Transesophageal echocardiography-guided anesthetic management of a patient with dilated cardiomyopathy, severe heart failure, and septic shock: a case report.

Perioperative management of severe dilated cardiomyopathy (DCM) with markedly reduced left ventricular ejection fraction (LVEF) is particularly complex, especially when complicated by septic shock, as standard resuscitative measures may trigger acute cardiac decompensation. This report describes a 41-year-old male with undiagnosed severe DCM (LVEF 16% by transthoracic echocardiography) and left ventricular thrombus, who presented with Aeromonas hydrophila-induced necrotizing fasciitis that rapidly progressed to septic shock and multiple organ dysfunction. The severity of septic manifestations obscured the underlying occult cardiomyopathy, underscoring the critical role of cardiac biomarkers and echocardiography in facilitating early diagnosis. Intraoperative transesophageal echocardiography (TEE) proved pivotal for the real-time, physiology-guided titration of a multi-agent pharmacological regimen (norepinephrine, dobutamine, esmolol) and for guiding positional adjustments, thereby balancing the conflicting hemodynamic demands of septic vasoplegia and end-stage heart failure during emergent limb-saving surgery.