Post-MVR Crashing Patient Case Challenge

You're the ICU doctor on call and a post cardiac surgery patient is dropped off in the unit a couple hours ago and now the nurse is calling you because the patient is crashing and she's maxed out on three pressors. The patient is a 60 year old gentleman who's had a history of significant myocardial regurgitation for quite a while. It's getting progressive now with progressive heart failure exacerbations. Otherwise hypertension, dyslipidemia and type 2 diabetes with an A1C of nine. The OR was pretty much unremarkable went well with the mitral valve replacement. They gave two units of packed RBCs in the OR as well some albumin. He was dropped off in the ICU about an hour ago at which point he was ventilated on minimal settings. He was on precedex and fentanyl, looked calm, not in any distress and his blood pressure was systolic in the hundreds. He was on like four of norepi and cardiac surgery had ordered some albumin, so he got about 500 ccs of albumin 5% in that past hour. And now in the past 15 to 20 minutes, the nurse tells you that the blood pressure has been tanking. The blood pressure is now into the 80s and you've given another dose of albumin and to which he responds very temporarily, but then the blood pressure keeps dropping. And now the nurse is maxed out on levophed at 30 mics. Vasos added and maxed. He's on dobutamine as well, which was added because the cardiac index was noted to drop. Here at the bedside, you're looking at the monitors, systolic is in the 80s, MAPs in the 50s and it's dropping. You're thinking of adding epi and you try to do a Pocus to look at the heart. Unfortunately, you get really horrible windows because of some smoking history, he has some emphysema and you really can't get a good view. The only one you can get is a subxiphoid view and you do rule out a massive pericardial effusion. You don't see one, thankfully. We're waiting for a stat X-ray to come. In the meantime, as you're waiting, what is the most important thing in this patient? You need to think about and rule out which will completely change your management and will save his life?