised patient.

The purpose of this observational study is to evaluate the role of hTEE in clinical decision-making in 30 patients recruited from OR-Trauma and in 30 patients from the Cardiovascular-OR. Hemodynamic trans-esophageal echocardiography (hTEE) incorporates an FDA-approved miniaturized, disposable probe for continuous use in patients for up to 72 hours. This device has been used for postoperative assessment in the ICU for several years with successful placement of probes and without any adverse incidents.

The probe allows for the rapid, intermittent or continuous evaluation of bi-ventricular function, volume status and valve function at bedside or intraoperatively. It also allows for the evaluation of pericardial effusions and or the exclusion of pericardial tamponade.

The device can evaluate trans-valvular flow as well as valvular regurgitation with the use of the color flow function. In many situations hTEE enables imaging not feasible by transthoracic echocardiography due to wounds, dressings, lines or edema.

The hTEE does not provide the visual acuity and detail of formal TEE, but it has the advantage of requiring a significantly smaller probe (hence the decreased risk of possible injury) with the ability of providing rapid, repeatable and sequential assessment by caregivers intraoperatively or at the bedside.

Data will be reviewed for outcome measures comparing efficiency, accuracy and clinical decision making capability of the FDA approved hTEE cardiac monitoring system vs. the standard of care Swan-Ganz/ echocardiographic information for publication. The ultimate goal will be to demonstrate whether or not after implementation of probes in surgical trauma and CVICU patients, there is a difference in:

1. Mortality and Morbidity
2. Organ dysfunction and failure
3. Blood product administration
4. Length of ICU stay
5. Hospital stay

2. Study Design and Statistical Procedures This is a two phase, single center, non-blinded, non-randomized, observational and retrospective study to be carried out at Memorial Hermann Hospital. The data from the hTEE study group will be compared to the control group (in-house OR-Trauma and CV surgery databases) and will be analyzed on a patient to patient basis for its impact on clinical decision-making.

Based upon our literature review, we hypothesize that hTEE will help guide point-of-care management upwards of 75 percent of cases. A decrease in iatrogenic complications from inappropriate blood product administration, volume resuscitation and or drug intervention based off of antiquated protocols and inaccurate technology is expected. Its use may benefit the hospital financially by decreasing the incidence of organ failure and mortality and allowing for the fulfillment of discharge criteria earlier from the hospital.

3. Study Procedures

1. Initiation A. Development of protocol and datasheet. (1 month) B. Training of anesthesia attendings, fellows, residents and technicians. (1 month) C. Formal presentation at Grand rounds. (1 month)
2. OR- Trauma/ CVICU:

   A. Training of the primary proceduralists. Board runners - 892 office. (1 month) B. Recording of real-time hemodynamic transesophageal echocardiographic movies of 60 patients. (3 months) C. Image analysis for clinical decision making with research assistants. (3 months)
3. Database retrospective review of above stated endpoints. (3 months)

   After admission to the OR and fulfillment of inclusion criteria, the hTEE probe will be placed by a trained attending or fellow as per standard care. A standardized exam will be performed that includes a: (1) superior vena cava view, (2) trans-esophageal four-chamber view and a (3) trans-gastric short axis view.

   As per current standard care, the information will be documented in the medical record and discussed with the PI, key study personnel and the patient's physician.

   For the purpose of the study, we will document carefully what impact the hTEE assessment has on the management plan on the first 60 patients who meet criteria and compare results to the standard of care use of CVP/ Echocardiography combination in terms of clinical decision making. Subsequent hTEE assessments will be made sequentially as clinically indicated, and the information obtained will be analyzed in the same way. All images will be stored for clinical interpretation on the machine itself, which is accessible to authorized personnel only. All patient data that is collected for the study will be coded; No subject identifiers will be recorded on study forms. See the privacy and confidentiality section for details.
4. Study Drugs or Devices: N/A
5. Study Instruments: N/A
6. Study Subjects:

Inclusion criteria:

• All study subjects 18 to 85 years old.

* OR-Trauma patients Presenting w/ hemodynamic instability. W/ expected intubation greater than 24 hours.
* CVICU patients Requiring non-isolated cardiac and vascular surgery

Exclusion criteria:

Current or previous esophageal injury

Eligibility Criteria:
Inclusion Criteria:

* • All study subjects 18 to 85 years old.

  * OR-Trauma patients Presenting w/ hemodynamic instability. W/ expected intubation greater than 24 hours.
  * CVICU patients (Cardiovascular Intensive Care Unit) Requiring non-isolated cardiac and vascular surgery

Exclusion Criteria:

* Current or previous esophageal injury