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Ann Thorac Surg 1997;64:368-373
© 1997 The Society of Thoracic Surgeons
Departments of Cardiothoracic Anesthesia, Thoracic and Cardiovascular Surgery, and Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. From March to November 1995, 82 consecutive high-risk patients undergoing coronary artery bypass grafting were studied in a four-stage protocol to determine the efficacy of intraoperative echocardiography in management planning. Alterations in surgical and anesthetic/hemodynamic management initiated by intraoperative echocardiography findings were documented in addition to perioperative morbidity and mortality.
Results. Intraoperative echocardiography initiated at least one major surgical management alteration in 27 patients (33%) and at least one major anesthetic/hemodynamic change in 42 (51%). Mortality and the rate of myocardial infarction in this consecutive high-risk study population using intraoperative echocardiography and in a similar group of patients without the use of intraoperative echocardiography was 1.2% versus 3.8% (not significant) and 1.2% versus 3.5% (not significant), respectively.
Conclusions. We conclude that when all of the isolated diagnostic and monitoring applications of perioperative echocardiography are routinely and systematically performed together, it is a safe and viable tool that significantly affects the decision-making process in the intraoperative care of high-risk patients undergoing primary isolated coronary artery bypass grafting and may contribute to the optimal care of these patients.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Transesophageal echocardiography is an imaging technique used in the monitoring and diagnostic assessment of cardiac anatomy and physiology. Since its introduction in the early 1970s, clinical acceptance of perioperative transesophageal echocardiography has steadily increased. Intraoperative echocardiography has demonstrated a significant impact in the clinical decision-making process during mitral valve operations [1, 2]. Surgical results have been improved in valvular operations [3, 4], congenital heart operations [5], and postoperative management [6].
Innovations in ultrasound technology have led to higher frequency transducers with multiplane capabilities providing improved two-dimensional imaging resolution. These improvements enhance anatomic and functional assessments. Improved Doppler technology permits more accurate assessment of transvascular blood flow velocities and hemodynamic profiles. Such innovations have expanded the ability of echocardiography to influence intraoperative patient management. Using state-of-the-art ultrasound equipment, the purpose of this study was to determine the impact of intraoperative echocardiography (transesophageal and epicardial echocardiography) in the management of high-risk patients undergoing coronary artery bypass grafting and its effect on clinical outcomes.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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A previously established preoperative severity scoring system for patients undergoing coronary artery bypass grafting demonstrated an increased morbidity and mortality in patients with severity scores of 4 or greater (Figs 1–3
) [7]:
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Eight-two consecutive high-risk patients with a severity score of 4 or greater were entered into the study. All patients were scheduled for primary isolated coronary artery bypass grafting by the same surgeon. To characterize the usefulness of intraoperative echocardiography in high-risk patients undergoing elective coronary artery bypass grafting, end points included the number of times intraoperative echocardiography initiated a change in surgical or anesthetic/hemodynamic management and evaluation of patient morbidity and mortality. The surgical and anesthesia team's management plans were documented without the assistance of intraoperative echocardiographic information at each of four stages during the surgical procedure: (I) before cardiopulmonary bypass, (II) before cardiopulmonary bypass separation with the heart adequately filled and actively ejecting, (III) after cardiopulmonary separation, and (IV) after chest closure. After all management plans were complete, the intraoperative echocardiographic findings at each stage were revealed to the blinded surgical and anesthesia management teams. Alterations in the surgical and anesthetic/hemodynamic management plans initiated by intraoperative echocardiographic findings were documented for each stage. Management changes were categorized into two groups: major or minor surgical and major or minor anesthetic/hemodynamic with different treatment subcategories:
Major surgical (n = 41)
Cannulation and reperfusion strategy (3)*
Axillary or femoral cannulation (1) [I]
Circulatory arrest (1) [I]
Coronary artery operation without cardiopulmo nary bypass (1) [I]
Regional wall motion assessment (RWMA) or global left/right ventricle (11)
Intraaortic balloon pump (4) [I, II, III, IV]
Unplanned grafts (4) [I, II, III, IV]
Repair or replace grafts (3) [II, III, IV]
Cardiopulmonary bypass (3)
Emergent initiation (1) [I]
Return to cardiopulmonary bypass (2) [III, IV]
Unplanned valve operation (16) [I, II, III, IV]
Mechanical support (left ventricular assist device or extracorporeal membrane oxygenation) (4) [I, II, III, IV]
Other (4) [I, II, III, IV]
Left ventricular rupture
Aortic dissection
Minor surgical (n = 3)
Cannulation and perfusion strategy (1)
Modify ascending aortic cannulation site (1) [I]
Aortic insufficiency (2)
Left ventricular venting [I, II]
Major anesthetic/hemodynamic (n = 16)
Treatment of RWMA (4) [I, II, III, IV]
Perfusion pressure, transfusion
Ca2+ channel
Slow heart rate
Change of anesthetic agents (4) [I, II, III, IV]
Treatment of global dysfunction (8)
Inotropes, vasodilators, inodilators
As RWMA treatment
Treatment of global right ventricular dysfunction (4)
[I, II, III, IV]
Hemodynamic management of valve disease (4) [I, II, III, IV]
Minor anesthetic/hemodynamic (n = 12)
Treatment of diastolic dysfunction (4) [I, II, III, IV]
Treatment of RWMA or global dysfunction (8) [I, II, III, IV]
Change of anesthetic concentration or dose
No distinction was made if the management alteration initiated by intraoperative echocardiography was supported by other information.
To calculate the percentages of patients affected by a major alteration in surgical or anesthetic management, we divided the total number of patients with more than one alteration during the four stages of their operation by the total number of study patients. This same calculation was carried out for minor alterations and combined groups. A patient who had management changes in two or more stages in the different subcategories (eg, treatment of new or increasing severity of global dysfunction in stages I and II) counted as only one treatment subcategory alteration.
For surgical management, 41 major and 3 minor decisions could be altered due to intraoperative echocardiographic findings. For anesthetic/hemodynamic measurements, 16 major and 12 minor alterations were possible. A SONOS 2500 (M2406A) Ultrasound System with a (21367A) 6.2/5.0-MHz OMNI II multiplane transesophageal echocardiographic probe and linear array 7.5-MHz (21367A) transducer for epivascular scanning (Hewlett Packard, Andover, MA) was used in each of the 82 patients. A comprehensive intraoperative echocardiographic examination at each of the four stages during the procedure consisted of assessing all cardiac chambers (systolic and diastolic function), valve structure and function, and the ascending and descending aorta. Assessment of the left and right ventricle included regional wall motion analysis and global ventricular function [8]. Between the comprehensive examinations, the transesophageal probe was positioned at the transgastric midpapillary muscle cross-section for monitoring purposes. Transgastric longitudinal imaging was used intermittently to monitor function of myocardium of the distal coronary perfusion beds. Mitral, aortic, pulmonary, and tricuspid valves were assessed for structural integrity and function. Insufficiency and stenosis for each of these valves was characterized as mild, moderate, or severe. Evaluation of the aorta was dependent on the degree of arteriosclerosis and the documented presence of atheromatous plaques. Atheromas were classified as either mural (sessile) or mobile. The extent of intimal thickening and the size of atheromatous sessile or mobile plaques were documented [9]. Epivascular echocardiography to assess the site of aortic cannulation and cross-clamp was performed if mobile plaques in the descending thoracic aorta were present or ascending aortic plaques were palpated. A site of cannulation was determined based on the absence of atheromatous plaques at the site or in an area that may be affected by the cannulation jet after the institution of cardiopulmonary bypass [10].
The outcome variables measured in this study were as follows:
Hospital death
Perioperative myocardial infarction
Intubation time >72 hours
Focal or global central nervous system deficit in intensive care unit and at hospital discharge
Cardiac morbidity
Intensive care unit and hospital length of stay
Intensive care unit intubation time
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Ascending aortic cannulation and cross-clamp sites were altered in 25 patients due to aortic atheromatous disease detected by transesophageal or epivascular echocardiography.
Surgical management alterations in patients with regional wall motion abnormalities or global ventricular dysfunction are illustrated in Table 1. Of 2 patients requiring emergent cardiopulmonary bypass, 1 underwent a third-time re-revascularization with a subtotal left main occlusion and normal left ventricular function. Twenty-five minutes after induction of anesthesia, subtle anterior wall motion hypokinesia was detected by transesophageal echocardiography without initial electrocardiographic changes. Surgical and anesthetic teams were immediately alerted; the patient was placed on femoral artery–femoral vein cardiopulmonary bypass as the ventricular function deteriorated. By the time electrocardiographic changes developed (3 minutes), the anterior wall was akinetic. The patient underwent successful reoperation with an uneventful perioperative course.
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As a result of intraoperative echocardiographic findings, 4 patients were returned to cardiopulmonary bypass for additional graft placement or replacement of existing grafts. In 1 patient who underwent an internal thoracic artery graft to the distal left anterior descending coronary artery, intermittent distal septal akinesia was detected 10 minutes after separation from cardiopulmonary bypass. Despite appropriate pharmacologic intervention, the intermittent regional wall motion abnormality continued. The patient was returned to cardiopulmonary bypass and the internal thoracic artery inspected. A small raised intimal flap obstructing distal coronary blood flow was found. This patient was successfully regrafted without sequelae.
Severe right and moderate left ventricular dysfunction were detected by echocardiography in 1 patient whose chest was ultimately reopened because of persistent dysfunction. After institution of cardiopulmonary bypass, placement of a right coronary artery graft was performed. After separation from cardiopulmonary bypass, the patient's biventricular dysfunction persisted with increasing hypoxemia and extracorporeal membrane oxygenation was instituted. This patient was weaned from extracorporeal support on the third postoperative day under transesophageal echocardiographic guidance. No further support was required.
An intraaortic balloon pump was inserted in 2 patients after cardiopulmonary bypass in response to new ventricular dysfunction detected by echocardiography. Both demonstrated improvement in regional function and neither required additional surgical interventions.
Based on intraoperative echocardiographic findings demonstrating regional or global dysfunction, 44 patients were permitted to eject for a 15- to 30-minute period before gradual separation from cardiopulmonary bypass. Of these patients, 20 demonstrated unanticipated regional wall motion abnormalities; 24 had global left or right ventricular dysfunction.
Six patients underwent unplanned valvular procedures in response to transesophageal echocardiographic diagnosis of significant valvular disease. Three patients underwent mitral valve ring annuloplasty; 2, aortic valve replacement procedures; and 1, a pulmonary valve repair.
Left ventricular venting was performed in 7 patients due to unsuspected significant aortic insufficiency diagnosed by a pre-cardiopulmonary bypass transesophageal echocardiography.
Anesthetic/hemodynamic management alterations are shown in Table 2. Of 35 patients with new or increased regional wall motion abnormalities detected by intraoperative echocardiography, electrocardiographic evidence of myocardial ischemia was noted in only 7; electrocardiographic changes followed the regional wall motion changes. Postoperative persistence of the regional wall motion abnormality remained in 3 of these patients, and 1 of these 3 patients sustained a myocardial infarction documented by creatine kinase level and electrocardiogram.
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Intraoperative echocardiographic findings precipitated treatment of diastolic dysfunction with volume loading (in the presence of "normal" or elevated pulmonary artery or left atrial pressures), pharmacologic management, or both. Intraoperative echocardiographic findings recorded significant valve disease that had not been previously reported and led to alteration in the hemodynamic management in 32 patients.
Management alterations were collated according to major or minor surgical and anesthetic/hemodynamic changes. Of 82 consecutive high-risk patients, 27 (33%) had one or more major surgical alterations in their management based on intraoperative echocardiographic findings; 42 (51%) had major alterations of their anesthetic/hemodynamic management. Combining major surgical and anesthetic/hemodynamic management changes, 52 patients (64%) had one or more alterations in their intraoperative course instituted because of intraoperative echocardiography. For both major and minor alterations, 47 patients (57%) had surgical management changes; 60 (73%) had anesthetic/hemodynamic alterations.
Table 3 compares patient outcomes of isolated coronary artery bypass patients with severity score of 4 or greater between the consecutive prospective study group (n = 82) and a control group (n = 478). Even though the nonintraoperative echocardiography group data were collected in a prospective fashion, it is difficult to adequately compare our study group with a nonrandomized population; however, given the increasing reliance by the cardiac surgical team on intraoperative echocardiography and an unwillingness to randomize high-risk patients in a blinded fashion, this type of comparison may be one of the only remaining methods to study the potential benefits of intraoperative echocardiography in this high-risk population.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Intraoperative echocardiography has not yet been routinely established as an intraoperative monitor in the development of management strategies in high-risk patients with coronary disease. Although perceptions vary for what constitutes care, optimal care should require the timely establishment of a definitive diagnosis with prompt and appropriately guided treatment. Diagnostic and monitoring techniques during coronary artery bypass grafting that guide treatment strategies should provide structural, functional, and hemodynamic information about the heart and great vessels. The underlying situation in patients for coronary artery bypass grafting is unique because their risk is superimposed on events directly related to cardiac operation, anesthesia, and extracorporeal circulation. It is well recognized that transesophageal echocardiography is more sensitive in detecting myocardial ischemia than electrocardiographic repolarization changes and more specific for determining preload changes (especially hypovolemia) than pulmonary artery or capillary wedge pressure monitoring [12]. The additional applications of intraoperative echocardiography should further advance its advantage over traditional monitoring strategies that incorporate pressure (arterial line and pulmonary artery catheter) and electrocardiographic monitoring.
It is not surprising that echocardiography compares favorably with traditional monitoring techniques. Intraoperative echocardiography is an established technology for assessing aortic pathology, valvular dysfunction, and ventricular function or segmental wall motion before and after coronary revascularization. This study demonstrates that when all of the isolated diagnostic and monitoring applications of perioperative echocardiography are routinely and systematically performed together, their added influence on patient management decisions and outcomes can be highly significant. Over the last three decades, great advances in cardiac surgery have enabled significant decreases in morbidity and mortality for coronary artery bypass grafting. Smaller gains require an attentiveness to detail and nuance otherwise not readily apparent in the past. Intraoperative echocardiography, when used in a complete and extensive manner, can positively affect surgical outcome. Based on our experience with intraoperative echocardiography, we are convinced that it plays a significant role in the management of high-risk cardiac surgical patients. Whether or not these results are reproducible in other settings is a question not yet answered. Given the low incidence of complications in patients undergoing myocardial revascularization, even in the high-risk population, outcome studies involving large numbers of patients will be necessary to conclusively validate the impact of intraoperative echocardiography on patient outcome.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Savage, Departments of Cardiothoracic Anesthesia and Cardiology, The Cleveland Clinic Foundation, 9550 Euclid Ave, Cleveland, OH 44195.
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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