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Ann Thorac Surg 2004;78:1586-1590
© 2004 The Society of Thoracic Surgeons
a Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
b Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
c Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
Accepted for publication May 3, 2004.
* Address reprint requests to Dr Click, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA 55905
click.roger{at}mayo.edu
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsCommentReferences |
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METHODS: From January 2001 to December 2003, 474 consecutive patients (76% men, 24% women) aged 30 to 89 years (mean age of 70 ± 10 years) who were undergoing coronary artery bypass graft surgery had prebypass and postbypass intraoperative transesophageal echocardiography. New findings and alterations in the surgical plan were documented prospectively.
RESULTS: New prebypass findings were found in 10% of patients, and the surgical plan was altered in 3.4% of patients. New postbypass findings were found in 3.2% of patients, altering the surgical plan in 2% of patients.
CONCLUSIONS: This large consecutive, nonselected, prospective study reveals the significant impact of intraoperative transesophageal echocardiography in patients having coronary artery bypass graft surgery as a primary procedure. New findings (prebypass and postbypass) were found in 13% of patients overall, and the surgical plan was altered in 5.5% of patients. This study supports the use of intraoperative transesophageal echocardiography in patients undergoing primarily coronary artery bypass graft surgery.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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To date, only small or selected series of studies have assessed the role of IOTEE in conjunction with coronary artery bypass graft (CABG) surgery. Savage and colleagues [13] analyzed the role of IOTEE in high-risk patients. Bergquist and colleagues [14] looked at how the IOTEE assessment of left ventricular function and regional wall motion abnormalities (RWMA) influenced anesthetic management in those patients with myocardial ischemia. The purpose of this study was to evaluate prospectively the use of IOTEE in a large, consecutive, nonselected group of patients undergoing CABG surgery as the primary operation.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Multiplane transesophageal echocardiography (TEE) systems were used in each case. The probe was inserted into the esophagus after the induction of general anesthesia. A complete TEE examination was performed, including two-dimensional, color flow, and Doppler as previously described [15]. Images were obtained before and after bypass, after the hemodynamics had been stabilized. The presence of a patent foramen ovale (PFO) was evaluated by color flow imaging and contrast (agitated saline, 10 mL) injection through a central venous catheter while positive end-expiratory pressure was released.
A data sheet was developed to gather demographic data about the patients, details of the surgical procedure, and the IOTEE findings. This data sheet has been part of our routine data collection on patients undergoing IOTEE and was approved by the Mayo Clinic Institutional Review Board on March 9, 1999. All data were recorded at the time of surgery by the echocardiographer who performed the IOTEE. All new findings detected by IOTEE and any substantive change in surgical plans and management were recorded, both before and after cardiopulmonary bypass (prebypass and postbypass).
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Prebypass: New Findings
Table 1 outlines the prebypass IOTEE findings and the surgical impact in 474 consecutive CABG patients. Fifty-two new findings were discovered in 46 patients (10%). The most common finding was an unrecognized PFO found in 22 patients (4.6%). The PFO was surgically closed in 7 patients (1.5%). In 12 patients (2.5%) previously unrecognized, significant regurgitation of the mitral valve (5 patients), tricuspid valve (4 patients), and aortic valve (3 patients) was discovered. In addition, 2 patients with aortic valve disease (mild aortic stenosis and Lambl's excrescence) and 1 subvalvular obstruction were seen. This resulted in valve repair surgery in addition to CABG in 8 patients (1.7%) (mitral valve repair in 2, tricuspid valve repair in 2, aortic valve repair in 1, and aortic valve exploration in 2) and left ventricular myectomy in 1 patient. Significant aortic atheromatous plaque was identified in 5 patients (1.1%), prompting a switch to OPCABG in 2 patients (0.4%). In 3 patients (0.6%) significant new global deterioration in left or right ventricular function (or both), or new RWMA, were evident when compared with the preoperative echocardiogram, but no management changes were made.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The important observation in this study was that there were 71 new findings in 61 (13%) CABG surgical cases that were studied with prebypass and postbypass IOTEE. The new observation had a direct effect on the surgical management of 26 patients (5.5%). In a previous study that looked at the impact of IOTEE in all types of adult cardiac surgical cases at the Mayo Clinic over a 5-year period, we reported new findings in 21% of patients, including prebypass and postbypass periods, with subsequent alteration in surgical management in 18% [15]. In this study the use of IOTEE in a subgroup of patients undergoing isolated CABG surgery demonstrated new findings in 33% of patients prebypass and 8% postbypass [15]. We speculated that the very high incidence of new findings was attributable to inherent bias related to self-selection of higher risk CABG patients when IOTEE was used. The purpose of the present study was to evaluate the role and the impact of IOTEE in a large, consecutive, unselected CABG surgical patient population.
Prior studies that have evaluated the role of IOTEE in patients undergoing CABG surgery have been in the form of case reports and small series, or have focused on high-risk groups or medical (anesthetic) management issues. Savage and colleagues [13] reported on high-risk patients having CABG. IOTEE findings initiated a major change in surgical management in 33% of patients, or a major change in anesthetic management or hemodynamic intervention in 51% of patients. These results are more in line with our original paper [15] that demonstrated new findings in 33% of selected CABG patients.
In a small series of 75 patients, Bergquist and colleagues [14] analyzed the impact of IOTEE on intraoperative anesthetic management during routine CABG. They found that 17% of intraoperative clinical interventions were influenced predominately by the IOTEE. Mishra and colleagues, [18] in a large IOTEE series, reported a subset of patients having only CABG surgery. In this nonconsecutive series with IOTEE based on probe availability and high-risk, IOTEE impacted on the surgical plan in 27% of patients.
Deutsch and colleagues, in a small prospective series of 50 patients, [16] reported that IOTEE provided essential diagnostic information in 4%. However, Sutton and colleagues [17] had similar results to ours in 120 patients having routine CABG surgery, with 21% new findings and 6% felt to be essential to the surgical plan.
Not surprisingly, in this series of 474 consecutive CABG surgical patients, the overall impact of IOTEE was lower than in studies that focused on high-risk subsets of patients. The most common new prebypass finding was a PFO in 22 patients (4.6%) that was closed in 7 patients. This prevalence of PFO is lower than that found in autopsy studies of normal hearts (25% to 34%, with the higher incidence in the first three decades of life) [21] or in intraoperative studies (26%) [22]. The reasons for closure of the PFO were varied and included the relatively large size of the PFO with the presence of an interatrial shunt or atrial septal aneurysm, or both. The decision to close an asymptomatic PFO was at the discretion of the individual surgeon, but is supported by the risk of paradoxical embolization in patients with larger PFOs or an atrial septal aneurysm [23–25].
A significant impact of the prebypass IOTEE was the finding of unanticipated valvular lesions in 15 patients, resulting in surgical intervention in 8 patients. The decision to repair these abnormalities in approximately half the patients was based on the severity of the valvular lesion as assessed by IOTEE.
In the postbypass period, 7 patients (1.5%) were returned to cardiopulmonary bypass for significant new findings: 5 patients had revision of bypass grafts and 2 patients had mitral valve repairs. It is impossible to know whether IOTEE would have accounted for all subsequent surgical interventions because neither the surgeons nor anesthesiologists were blinded to the IOTEE findings. It is quite possible that in patients struggling to come off cardiopulmonary bypass, additional interventions would have been used in the absence of IOTEE. However, it is clear that these interventions would have been delayed, inexact, or incomplete in the absence of IOTEE. In addition, being able to assess left ventricular function and size in the postbypass period, while subjective, is extremely useful in overall hemodynamic management during this often unstable period.
It is also possible that IOTEE resulted in interventions that were not necessary and hence put the patients at increased risk. An example of this might be the closure of a PFO in an otherwise asymptomatic patient. However, our approach was conservative in dealing with this problem and was always balanced by weighing of risk-benefit as judged by the medical team (surgeon, anesthesiologist and echocardiographer) in the operating room.
An additional concern about the routine use of IOTEE is the risk of patient injury from the introduction and manipulation of the probe in the esophagus and stomach. In a retrospective review of 7200 adult cardiac surgical patients, Kallmeyer and colleagues reported an incidence of 0.2% TEE-associated morbidity, including odynophagia (0.1%), dental injury (0.03%), endotracheal tube malpositioning (0.03%), upper gastrointestinal hemorrhage (0.03%), and esophageal perforation (0.01%) [26]. No patients in this study suffered any serious trauma, but there is a definite, albeit small, risk of esophageal injury or dysfunction with this technique [27].
The availability of physicians skilled in the use of IOTEE is another important concern. In the hands of inexperienced personnel, diagnostic accuracy will be lower, thus making the risk of incorrect or inappropriate decisions more likely. Although we did not look at cost-effectiveness, the discovery of even 1 major abnormality in 100 patients by IOTEE that would otherwise have been missed would be likely be cost-effective [19].
Based on our previous study of IOTEE [15], we suggested that the impact of IOTEE in surgical decision-making was important and that all patients undergoing a cardiac surgical procedure should have an IOTEE. The current study confirms that even in an unselected group of patients having routine CABG surgery, IOTEE will provide new and clinically useful information in 13% of patients that results in a change in surgical approach in 5% to 6% of these patients. Although serious injury from IOTEE can occur, we believe that, on balance, IOTEE is beneficial in patient care, and is therefore indicated when the necessary expertise exists to correctly diagnose the underlying pathology.
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References |
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This article has been cited by other articles:
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  M. Swaminathan Thinking From Inside the Box Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2008; 12(4): 225 - 227. [PDF]
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 M. Enriquez-Sarano, V. T. Nkomo, and H. Michelena Principles and Practice of Echocardiography in Cardiac Surgery Card. Surg. Adult, January 1, 2008; 3(2008): 315 - 348. [Full Text]
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E. Gongora and T. M. Sundt III Myocardial Revascularization with Cardiopulmonary Bypass Card. Surg. Adult, January 1, 2008; 3(2008): 599 - 632. [Full Text]
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