This case report shows that junctional rhythm can cause deterioration of SAM, LVOTO, and MR, and can lead to unstable hemodynamics in a patient with right ventricular failure after MVR. Atrial pacing can resolve SAM, LVOTO, and MR and can improve hemodynamics in a patient with unstable normal sinus rhythm. TEE in the ICU can play a pivotal role in clinical decision-making. Given that there are various causes of hemodynamic deterioration after cardiac surgery and some cannot be diagnosed without TEE, both TTE and basic TEE skills are required for intensivists. We identified two important clinical issues. Junctional rhythm can cause deterioration of SAM, LVOTO, and MR, and atrial pacing can improve hemodynamics in unstable normal sinus rhythm. TEE is useful for the identification of causes of unstable hemodynamics after cardiac surgery in the ICU as well as in the operating room.

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