Des diagnostics cliniques et échocardiographiques contradictoires dans des cas d’instabilité hémodynamique inexpliquée à la suite d’une intervention en cardiochirurgie

Abstract

P Pu ur rp po os se e: : To investigate 1) if clinical indications match diagnostic findings from urgent transesophageal echocardiography (TEE) in hemodynamically unstable patients after cardiac surgery and 2) the clinical impact of the TEE findings.

Transthoracic and transoesophageal echocardiography: a systematic review of feasibility and impact on diagnosis, management and outcome after cardiac surgery

“…There were seven studies reporting the use of transthoracic echocardiography [9,11,[18][19][20][21][22] and eight for transoesophageal echocardiography [23][24][25][26][27][28][29][30]. There were eight uncontrolled prospective observational studies [9, 11, 19, 21-23, 26, 28], and seven retrospective cohort studies [18,20,24,25,27], of which only two had a control group [29,30]. There was considerable variability in the study aims, indications for echocardiography, patient populations and end-points used.…”

“…Transthoracic echocardiography frequently identified cardiac dysfunction in 36% of patients in whom it was not suspected clinically, even though transthoracic echocardiography was used as a screening tool, rather than for an indication such as haemodynamic instability. There were three studies that reported a change in diagnosis between transoesophageal echocardiography and clinical assessment (25-59%) [25,29,30]. Pericardial effusion was detected with transoesophageal echocardiography more frequently (6-48%) than transthoracic echocardiography (2%).…”

“…Six of these were for transoesophageal echocardiography and one for transthoracic echocardiography. Two studies reported the overall proportion of patients in whom transoesophageal echocardiography resulted in a change in diagnosis compared with conventional clinical assessment (49% vs. 59%) [25,30]. The most commonly reported change in patient management due to transoesophageal echocardiography was to drain pleural effusions (10-38%) or to reoperate for pericardial tamponade (6-38%).…”

Impact of the opening of a specialized cardiac surgery recovery unit on postoperative outcomes in an academic health sciences centre

“…The increasing familiarity and certification of CSRU consultants in transesophageal echocardiography could have been helpful in promoting earlier surgical reintervention in hemodynamically unstable patients, given recent evidence of discordance between clinical and echocardiographic diagnoses in patients with unexplained hemodynamic instability after cardiac surgery. 12 Moreover, the change in the consultant call system to a day-night rotation involving two consultants instead of the previous single consultant per week may have had an independent beneficial effect. In addition, an acute care nurse practitioner joined the CSRU team at the beginning of year 2 of the study, whereas no nurse practitioner had worked in the medical-surgical ICU at the receiving institution prior to merger.…”

Transthoracic echocardiography does not improve prediction of outcome over APACHE II in medical-surgical intensive care

“…30 A recent study also highlighted the utility of TEE in assisting management strategies in 58% of postoperative cardiac surgical patients who had TEE. 31 A secondary finding was a lower associated mortality in patients having a surgical intervention as a result of the TEE diagnosis. Our study differs significantly from this previous study as we examined the role of TTE in predicting mortality in a much larger group of patients admitted to the MSICU.…”