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Resuscitation 82 (2011) 355–357

Contents lists available at ScienceDirect

Resuscitation

journa l homepage: www.e lsev ier .com/ locate / resusc i ta t ion

ase report

onitoring myocardial recovery during induced hypothermia with a disposableonoplane TEE probe

had Wagnera,∗, Joseph Fredib, Julian Bicka, John McPhersonb

The Department of Anesthesiology, Vanderbilt University, United StatesThe Department of Cardiology, Vanderbilt University, United States

r t i c l e i n f o

rticle history:

a b s t r a c t

A 73 year old female with a history coronary artery bypass grafting and coronary stents had a witnessed

eceived 24 August 2010eceived in revised form 13 October 2010ccepted 31 October 2010

eywords:ypothermiaardiac arrest

cardiac arrest at home. She was transferred to an outside hospital and emergency heart catheterizationrevealed patent LIMA to LAD, stented grafts open, and no new culprit lesions. A temporary transvenouspacing wire was placed for bradycardia. She was transferred to the ICU where she was sedated and para-lyzed for induction of hypothermia approximately five hours after the arrest. A miniaturized disposableTEE probe (Photo 1) was placed to allow ongoing monitoring of cardiac function and intravascular volume.

© 2010 Elsevier Ireland Ltd. All rights reserved.

ransesophageal echocardiography

A 73 year old female with a history of coronary artery bypassrafting and coronary stents had a witnessed cardiac arrest at home.he was transferred to an outside hospital and emergency heartatheterization revealed patent left internal mammary artery grafto left anterior descending coronary artery, stented grafts open ando new culprit lesions. A temporary transvenous pacing wire waslaced for bradycardia. She was transferred to the ICU where sheas sedated and paralyzed for induction of hypothermia approx-

mately five hours after the arrest. A miniaturized disposable TEErobe (Photo 1) was placed to allow ongoing monitoring of cardiacunction and filling.1

Initially the mid esophageal four chamber view (Video 1)evealed moderate to severe right ventricular dysfunction with aistended right ventricle. Transgastric short axis view (Video 2)evealed septal dyskinesis, severe apical and inferior hypokinesis,nd left ventricular (LV) fractional area change (FAC) of around 13%.ine hours after the arrest repeat echo in the mid esophageal four

hamber view revealed improved right ventricular function. Theransgastric short axis images revealed a FAC of 40%, overall globalmprovement in LV function.

∗ Corresponding author at: The Department of Anesthesiology, Vanderbilt Uni-ersity, 1211 21st Ave South Suite 526 MAB, Nashville, TN 37212, United States.el.: +1 615 343 6268.

E-mail address: chad.e.wagner@vanderbilt.edu (C. Wagner).1 The ImaCor ZuraTM system, including the ClariTEE probe (Photo 1) is a disposableonoplane TEE probe approved by the United States Food and Drug Administration

or use in mechanically ventilated patients for up to 72 h.

300-9572/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.resuscitation.2010.10.031

Overnight the patient required 2 mcg/min of norepinephrine tomaintain a MAP of 65 and was still paced at 60 BPM with a tempo-rary ventricular lead. 26 h after the arrest, the mid esophageal fourchamber view revealed normal right ventricle function (Video 3).The transgastric left ventricle mid-papillary short axis view demon-strated hyperdynamic LV function with a FAC of 61% (Video 4).There were still mild wall motion abnormalities in inferior/apicalregions, and the ventricle was underfilled. Over the next 24 h thepatient was fully re-warmed and the patient was fluid resuscitatedwith 4 l of crystalloid with corresponding improvement of ven-tricular filling apparent on echo. Table 1 lists other parameters ofresuscitation during the patient’s recovery.

1. Discussion

Myocardial dysfunction is common following cardiac arrestresuscitation and is generally reversible with recovery within24–48 h.3–5 Direct assessment of cardiac function and filling is cru-cial during the induction, maintenance and warming phases oftherapeutic hypothermia. Failure of myocardial recovery is oftendue to persistent hemodynamic instability leading to inadequateorgan perfusion. The ability to directly monitor cardiac func-tion and filling may facilitate hemodynamic stability and avoidinterventions that would worsen myocardial performance such as

increasing intravascular volume in the setting of a failing right ven-tricle.

The International Liaison Committee on Resuscitation (ILCOR)consensus statement in 2008 recommended hemodynamic opti-mization of CVP = 8–12 mmHg, MAP = 65–90, and urine output

356 C. Wagner et al. / Resuscitation 82 (2011) 355–357

Fig. 1. TEE monitoring system consists of a customized c

gbshe

caoliata

TI

Photo 1.

reater than 1.0 ml/kg/h.1 The guidelines also recommend possi-ly using pulmonary artery catheters and central venous oxygenampling. Evidence based goal directed therapy for inducedypothermia patients has yet to be defined but may includechocardiographic assessment of cardiac function and filling.

Poor myocardial compliance secondary to reperfusion injury isommon after cardiac arrest making assessment of cardiac functionnd filling by pressure measurements problematic. Poor correlationf invasive pressure monitoring and echocardiographic indices of

eft ventricular function has been demonstrated. (6) The first set ofmages taken seven hours post arrest with a CVP of 13 mmHg showsright ventricle that is volume overloaded and severely dysfunc-

ional. The left ventricle is globally hypokinetic with has anteriornd inferior wall motion abnormalities. While some wall motion

able 1ndices of resuscitation.

Time fromarrest

Temperature(◦C)

CVP(mmHg)

BE(mmol/l)

Lactate(mmol/l)

LV FAC

7 h 32.9 12 −9 2.5 13%9 h 32.9 10 −2 1 40%26 34.1 10 −2 1 61%

1

onsole, a reusable handle, and a disposable probe.

abnormalities could be from ventricular pacing, all wall motionabnormalities improved despite ongoing pacing from a temporaryventricular lead. Nine hours post arrest the CVP had dropped to10 mmHg and systolic recovery had started to occur in both theright and left ventricle. There had been no therapeutic changes incare between the two echocardiographic assessments; the patienthad made 200 ml of urine with a positive 100 ml fluid balancesince admission. The third echocardiographic assessment revealedbiventricular recovery with evidence of an underfilled left ventricle.

This case report demonstrates the clinical utility of a miniatur-ized monoplane TEE probe (ClariTEE, ImaCor, Uniondale, NY). The5.5 mm diameter ClariTEE probe (Photo 1, Fig. 1) is detachable fromthe handle, disposable, and cleared by the FDA to remain indwellingfor up to 72 h.

The ClariTEE probe offers all standard monoplane (transverse, 0-degree) views, including the esophageal four chamber view and thetransgastric short-axis view (TGSAV). The detachable handle allowsfor one machine to be used for multiple critically ill patients. Theprobe has not been cleared for use during defibrillation, but couldpotentially be utilized during cardiopulmonary resuscitation. Thecost of the probe currently is $940 USD; the echo platform andhandle must also be purchased from ImaCor.

In this case, direct assessment of cardiac function and filling pro-vided by the indwelling TEE probe was of greater clinical utility incaring for the patient than was invasive hemodynamic pressuremonitoring. Given the convenience, ease of placement, and min-imally invasive nature of a miniaturized TEE probe, prospectivestudies are needed to assess the clinical impact of echocardiogra-phy as a dynamic measure of cardiac filling volumes and ventricularcontractile indices in patients undergoing therapeutic hypothermiaafter cardiac arrest.7

All 4 authors have no conflict of interest, there were no financial,personal relationships, or organizations which influenced this casereport.

Conflict of interest statement

None to declare.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, inthe online version, at doi:10.1016/j.resuscitation.2010.10.031.

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. Laurent I, Monchi M, Chiche JD, et al. Reversible myocardial dys-function in survivors of out-of-hospital cardiac arrest. JACC 2002;40:2110–6.

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. Ruiz-Bailen M, Aguayo de Hoyos E, Ruiz-Navarro S, et al. Reversible myocardialdysfunction after cardiopulmonary resuscitation. Resuscitation 2005;66:175–81.

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