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Original Articles: Cardiovascular

The Influence of Epiaortic Ultrasonography on Intraoperative Surgical Management in 6051 Cardiac Surgical Patients

^a Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany
^b Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
^c Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
^d Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
^e Mucosal Inflammation Program, Department of Anesthesiology and Perioperative Medicine, University of Colorado Health Science Center, Denver, Colorado

Accepted for publication August 29, 2007.

^_* Address correspondence to Dr Eltzschig, Mucosal Inflammation Program, Department of Anesthesiology and Perioperative Medicine, Biochemistry Research Building (BRB), Room 852, 4200 E 9th Ave, Mailstop B112, Denver, CO 80262 (Email: holger.eltzschig{at}uchsc.edu).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background: Intraoperative echocardiography has become a mainstay monitor of cardiac function and a popular diagnostic tool in patients undergoing cardiac procedures. Previous reports suggest that epiaortic ultrasonography (EU) is superior to transesophageal echocardiography and manual palpation in identifying ascending aortic atheroma. Its impact on surgical decision making has not been thoroughly investigated, however.

Methods: We retrospectively analyzed the medical records of 6051 consecutive patients who underwent EU of their ascending aorta during cardiac operations between 1996 and 2006 to determine a potential impact on intraoperative surgical decision making. Aortic atheroma was graded according to standard classification. Neurologic complications were evaluated according to the Society of Thoracic Surgeon definition for stroke and transient ischemic attack (TIA).

Results: The overall impact of EU on surgical decision making was 4.1% and included a change in the technique for inducing cardiac arrest in 1.8%, aortic atherectomy or replacement surgery in 0.8%, requirement for off-pump coronary artery bypass grafting (CABG) in 0.6%, avoidance of aortic cross-clamping and use of ventricular fibrillatory arrest in 0.5%, change in arterial cannulation site in 0.2%, or avoidance of aortic cannulation in 0.2%. The greatest affect of EU was observed in patients undergoing combined CABG with aortic/mitral valve procedures (6.7%). The smallest impact was seen in patients undergoing mitral valve operations (1.4%). Aortic atheroma was more frequent on the anterior aspect of the aorta (n = 171) in patients with a change in surgical plan than on the posterior aspect (n = 78). The overall stroke rate was lower in patients with intraoperative EU compared with all patients undergoing surgical procedures.

Conclusions: Epiaortic ultrasonography is a useful technique to detect ascending aortic atheroma, has a significant impact on surgical decision making in more than 4% of cardiac surgical patients, and might result in improved perioperative neurologic outcome.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Epicardial echocardiography was initially introduced into clinical practice in the early 1970s as a monitor of valvular function in cardiac surgical patients [1]. However, the use of intraoperative epicardial echocardiography has declined due to the increasing availability and improved technologic development of transesophageal echocardiography (TEE). Nonetheless, epiaortic ultrasonography (EU) remains a frequently used intraoperative diagnostic technique during cardiac procedures [2, 3], and compared with TEE, provides superior imaging for evaluating the aortic arch, ascending aortic atherosclerotic disease, cannulation, and cross-clamp sites [4, 5].

A correlation between the presence of significant ascending aortic pathology and perioperative stroke has been well established [4, 6–11]. However, investigations that have attempted to evaluate the effect of EU on cardiac surgical decision making and its role in preventing adverse clinical outcomes have often been limited to observations in relatively small populations. Most recently, Bolotin and colleagues [12] demonstrated that EU influenced a change in the surgical procedure in 28% of 105 patients undergoing only coronary artery bypass grafting (CABG) procedures. As shown in a recent study by Hammon and colleagues [6], this change in surgical approach might result in an improved postoperative cognitive outcome.

Although information acquired during a comprehensive EU examination may direct the surgeon to change an approach, such as modifying the cannulation or proximal coronary artery graft site, avoiding aortic cross-clamping, or even performing an ascending aortic débridement or replacement, most studies have included only a limited number of patients or have focused only on patients undergoing CABG. Therefore, we investigated the impact of EU on surgical decision making and management in a consecutive series of 6051 patients undergoing different types of cardiac and thoracic aortic procedures from a single institution.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patient Population
The study population consisted of a consecutive series of all cardiac surgical patients from the Brigham and Women’s Hospital in Boston, Massachusetts, in whom intraoperative EU was performed between 1996 and 2006. The decision to perform EU was determined together by the attending cardiac surgeon and the cardiac anesthesiologist for each case. Surgeon preference was an important factor in the decision not to perform EU. The study and the retrospective review of the patients’ medical records were approved by the Institutional Review Board.

Epiaortic Ultrasonographic Examination
Comprehensive EU examinations were performed after median sternotomy and pericardiotomy but before aortic cannulation. In preparation for the EU examination, the pericardial space was filled with warm saline to improve transducer contact. A 7-Mhz ultrasound transducer (V7, Acuson, Mountain View, CA; Philips Medical Systems, Andover, MA) was then inserted into a sterile plastic sheath containing sterile conductive gel and was initially positioned over the proximal ascending aorta by the attending cardiac surgeon. The entire ascending aorta and proximal aortic arch were then scanned for pathology in short and long axes under the direction and interpretation of attending cardiac anesthesiologists, all of whom had extensive training and experience in perioperative echocardiography and EU. Results of the examinations were discussed with the attending cardiac surgeon. Data from the intraoperative TEE and EU examinations was recorded on videotape and stored on a digital database for offline review and analysis.

Study Design
Patient demographic and EU data were obtained from the departmental digital database, which included demographic data and information pertaining to the impact of EU on perioperative surgical decision making. Only intraoperative EU findings that were not known preoperatively and directly resulted in a significant alteration in surgical management were included in this study. Alterations in surgical management were defined as the addition of an unplanned surgical procedure or the omission of a planned procedure, or both, and were classified as:

1 previously unplanned circulatory arrest;

2 avoidance of aortic cross clamp or previously unplanned hypothermic ventricular fibrillatory cardiac arrest;

3 off-pump CABG (OPCABG) instead of initially planned on-pump CABG;

4 changing the arterial cannulation site for cardiopulmonary bypass (CPB) to a site other than the ascending aorta, such as femoral or axillary; or

5 previously unplanned débridement or replacement of the aorta or aortic valve (AV) in a patient with contraindication to TEE probe placement.

Cases in which EU only influenced the delineation of an ideal cannulation or cross-clamp site were not included because the independent and direct influence of EU on these specific decisions was often difficult to determine from the database.

Epiaortic Ultrasound Grading of Aortic Atheroma
The classification of Wareing and colleagues [13] was used to classify and grade the severity of aortic atheroma. Mild atheroma, was defined as localized atherosclerotic thickening of less than 3 mm, moderate atheroma as atherosclerotic thickening between 3 and 5 mm, and severe atheroma as atherosclerotic thickening exceeding 5 mm. Protruding or mobile plaques were recorded separately.

Stroke and Transient Ischemic Attack
The Society of Thoracic Surgeon standard definition was used to define postoperative neurologic complications. Stroke was defined as a neurologic deficit persisting for more than 72 hours postoperatively. Transient ischemic attack (TIA) was defined as a transient neurologic deficit with recovery within 24 hours.

Statistical Analysis
Statistical analyses were performed using SAS 9.1 software (SAS Institute, Cary, NC). Univariate analysis using ² test was done to determine significant differences in the incidence of stroke and TIA in patients undergoing the same type of procedure. Multivariable logistic regression was used to determine the odds ratio (OR) for stroke or TIA in all patients undergoing EU compared with patients without EU. The ORs and corresponding 95% confidence intervals (CIs) were determined. A p < 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Patients and Operations
A total of 15,120 patients underwent cardiac procedures at the Brigham and Women’s Hospital from January 1996 to July 2006. Intraoperative TEE was performed in 8239 patients (55%), and EU was performed in 6051 patients (73%) of the TEE subpopulation. The remaining patients did not receive EU because of surgeon preference.

The mean age of the EU population was 68 years (range, 12 to 95 years), with 34% women and 66% men (Table 1). CABG was done in 3535 patients (58.4%), and 914 patients (15.1%) were scheduled for procedures of the mitral valve (MV), AV, or both. Combined CABG and valvular procedures were planned in 1216 patients (20%). The remaining 386 patients (6.3%) presented for miscellaneous procedures, including valvular operations not involving the AV or MV, thoracic exploratory procedures, aortic procedures, and other miscellaneous cardiac operations (Fig 1A and B).

View larger version (13K): [in this window] [in a new window]   Fig 1. Number of surgical procedures performed in patients in whom intraoperative epiaortic ultrasonography (EU) was performed. (A) Coronary artery bypass graft (CABG) and valve procedures performed in patients undergoing EU. (B) Miscellaneous procedures performed with EU. (An = aneurysm; ASD = atrial septal defect; AV = aortic valve; MV = mitral valve; Thr = thrombus; VAD = ventricular assist device; VSD = ventricular septal defect.)

View larger version (16K): [in this window] [in a new window]   Fig 2. Overall impact of epiaortic ultrasonography (EU) in 6051 patients undergoing cardiac surgical procedures in whom EU was performed. (Asc Ao = ascending aortic; AV = aortic valve; CABG = coronary artery bypass grafting; HFA = hypothermic fibrillatory arrest; MVP = mitral valve plasty.)

Combined Cardiac Procedures
An overview of the effect of EU on the surgical management of patients undergoing different combined procedures is in Table 2. Information acquired from the EU examination influenced surgical decision making in 33 of 611 patients (5.4%) undergoing combined CABG and AV procedures. Unplanned circulatory arrest instead of aortic cross-clamping and continuous CPB was performed in 11 patients (1.8%), and an aortic operation was added to the initially planned procedure in 19 (3.1%). Among 89 patients undergoing combined CABG, AV, and MV procedures, a change in surgical plan was documented in 6 (6.7%), with 3.3% of patients requiring circulatory arrest, and 3.3% of patients undergoing additional aortic procedures. Information acquired from the EU examination influenced surgical management in 2.9% of the 516 patients undergoing planned CABG and MV procedures and 3.3% of those undergoing combined AV and MV operations.

Miscellaneous Cardiac Procedures
Miscellaneous cardiac surgical procedures performed in 386 patients included heart transplantation, resection of an intracardiac mass or thrombus and atrial/ventricle septal defect closures (Table 3). In this subpopulation, EU altered the surgical plan in 4 patients (1.0%), including 2 patients (0.5%) in whom an ascending aortic procedure was added.

Atheroma Location Identified With Epiaortic Ultrasonography
Intraoperative EU identified atheroma on the anterior aspect of the ascending aorta (n = 171) more frequently than the posterior aspect in patients in whom the surgical plan was altered accordingly (n = 78; Fig 3). Mobile atheromas were identified in a significant number of patients within the anterior ascending aorta in 19 patients and the posterior aorta in 11.

View larger version (10K): [in this window] [in a new window]   Fig 3. Location of ascending aortic atheroma in 249 patients in whom epiaortic ultrasonography (EUS) influenced surgical management. Atheroma was graded as mild, moderate, severe, or mobile thrombus and was subdivided by location into the anterior (filled bar) and posterior (clear bar) aspect of the aorta.

View larger version (16K): [in this window] [in a new window]   Fig 4. Incidence of stroke and transient ischemic attacks (TIA) in overall patient population who did not have intraoperative epiaortic ultrasound (EU) examination (black bars) vs those who did (clear bars). (A) Incidence of perioperative stroke. (B) Incidence of perioperative TIA. (CABG = coronary artery bypass grafting.)

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
Neurologic complications are among the most frequent and devastating complications after cardiac operations. Atheromatous disease of the aorta is one of the most important predictors of such neurologic complications [9, 10, 14]. Depending on the degree of aortic manipulation, the severity of aortic disease, and the procedure performed, up to 16% of cardiac surgical patients may have a stroke [6, 9, 15]. Surgical strategies directed towards reducing perioperative adverse neurologic events during cardiac operations include the avoidance of aortic cannulation or cross-clamping, no-touch techniques [13, 16, 17], and aortic débridement or replacement.

The degree of aortic atheromatous disease can be assessed by palpation, TEE, or EU; however, several investigations suggest that EU remains the most sensitive, practical, and safest of these techniques in cardiac surgical patients committed to a median sternotomy [4, 12, 18, 19]. In addition, published guidelines from the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists for Training in Perioperative Echocardiography indicate epiaortic imaging is recommended as a core component of advanced training [20].

Nonetheless, intraoperative EU is not used routinely, perhaps because its effect on surgical decision making has not been thoroughly investigated. Therefore, we analyzed the medical records of 6051 cardiac surgical patients and demonstrated that EU influenced surgical management in 4.1%. We demonstrate that EU identifies significant aortic pathology and may have a favorable effect on reducing adverse, perioperative neurologic outcomes.

Several investigations have shown that EU is superior to manual palpation of the aorta and TEE for detecting ascending aortic and arch atheroma [4, 12, 19, 21]. In a study of 44 CABG patients, Davila-Roman and colleagues [4] demonstrated that EU was significantly more accurate than TEE for identifying ascending aortic atherosclerosis and that both ultrasound imaging techniques were superior to manual palpation [4]. However, visualization of aortic cross-clamping and cannulation sites in the distal ascending aorta is limited with TEE owing to the interposition of the left mainstem bronchus between the esophagus and the aorta [22, 23].

Studies in the literature vary in their stated impact of EU on cardiac surgical management. For example, Bolotin and colleagues [12] demonstrated in 105 CABG patients, that EU was significantly more sensitive in identifying aortic atherosclerotic disease compared with manual palpation and influenced surgical management in 28% of the patients [12]. A 17% change in surgical strategy was also reported by Davila-Roman and colleagues [19] in a study of 100 cardiac surgical patients. The low threshold at this specific institution to perform OPCABG may explain the difference in the incidence of surgical alterations compared with our study [14].

We found an overall impact on surgical decision making in 4.1% of all patients, with a range of 1.4% in MV procedures to 6.7% in patients scheduled for combined CABG, MV, and AV procedures. The large size of our study population and the use of relatively conservative definitions for determining when the influence of EU on surgical decision making was significant, may have contributed to lower incidences and an underestimation of effect in our study compared with some others reported in the literature. Furthermore, we demonstrate that EU identifies significant aortic pathology in the patients in whom the surgical plan was altered. We also report a lower incidence of neurologic complications in the patient population managed with EU.

We did not have a formal control population that included matched and randomized cardiac surgical patients with similar risk profiles in whom EU was not performed. Ultimately, large-scale prospective, randomized trials would be required to determine the absolute effectiveness and benefit of EU on perioperative clinical outcomes. The practical and ethical limitations of conducting such a definitive study may be prohibitive, however. Nonetheless, our results and the observations of other studies strongly support the value of EU in the management of cardiac surgical patients.

Although complications from epiaortic scanning are extremely rare, some limitations of this technique warrant consideration. The EU examination lengthens the intraoperative time before the institution of CPB, potentially increases the risk of contaminating the surgical field, requires the purchase of optimal high-frequency surface ultrasound transducers, and requires additional technical skills for obtaining the imaging planes and experience in interpreting the acquired diagnostic information [7]. Konstadt and colleagues [7] reported a sensitivity of 100% with TEE in the assessment of the ascending aorta for atherosclerotic disease. These authors also proposed that EU is only necessary if plaque was first identified by TEE. However, higher-frequency surface ultrasound transducers that provide higher-resolution imaging should ideally be used for EU examinations. EU may also be necessary when placement of a TEE probe is difficult or contraindicated [2, 3].

In summary, EU remains a safe, practical, and sensitive technique for evaluating ascending aortic and arch pathology in cardiac surgical patients and therefore provides the surgeon with the opportunity to change the planned surgical approach to reduce the incidence of adverse perioperative clinical outcomes. In this study, which investigated a large patient population, we have shown that EU influences surgical decision making in 4.1% of a diverse population of cardiac surgical patients. Epiaortic ultrasonography identifies significant aortic calcification and may have a favorable influence on postoperative complication rates. As the profile of cardiac surgical patients continues to shift towards higher-risk populations predisposed to increased perioperative morbidity and mortality, the value of this important diagnostic tool may increase substantially.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stanton K. Shernan Prem S. Shekar John A. Fox Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rosenberger, P. Articles by Eltzschig, H. K. Search for Related Content PubMed PubMed Citation Articles by Rosenberger, P. Articles by Eltzschig, H. K. Related Collections Cardiac - other