Title: hTEE for tamponade management: A win-win-win
Author: Harold M. Hastings PhD CTO and Co-Founder
Facility: ImaCor Inc. Garden City NY

Background. Your patient becomes unstable. You suspect tamponade. What should you do? TTE? hTEE? Re-explore surgically?


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Let's look to the evidence for guidance:
1. Fewer than half of the patients with tamponade physiology may actually have tamponade (43% - Hirose H et al. J Surg Research 2014; 44% - Floerchinger B et al., J Cardiothorac Surg 2013). ... need more information about my patient.


2. Re-operation increases morbidity and mortality, (Ranucci et al., Ann Thorac Surg 2008; Kristensen et al., 2012), also cost: approximately $ 25,000 in 2008 dollars, over $ 30,000 today (Speir et al, 2009). ... avoid re-operation if possible.


3. However, delays increase the likelihood of adverse events (Karthik S et al. Ann Thorac Surg 2004). ... intervene quickly when necessary.


4. TTE is of limited utility (Floerchinger et al. 2013; Grumann A et al. Ann Thorac Cardiovasc Surg. 2012), alternatives include CT (Floerchinger et al. 2013) and TEE (Grumann et al., 2012). ... CT requires moving my patient, ... can't wait for CT or TEE.


5. "The diagnosis of pericardial tamponade postcardiotomy is feasible using a disposable hTEE ..." (Hirose H et al. J Surgical Research 2014, see also Sarosiek et al. ASAIO J. 2014. ... use hTEE.


Here are links to several early case reports (http://imacorinc.com/evidence/case-studies/279-htee-diagnosis-and-management-of-effusion-and-tamponade.html) and a full bibliography (http://imacorinc.com/evidence/bibliography.html).

The wins:
1. The patient – no re-operation half the time, less morbidity, less mortality.


2. The hospital medical team – everyone prefers the combination of better outcomes with less intervention


3. The hospital administration - using hTEE on all patients with tamponade physiology saves an average of over $15,000 per patient at a cost of $ 1,000 for the probe (the $ 70,000 ultrasound engine is rapidly amortized). In other terms, using hTEE on the first six cases of tamponade physiology can result in three avoided re-operations, more than paying for the ultrasound engine and six probes; after avoided re-ops pay back the cost of probes 15 to 1.

References
Čanádyová J, Zmeko D, Mokráček A. Re-exploration for bleeding or tamponade after cardiac operation. Interact Cardiovasc Thorac Surg. 2012;14:704-7. doi: 10.1093/icvts/ivs087. Epub 2012 Mar 20.

Charalambous CP, Zipitis CS, Keenan DJ. Chest reexploration in the intensive care unit after cardiac surgery: a safe alternative to returning to the operating theater. Ann Thorac Surg. 2006;81:191-4.

Colreavy FB, Donovan K, Lee KY, Weekes J. Transesophageal echocardiography in critically ill patients. Crit Care Med. 2002;30(5):989-996. "Transesophageal echocardiography when performed by intensive care physicians is a safe procedure and provides useful information for the evaluation and management of critically ill patients."

Floerchinger B, Camboni D, Schopka S, Kolat P, Hilker M, Schmid C. Delayed cardiac tamponade after open heart surgery - is supplemental CT imaging reasonable? J Cardiothorac Surg. 2013;8:158. doi: 10.1186/1749-8090-8-158. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698060/) "Diagnostic accuracy of transthoracic echocardiography is limited in patients after open heart surgery. Supplemental CT imaging provides rapid diagnostic reliability in patients with delayed cardiac tamponade."

Greenhalgh DL, Patrick MR. Perioperative transesophageal echocardiography: past, present & future. Anesthesia 2012;67:343-6.

Grumann A, Baretto L, Dugard A, Morera P, Cornu E, Amiel JB, Vignon PP. Localized cardiac tamponade after open-heart surgery. Ann Thorac Cardiovasc Surg. 2012;18(6):524-9. Epub 2012 Jun 29. (https://www.jstage.jst.go.jp/article/atcs/18/6/18_oa.11.01855/_pdf) "Since localized tamponade complicating open-heart surgery has various, nonspecific clinical presentations and TTE is not diagnostic, indications of TEE must be liberal in this setting to prompt diagnosis and surgical reoperation."

Hirose H, Gupta S, Pitcher H, Miessau J, Yang Q, Yang J, Cavarocchi N. Feasibility of diagnosis of postcardiotomy tamponade by miniaturized transesophageal echocardiography. J Surg Res. 2014 Jul;190(1):276-9. doi: 10.1016/j.jss.2014.02.039. Epub 2014 Feb 28. ""Conclusions: The diagnosis of pericardial tamponade postcardiotomy is feasible using a disposable hTEE based on our limited experience. We avoided unnecessary explorations while concomitantly made prompt diagnosis in emergent situations. The hTEE device was a valuable tool in hemodynamic management in the intensive care unit, allowing rapid evaluations."

Iribarne A, Burgener JD, Hong K, Raman J, Akhter S, Easterwood R, Jeevanandam V, Russo MJ. Quantifying the incremental cost of complications associated with mitral valve surgery in the United States. J Thorac Cardiovasc Surg. 2012;143:864-72. doi: 10.1016/j.jtcvs.2012.01.032. "The most costly complication was cardiac tamponade, which resulted in an increase in hospital cost of $56,547 and an increase in length of stay of 19.3 days (p < .001)."

Karthik S. Grayson AD, McCarron EE, Pullan DM, Desmond MJ. Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay. Ann Thorac Surg. 2004;78:527-34. "Patients needing reexploration are at higher risk of complications if the time to reexploration is prolonged. Policies that promote early return to the operating theater for reexploration should be encouraged."

Kristensen KL, Rauer LJ, Mortensen PE, Kjeldsen BJ. Reoperation for bleeding in cardiac surgery. Interact Cardiovasc Thorac Surg. 2012;14:709-13. doi: 10.1093/icvts/ivs050. Epub 2012 Feb 24. "5-9% of all unselected cardiac surgical patients undergo reoperation due to excessive bleeding. The reoperated patients have an approximately three times greater mortality than non-reoperated."

Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR. Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg. 2002;74:1148-53. "CT after OHS is more common following valve surgery than CABG alone and may be related to the preoperative use of anticoagulants. Females appear to be at higher risk for developing early postoperative CT. When diagnosed and treated promptly, postoperative CT should not significantly increase mortality." (Emphasis added)

Ranucci M, Bozzetti G, Ditta A, Cotza M, Carboni G, Ballotta A. Surgical reexploration after cardiac operations: why a worse outcome? Ann Thorac Surg. 2008;86:1557-62. doi: 10.1016/j.athoracsur.2008.07.114. "Patients in the surgical reexploration group had greater morbidity (low cardiac output, acute renal failure, sepsis) and longer mechanical ventilation time and intensive care unit stay than did control patients, and a significantly higher mortality rate (14.2% versus 3.4%, p = 0.001). ... Delaying the timing of reexploration may represent a risk factor only when the delay creates the need for an excessive use of allogeneic blood products, or in the presence of clinical signs of cardiac tamponade." (Emphasis added)

Sarosiek K, Kang CY, Johnson CM, Pitcher H, Hirose H, Cavarocchi NC. Perioperative use of the ImaCor hemodynamic transesophageal echocardiography probe in cardiac surgery patients: initial experience. ASAIO J. 2014;60(5):553-8. doi: 10.1097/MAT.0000000000000113. "Among the 14 patients in whom we suspected tamponade, hTEE diagnosed mediastinal tamponade in 5 and hemothorax in 3. The 5 patients who were diagnosed with mediastinal tamponade were taken to the operating room for emergent evacuation of a hematoma and the 3 patients with a hemothorax were treated at the bedside through aggressive chest tube management. In 6 additional patients we suspected cardiac tamponade due to clinical manifestations; however, hTEE eliminated the diagnosis of tamponade and operative intervention was avoided."

Tusscher BL, Groeneveld JA, Kamp O, Jansen EK, Beishuizen A, Girbes AR. Predicting outcome of rethoracotomy for suspected pericardial tamponade following cardio-thoracic surgery in the intensive care unit. J Cardiothorac Surg. 2011;6:79. doi: 10.1186/1749-8090-6-79. "Clots and fluids in the pericardial space causing regional tamponade and responding to surgical evacuation after primary cardio-thoracic surgery, are difficult to diagnose preoperatively, by clinical, haemodynamic and even echocardiographic evaluation in the ICU."