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Journal ArticleDOI

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

22 Aug 2012-Icu Director (SAGE Publications)-Vol. 3, Iss: 5, pp 230-234

TL;DR: 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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TL;DR: The ability of episodic monoplane TEE to identify discordance between hemodynamic monitoring and episodic TEE was qualitatively observed in 14 patients was demonstrated to better define clinical scenarios in unstable cardiac surgery patients.
Abstract: Objective A new slender, flexible, and miniaturized disposable monoplane transesophageal TEE probe has been approved for episodic hemodynamic transesophageal echocardiographic monitoring. The authors hypothesized that episodic monoplane TEE with a limited examination would help guide the postoperative management of high-risk cardiac surgery patients. Design The authors analyzed the initial consecutive observational experience with the miniaturized transesophageal echocardiography monitoring system (ClariTEE, ImaCor, Uniondale, New York). Setting Single institution in a university setting. Participants Unstable cardiac surgery patients. Interventions The authors assessed fluid responsiveness, echocardiographic data, and concordance among hemodynamic data. Measurements and Main Results From June 2010 to February 2011, 21 unstable cardiac surgery patients with postoperative instability were identified. Two patients (10%) required reoperation for bleeding and tamponade physiology. Right ventricular dysfunction was diagnosed by episodic TEE monitoring in 7 patients (33%), while hypovolemia was documented in 12 patients (57%). Volume responsiveness was documented in 11 patients. In this observational study, discordance between hemodynamic monitoring and episodic TEE was qualitatively observed in 14 patients (66%). Conclusion The authors demonstrated the ability of episodic monoplane TEE to identify discordance between hemodynamic monitoring to better define clinical scenarios in unstable cardiac surgery patients. For these challenging patients, limited episodic TEE assessment has become a cornerstone of ICU care in this institution.

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Abstract: Peripheral veno-arterial extra corporeal membrane oxygenation (VA-ECMO) is an established technique for short-to-medium support of patients with severe cardiac failure. However, in patients with concomitant respiratory failure, the residual native circulation will provide deoxygenated blood to the upper body, and may cause differential hypoxemia of the heart and brain. In this paper, we present a general computational framework for the identification of differential hypoxemia risk in VA-ECMO patients. A range of different VA-ECMO patient scenarios for a patient-specific geometry and vascular resistance were simulated using transient computational fluid dynamics simulations, representing a clinically relevant range of values of stroke volume and ECMO flow. For this patient, regardless of ECMO flow rate, left ventricular stroke volumes greater than 28 mL resulted in all aortic arch branch vessels being perfused by poorly-oxygenated systemic blood sourced from the lungs. The brachiocephalic artery perfusion was almost entirely derived from blood from the left ventricle in all scenarios except for those with stroke volumes less than 5 mL. Our model therefore predicted a strong risk of differential hypoxemia in nearly all situations with some residual cardiac function for this combination of patient geometry and vascular resistance. This simulation highlights the potential value of modelling for optimising ECMO design and procedures, and for the practical utility for personalised approaches in the clinical use of ECMO.

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References
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Journal ArticleDOI
Paul E. Marik1, Michael Baram1, Bobbak Vahid1Institutions (1)
01 Jul 2008-Chest
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.
Abstract: Background Central venous pressure (CVP) is used almost universally to guide fluid therapy in hospitalized patients. Both historical and recent data suggest that this approach may be flawed. Objective A systematic review of the literature to determine the following: (1) the relationship between CVP and blood volume, (2) the ability of CVP to predict fluid responsiveness, and (3) the ability of the change in CVP (ΔCVP) to predict fluid responsiveness. Data sources MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. Study selection Reported clinical trials that evaluated either the relationship between CVP and blood volume or reported the associated between CVP/ΔCVP and the change in stroke volume/cardiac index following a fluid challenge. From 213 articles screened, 24 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, healthy control subjects, and ICU and operating room patients. Data extraction Data were abstracted on study design, study size, study setting, patient population, correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator characteristic [ROC]) between CVP/ΔCVP and change in stroke index/cardiac index, percentage of patients who responded to a fluid challenge, and baseline CVP of the fluid responders and nonresponders. Metaanalytic techniques were used to pool data. Data synthesis The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/ΔCVP and change in cardiac performance following a fluid challenge. The pooled correlation coefficient between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28). Overall, 56 ± 16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between ΔCVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21). Baseline CVP was 8.7 ± 2.32 mm Hg [mean ± SD] in the responders as compared to 9.7 ± 2.2 mm Hg in nonresponders (not significant). Conclusions This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/ΔCVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.

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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.
Abstract: 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; Anderson A: University of Chicago, Chicago, Illinois, USA; Chan M: University of Alberta, Edmonton, Alberta, Canada; Desai S: Inova Fairfax Hospital, Fairfax, Virginia, USA; Fedson S: University of Chicago, Chicago, Illinois, USA; Fisher P: Ochsner Clinic, New Orleans, Louisiana, USA; Gonzales-Stawinski G: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Martinelli L: Ospedale Niguarda, Milano, Italy; McGiffin D: University of Alabama, Birmingham, Alabama, USA; Parisi F: Ospedale Pediatrico Bambino Gesu, Rome, Italy; Smith J: Freeman Hospital, Newcastle upon Tyne, UK Task Force 2 Taylor D: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Meiser B: University of Munich/Grosshaden, Munich, Germany; Baran D: Newark Beth Israel Medical Center, Newark, New Jersey, USA; Carboni M: Duke University Medical Center, Durham, North Carolina, USA; Dengler T: University of Hidelberg, Heidelberg, Germany; Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, USA; Frigerio M: Ospedale Niguarda, Milano, Italy; Kfoury A: Intermountain Medical Center, Murray, Utah, USA; Kim D: University of Alberta, Edmonton, Alberta, Canada; Kobashigawa J: Cedar-Sinai Heart Institute, Los Angeles, California, USA; Shullo M: University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Stehlik J: University of Utah, Salt Lake City, Utah, USA; Teuteberg J: University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Uber P: University of Maryland, Baltimore, Maryland, USA; Zuckermann A: University of Vienna, Vienna, Austria. Task Force 3 Hunt S: Stanford University, Palo Alto, California, USA; Burch M: Great Ormond Street Hospital, London, UK; Bhat G: Advocate Christ Medical Center, Oak Lawn, Illinois, USA; Canter C: St. Louis Children Hospital, St. Louis, Missouri, USA; Chinnock R: Loma Linda University Children's Hospital, Loma Linda, California, USA; Crespo-Leiro M: Hospital Universitario A Coruna, La Coruna, Spain; Delgado R: Texas Heart Institute, Houston, Texas, USA; Dobbels F: Katholieke Universiteit Leuven, Leuven, Belgium; Grady K: Northwestern University, Chicago, Illlinois, USA; Kao W: University of Wisconsin, Madison Wisconsin, USA; Lamour J: Montefiore Medical Center, New York, New York, USA; Parry G: Freeman Hospital, Newcastle upon Tyne, UK; Patel J: Cedar-Sinai Heart Institute, Los Angeles, California, USA; Pini D: Istituto Clinico Humanitas, Rozzano, Italy; Pinney S: Mount Sinai Medical Center, New York, New York, USA; Towbin J: Cincinnati Children's Hospital, Cincinnati, Ohio, USA; Wolfel G: University of Colorado, Denver, Colorado, USA Independent Reviewers Delgado D: University of Toronto, Toronto, Ontario, Canada; Eisen H: Drexler University College of Medicine, Philadelphia, Pennsylvania, USA; Goldberg L: University of Pennsylvania, Philadelphia, Pennsylvania, USA; Hosenpud J: Mayo Clinic, Jacksonville, Florida, USA; Johnson M: University of Wisconsin, Madison, Wisconsin, USA; Keogh A: St Vincent Hospital, Sidney, New South Wales, Australia; Lewis C: Papworth Hospital Cambridge, UK; O'Connell J: St. Joseph Hospital, Atlanta, Georgia, USA; Rogers J: Duke University Medical Center, Durham, North Carolina, USA; Ross H: University of Toronto, Toronto, Ontario, Canada; Russell S: Johns Hopkins Hospital, Baltimore, Maryland, USA; Vanhaecke J: University Hospital Gasthuisberg, Leuven, Belgium.

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