title: Transesophageal echocardiography predicts mortality in critically ill patients with unexplained hypotension.
abstract: OBJECTIVE
  This study sought to determine the prognostic yield and utility of transesophageal echocardiography in critically ill patients with unexplained hypotension.
  
  
  BACKGROUND
  Transesophageal echocardiography is increasingly utilized in the intensive care setting and is particularly suited for the evaluation of hypotension; however, the prognostic yield of transesophageal echocardiography in these patients is unknown.
  
  
  METHODS
  We prospectively studied 61 adult patients in the intensive care unit with sustained (> 60 min) unexplained hypotension. Both transthoracic and transesophageal echocardiography were performed, and results were immediately disclosed to the primary physician, who reported any resulting changes in management. Patients were classified on the basis of transesophageal echocardiographic findings into one of three prognostic groups: 1) nonventricular (valvular, pericardial) cardiac limitation to cardiac output; 2) ventricular failure; and 3) noncardiac systemic disease (hypovolemia or low systemic vascular resistance, or both). Primary end points were death or discharge from the intensive care unit.
  
  
  RESULTS
  A transesophageal echocardiographic diagnosis of nonventricular limitation to cardiac output was associated with improved survival to discharge from the intensive care unit (81%) versus a diagnosis of ventricular disease (41%) or hypovolemia/low systemic vascular resistance (44%, p = 0.03). Twenty-nine (64%) of 45 transthoracic echocardiographic studies were inadequate compared with 2 (3%) of 61 transesophageal echocardiographic studies (p < 0.001). Transesophageal echocardiography contributed new clinically significant diagnoses (not seen with transthoracic echocardiography) in 17 patients (28%), leading to operation in 12 (20%).
  
  
  CONCLUSIONS
  Transesophageal echocardiography makes a clinically important contribution to the diagnosis and management of unexplained hypotension and predicts prognosis in the critical care setting.
authors.affiliation: Department of Medicine, University of California, San Francisco 94143-0214, USA.
authors.forename: P A
authors.initials: PA
authors.lastname: Heidenreich
authors.forename: R F
authors.initials: RF
authors.lastname: Stainback
authors.forename: R F
authors.initials: RF
authors.lastname: Redberg
authors.forename: N B
authors.initials: NB
authors.lastname: Schiller
authors.forename: N H
authors.initials: NH
authors.lastname: Cohen
authors.forename: E
authors.initials: E
authors.lastname: Foster
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness; D017548:Echocardiography, Transesophageal; D005260:Female; D006331:Heart Diseases / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality; D006801:Humans; D007022:Hypotension / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D015996:Survival Rate; D014655:Vascular Resistance; D018754:Ventricular Dysfunction / Q000150:complications* / Q000000981:diagnostic imaging