Case scenario about TEE: Patient with dilated cardiomyopathy undergoing laparoscopic cholecystectomy

42-year-old woman, who presented with DCM (American Society of Anesthesia, ASA class IV), suffered from gallstone for years, and was scheduled for laparoscopic cholecystectomy. Echocardiography demonstrated a severely dilated left ventricle with global hypokinesia and reduction of left ventricular systolic function, ejection fraction (EF) 34% with mild mitral regurgitation and severe tricuspid regurgitation. After intubation, a transesophageal echocardiography (TEE) probe was inserted. When the IAP was gradually ascended to 14 mmHg during the laparoscopy, EF fell to 19% and the systolic pressure fell to 78 mmHg and TEE showed severely poor wall motion. But the central venous pressure (CVP) still showed about 4 mmHg throughout the whole procedure. After decreasing the IAP to 10 mmHg, we adjusted the rate of pacemaker to 70 times per minute then the systolic pressure was kept at around 100 mmHg, and the diastolic pressure was kept at 60 mmHg. EF was 30% after the reduction of IAP and the adjusting of the heart rate set. TEE is a helpful monitor in anesthesia management of patients with DCM during noncardiac surgery and CVP is useless especially for the procedure with severe hemodynamic effects.