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Initial experience with Imacor hTEE-guided management of patients following transplant and mechanical circulatory support.

TLDR
Real-time “hemodynamic” TEE (hTEE) can help provide effective management by direct visualization of cardiac filling and function and help guide hemodynamic management following transplant or MCS.
Abstract
This study reviews an initial experience using a miniaturized transesophageal echocardiography (TEE) probe (ImaCor, Garden City, NY) with 3 patients in whom Imacor hTEE intervention was used as a point-of-care device to manage extracorporeal membrane oxygenation cannula placement, cardiac hemodynamics, and postoperative cardiac pathophysiology. The management of transplant or mechanical circulatory support (MCS) patients is especially challenging: Transplanted hearts pose unique pathophysiological challenges, and MCS significantly alters pressure–volume–flow relationships. Real-time “hemodynamic” TEE (hTEE) can help provide effective management by direct visualization of cardiac filling and function and help guide hemodynamic management. In the authors’ initial experience, hTEE can provide point-of-care management following transplant or MCS.

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1
As submitted to:
ICU Director
And later published as:
Initial Experience with Imacor hTEE-guided management of
patients following Transplant and Mechanical Circulatory
Support.
August 22, 2012,
doi:10.1177/1944451612456703
Abstract
We reviewed an initial experience using a miniaturized transesophageal
echocardiography (TEE) probe (ImaCor, Garden City, NY) with 3 patients in whom
Imacor hTEE intervention was used as a point of care device to manage extracorporeal
membrane oxygenation cannula placement, cardiac hemodynamics, and post-op cardiac
pathophysiology. The management of transplant or mechanical circulatory support
(MCS) patients is especially challenging: transplanted hearts pose unique
pathophysiological challenges, and MCS significantly alters pressure-volume-flow
relationships. Real-time “hemodynamic” TEE (hTEE) can help provide effective
management by direct visualization of cardiac filling and function and help guide
hemodynamic management. In our initial experience, hTEE can provide point-of-care
management following transplant or MCS. (Word count of abstract: 105)

2
Keywords: ECMO, TEE, mechanical circulatory support, hemodynamics
Conflict of Interest
XXXX is an employee and stockholder in ImaCor. Other authors has no conflict of
interest. This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.

3
Introduction
Fluid and hemodynamic management, fundamental in critical care, becomes
significantly more challenging in transplant patients and patients with mechanical
circulatory support. Transplanted hearts pose unique pathophysiological challenges
1, 2
,
and mechanical support significantly alters pressure-volume-flow relationships. These
alterations can further limit the utility of standard pressure measurements, both central
venous pressure and pulmonary artery pressure. Central venous pressure has been shown
to have a poor relationship with volume status.
3
The Swan-Ganz catheter provides
indirect measurements that can be difficult to interpret; moreover altered pressure-
volume-flow relationships. Transesophageal echocardiography (TEE) directly visualizes
the heart, allowing accurate assessment of cardiac function and volume status with other
parameters.
4
Cardiac anesthesiologists rely on TEE images to make hemodynamic
assessments and interventions in the cardiac operating room. TEE would appear to be the
ideal tool for hemodynamic assessment and management of critically ill patients
5
,
provided that availability and the need for trained personnel and anesthesia can be
overcome. An editorial called for a TEE probe which could remain indwelling 48 hours
in critically ill patients.
6
To address these issues,
a miniaturized TEE probe (hTEE probe, ImaCor, Garden
City, NY
) with a diameter of 5.5 mm was developed to provide hemodynamic
management and assessment in critical care to aid in assessment of volume status and
cardiac function with other parameters. The hTEE probe was cleared by the FDA to
remain indwelling up to 72 hours.
The hTEE probe has 15 cm of penetration at 6.67

4
MHz (B-mode) and can obtain the images of left and right ventricular function and
volume status.
7
Methods
We reviewed our initial experience with 3 patients in whom the Imacor hTEE system was
used as a point-of-care device to manage extracorporeal membrane oxygenation (ECMO)
cannula placement, cardiac hemodynamics, and post-op cardiac pathophysiology. This
study was approved by an institutional review board at Thomas Jefferson University
Hospital.
Results
Case 1: A 55-year-old female with a history of dilated cardiomyopathy, presented for a
heart transplantation evaluation. She quickly decompensated into multiple organ failure
despite significant inotropic support. It was decided that emergent Veno-arterial ECMO
placement for biventricular support was necessary (Figure 1A). Over 3 weeks of VA
ECMO support, the patient was deemed not a candidate for heart transplantation.
Although the patient remained eligible for a left ventricular (LV) assist device, right
ventricular (RV) function had not been evaluated prior to decompensation.
A weaning protocol was initiated with hTEE for direct visualization of cardiac
function to assess RV function. Over four hours, ECMO flows were decreased, and
volume and dobutamine were administered. hTEE showed that the right heart was
adequate to tolerate a bridge to LVAD (Figure 1B). The patient was successfully weaned
off ECMO and bridged to an LVAD as predicted.
Case 2: A 47-year-old male with a Heartmate II LVAD (Thoratec,
Pleasanton, CA)
underwent orthotropic heart transplantation. Postoperatively, the patient required

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A computational framework for adjusting flow during peripheral extracorporeal membrane oxygenation to reduce differential hypoxia.

TL;DR: A general computational framework for the identification of differential hypoxemia risk in VA-ECMO patients is presented and the potential value of modelling for optimising ECMO design and procedures is highlighted, and for the practical utility for personalised approaches in the clinical use of ECMO.
References
More filters
Journal ArticleDOI

The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients

Maria Rosa Costanzo, +56 more
TL;DR: Institutional Affiliations Chair Costanzo MR: Midwest Heart Foundation, Lombard Illinois, USA Task Force 1 Dipchand A: Hospital for Sick Children, Toronto Ontario, Canada; Starling R: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Starlings R: University of Chicago, Chicago, Illinois,USA; Chan M: university of Alberta, Edmonton, Alberta, Canada ; Desai S: Inova Fairfax Hospital, Fairfax, Virginia, USA.
Journal ArticleDOI

Does Central Venous Pressure Predict Fluid Responsiveness?: A Systematic Review of the Literature and the Tale of Seven Mares

TL;DR: A systematic review of the literature demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/DeltaCVP to predict the hemodynamic response to a fluid challenge.
Journal ArticleDOI

Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock.

TL;DR: Patients who tolerated a full ECMO weaning trial and had aortic VTI ≥10 cm, LVEF >20–25%, and TDSa ≥6 cm/s at minimal ECMO flow were all successfully weaned, and further studies are needed to validate these simple and easy-to-acquire Doppler echocardiography parameters as predictors of subsequent EC MO weaning success in patients recovering from severe cardiogenic shock.
Journal ArticleDOI

The evolving management of acute right-sided heart failure in cardiac transplant recipients.

TL;DR: Only through careful preoperative planning can this life-threatening condition be managed in the postoperative period.
Related Papers (5)
Frequently Asked Questions (13)
Q1. What have the authors contributed in "Initial experience with imacor htee-guided management of patients following transplant and mechanical circulatory support" ?

The authors reviewed an initial experience using a miniaturized transesophageal echocardiography ( TEE ) probe ( ImaCor, Garden City, NY ) with 3 patients in whom Imacor hTEE intervention was used as a point of care device to manage extracorporeal membrane oxygenation cannula placement, cardiac hemodynamics, and post-op cardiac pathophysiology. 

Heart transplant patient with prolonged ischemic time and elevated recipient pulmonary vascular resistance often develop RV failure, which can progress to biventricular failure. 

in the presence of escalating vasopressor support secondary to systemic vasoplegia syndrome, normal pressure may not yield normal perfusion. 

Fluid and hemodynamic management, fundamental in critical care, becomessignificantly more challenging in transplant patients and patients with mechanical circulatory support. 

ECMO weaning requires ongoing observation of cardiac function through major circulatory changes which are visualized by real time continuous hTEE. 

The management of transplant or mechanical circulatory support patients is especially challenging: transplanted hearts pose unique pathophysiological challenges, and mechanical circulatory support significantly alters pressure-volume-flow relationships. 

Primary biventricular failure post-transplantation, as seen in Case 2, may berelated to poor myocardial preservation of the donor, prolonged ischemic time, residual pulmonary hypertension, and decreased compliance of the lungs post cardiopulmonary bypass. 

Real-time “hemodynamic” TEE (hTEE) can help provide effective management by direct visualization of cardiac filling and function and help guide hemodynamic management. 

TEE would appear to be the ideal tool for hemodynamic assessment and management of critically ill patients 5 , provided that availability and the need for trained personnel and anesthesia can be overcome. 

Placement of a Swan-Ganz catheter (SGC)venous gas analysis would also be useful to evaluate the circulation and function of the heart; however, the lag between the sampling the blood and results may makes ongoing real-time adjustments difficult. 

This lack of normal perfusion was the apparent cause of near ventricular standstill detected by hTEE, a condition which if not managed by central ECMO might otherwise have led to cardiac arrest. 

The hTEE probe provides real time images of the heart, allowing the intensivist to determine if the preload is appropriate and cardiac function is adequate and intervene rapidly if necessary. 

If ventricular recovery is questionable, hTEE probe can be left in the patient for continuous monitoring of the cardiac function, potentially saving the cost of taking the patient to the operating room.