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Ann Thorac Surg 2000;69:489-490
© 2000 The Society of Thoracic Surgeons
a Department of Anesthesiology, University of Pennsylvania, Dulles 7, 3400 Spruce St, Philadelphia, PA 19104, USA
b Department of Anesthesiology, Washington University School of Medicine, 600 S Euclid Ave, Box 8054, St. Louis, MO 63110, USA
e-mail: hoguec{at}notes.wustl.edu
Invited commentary
The importance of intraoperative transesophageal echocardiography (TEE) in the modern practice of cardiovascular surgery and anesthesia is well established. The information provided by TEE enables the precise definition of cardiac valve lesions, the ability to detect regional myocardial ischemia and dysfunction, and to diagnose dissection, aneurysm, traumatic disruption, or atherosclerosis of the thoracic aorta [1]. Application of intraoperative TEE has contributed to the increased number and success of valve repair procedures [2], the development of minimally invasive cardiac surgical procedures [3], and improved outcome in emergency operations of the thoracic aorta [4]. Despite the rapidly expanding use of intraoperative TEE, complications from its use have been infrequent. Complications were often attributed to unrecognized diseases of the esophagus or difficulty inserting the TEE probe [5]. General anesthesia and cardiopulmonary bypass could further increase risks when using TEE. Anesthetized patients cannot voice discomfort during probe insertion or manipulation and TEE probes are often left in place during conditions of nonpulsatile perfusion and systemic hypothermia.
Swallowing dysfunction after cardiac surgery is a serious complication that increases the risk for aspiration pneumonia, the need for tracheostomy, and prolonged hospitalization [6]. In this issue of The Annals, Rousou and colleagues [7] report that the frequency of dysphagia based on barium cineradiographic diagnosis was 7.9% for the 126 cardiac surgical patients who had intraoperative TEE versus 1.8% for 712 patients who did not have TEE. After adjusting for confounding variables including age, duration of intubation and stroke, TEE use was independently associated with dysphagia (odds ratio 7.8, 95% confidence interval, 1.81 to 33.60, p < 0.001). These findings were similar to those reported by Hogue and colleagues [6] who found dysphagia in 4% of 869 cardiac surgical patients. In the latter report, intraoperative TEE use was also independently associated with dysphagia even after statistically adjusting for the effects of other risk factors such as age, duration of intubation, stroke and other postoperative complications [6]. In contrast, others have not found an association between intraoperative TEE use and the development of dysphagia [8].
If TEE proves to be causally related to dysphagia after cardiac surgery, the risks of intraoperative TEE may be greater than previously suspected. Despite these reports, it remains difficult to prove that TEE use alone was the cause for postoperative dysphagia. There are multiple problems when linking TEE use to dysphagia as based on the reported series. These include the lack of preoperative assessments for dysphagia, the delay between the TEE examination and the diagnosis of dysphagia, non-uniform documentation of the disorder, and differences in the patient populations and indication for TEE between centers. Further, because in these retrospective studies TEE use was not prospectively randomized, bias for the use of TEE in more complex surgical procedures and for more complicated patients could influence the results. One must acknowledge, though, that multivariate logistic regression analysis used in both the reports by Rousou and associates [8] and Hogue and coworkers [6] adjusted for many of these confounding variables including the type of procedure, duration of cardiopulmonary bypass, and length of the operation. Regardless, these results only show that TEE was statistically associated with dysphagia and its use may or may not be causally related to the complication. In the meantime, uncertainty as to the exact role of TEE in the pathophysiology of this complication should not deter the appropriate use of TEE when medically indicated. However, awareness of the potential for occult injury should constitute a warning against the indiscriminate use of TEE for cardiac operations. It is advisable to follow established guidelines for safe probe insertion and conduct of the TEE examination in anesthetized patients to prevent injuries that can potentially be avoided [9].
References
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