Case Report
An 85 year old had a past medical history remarkable for chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and severe peripheral vascular disease (s/p R superficial femoral arterial stent). She was followed in clinic for several years with progressive aortic stenosis, aortic insufficiency, mitral stenosis, and mitral regurgitation. Over the several months prior to surgery, her dyspnea had worsened and she was developing progressive chest pain. Cardiac catheterization revealed a 99% occlusion of her proximal right coronary artery. She was scheduled for elective AVR and CABG x 1. Intraoperative transesophageal echocardiography again demonstrated critical aortic stenosis and mild aortic insufficiency. Additionally, she was found to have severe left ventricular hypertrophy, mitral annular calcification, moderate mitral stenosis and regurgitation. It was felt that the risk of attempted repair/replacement of her mitral valve was too great. As a result, she underwent an AVR with a 21 mm mitroflow supra-annular valve and CABG x 1 (SVG-RCA). Post CPB TEE showed no paravalvular leak or stenosis, and continued mitral stenosis/regurgitation. She had good biventricular function on 6 mcg/min of Epinephrine and was brought to the ICU intubated. After 24 hours the patient had still not awoken despite complete discontinuation of all sedation and was also becoming increasingly oliguric with a rising creatinine. On post-operative day 2 she had still not awoken and had worsening renal failure. Her cardiac index remained below 2, while on 6 mcg/min Epinephrine, despite adequate resuscitation with CVP 16 and PAP 60/25. Further information was needed.
A miniaturized TEE probe (ImaCor ClariTEE®, Garden City, NY) was inserted for hemodynamic monitoring. It was rapidly established that the patient was in severe right heart failure. Her LV was hyperdynamic and underfilled and her RV was moderately dilated with moderate-severe decreased function. Of note, her EKG had been unchanged this entire time and it was not felt to be a problem with the new graft. As a result of this new information, inhaled prostacyclin was started (to decrease RV afterload) in addition to Milrinone. Within several hours, the patient’s cardiac index had increased from 1.8 to 2.9 (and her Epinephrine was reduced from 6 to 3 mcg/min). Epinephrine was weaned off the next day; however, the patient unfortunately never regained neurologic function. After discussion with neurology, the decision was made to stop life support measures and the patient subsequently died. It was felt that the patient most likely suffered a neurologic event intraoperatively.
Discussion
Despite the poor eventual outcome in this patient, hemodynamic TEE monitoring provided valuable information about heart function that enabled an immediate change in her therapy and culminated in improved cardiac function.