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Click here to read this article as a CME activity
a Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany
b Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
c Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
d Department of Anesthesiology and Perioperative Medicine, University of Colorado Health Science Center, Denver, Colorado
Accepted for publication November 5, 2007.
* Address correspondence to Dr Eltzschig, Mucosal Inflammation Program, Department of Anesthesiology and Perioperative Medicine, Biochemistry Research Building, Room 852, 4200 E 9th Ave, Mailstop B112, Denver, CO 80262 (Email: holger.eltzschig{at}uchsc.edu).
| Cardiothoracic anesthesiology:
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsCommentFootnotesReferences |
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Methods: We analyzed all patients undergoing cardiac surgical procedures who had an intraoperative TEE examination between 1990 and 2005 at the Brigham and Women’s Hospital. Results of the TEE examinations were entered into a database. Previously undiagnosed TEE findings from the pre- and post-CPB examinations that directly impacted surgical decisions were evaluated.
Results: Before and after CPB TEE examinations influenced surgical decision making in 7.0% and 2.2%, respectively, of all evaluated patients (n = 12,566). In patients undergoing only coronary artery bypass graft surgery (CABG [n = 3,835]), surgical decisions were influenced by 5.4% of the pre-CPB and 1.5% of the post-CPB TEE examinations, and in 6.3% and 3.3%, respectively, of those patients undergoing isolated valve procedures (n = 3,840). In combined CABG and valve procedures (n = 2,944), surgical decisions were influenced by 12.3% of the pre-CPB and 2.2% of the post-CPB TEE examinations.
Conclusions: Intraoperative TEE influences cardiac surgical decisions in more than 9% of all patients in the presented study population, with the greatest observed impact in patients undergoing combined CABG and valve procedures.
| Drs Shernan and Fox disclose that they have a financial relationship with Philips Medical Systems, Inc.
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Since the introduction of intraoperative echocardiography into clinical practice in the 1980s, its popularity has steadily increased. Today, more than 90% of training programs in the United States use intraoperative transesophageal echocardiography (TEE) as a diagnostic and monitoring tool [1]. The American Society of Anesthesiologists, the American Society of Echocardiography, and the Society of Cardiovascular Anesthesiologists have issued guidelines for the intraoperative use of TEE [2–4]. Previous studies have suggested that in cardiac surgical patients, TEE provides essential before and after cardiopulmonary bypass (CPB) information regarding cardiac performance [5], valve function [6, 7], great vessel pathology [8], and congenital anomalies that has been shown to have a favorable impact on perioperative clinical outcomes [9–12].
Despite the increasing popularity of intraoperative TEE, its impact on perioperative decision making as well as on clinical outcomes has been questioned [9]. Ideally, intraoperative TEE should prevent unnecessary surgical procedures and associated morbidity. In addition, TEE can identify previously undiagnosed pathology and residual defects after surgical intervention to enable an immediate correction if necessary. Several clinical studies that have investigated the impact of TEE on surgical decision making have been limited by only enrolling a relatively small number of patients, focusing only on a particular surgical procedure, or reporting only post-CPB findings [9–19]. Therefore, we conducted a study to assess the influence of intraoperative TEE on surgical decision making, in 12,566 patients from a single institution who underwent different types of cardiac and thoracic aortic surgical procedures.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentFootnotesReferences |
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Technique of TEE Examination
All TEE probes (Siemens, Mountain View, California; or Philips Medical Systems, Andover, Massachusetts) were inserted after induction of general anesthesia. Complete and comprehensive intraoperative TEE examinations were performed by cardiac anesthesiologists, all of whom had extensive training and experience in perioperative echocardiography. Results of the examinations were discussed with the attending cardiac surgeon. Data from the intraoperative TEE examinations were recorded on videotape, and stored on a digital database for offline review and analysis.
Study Design
Patient demographic and echocardiographic data were obtained from the departmental digital database, which included information pertaining to the impact of intraoperative echocardiography on perioperative surgical decision making. For intial data collection, a prospectively designed clinical data form was utilized. Intraoperative TEE findings that were not known preoperatively, despite a comprehensive preoperative workup, were considered new pre-CPB findings. Only new findings that resulted in an 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.
A new post-CPB finding was defined as an intraoperative TEE diagnosis of unexpected residual pathology. Only those new post-CPB findings that led to a return to CPB for the correction of this finding were documented in this study. Any diagnosis obtained by TEE that led only to an alteration in hemodynamic or anaesthetic management was not considered in the analysis of the present study.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentFootnotesReferences |
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Patients Undergoing Valve Surgery
Before–cardiopulmonary bypass TEE examinations influenced surgical decision making in 242 of the 3,835 patients (6.3%) undergoing valve procedures. The most common alterations in the surgical procedure included the addition or omission of a MV procedure (1.3%), and the addition or omission of an atrial septal defect repair in 47 patients (1.2%).
During isolated AV procedures, surgical decisions were influenced by 4.4% of the pre-CPB and 2.2% of the post-CPB TEE examinations (Fig 4). The most common alterations in the surgical procedure influenced by pre-CPB TEE diagnoses included the addition of an MV procedure. The post-CPB TEE most commonly influenced the decision to revise the AV procedure. Intraoperative TEE had a generally greater impact on patients undergoing isolated MV surgery compared with patients undergoing AV procedures. During isolated MV procedures, surgical decisions were influenced by 6.6% of the pre-CPB and 4.1% of the post-CPB TEE examinations. For example, an addition/omission of a tricuspid valve procedure (1.8%) or atrial septal defect repair (1.6%) occurred more frequently among patients undergoing isolated MV procedures than AV procedures (Fig 5). In addition, the post-CPB TEE had its greatest impact on influencing the decision to revise a MV repair or replacement in 2.9% of patients undergoing isolated MV surgery. The decision to repair an atrial septal defect or patent foramen ovale was considered to be guided by intraoperative TEE only when these diagnoses were made before left or right atriotomy. Even greater percentages of changes in surgical management associated with intraoperative TEE diagnoses were observed in the 407 patients undergoing combined AV and MV surgery, including 9.1% of the patients in whom one of the two valve procedures was omitted (Fig 6). In addition, post-CPB TEE examinations most commonly provided information that led to the decision to revise the initial MV procedure or aortic valve replacement in 3% of the patients.
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In patients undergoing CABG with AV surgery, the omission of the AV procedure or the addition of a MV procedure was the most frequent change in surgical management, in 2.5% and 1.4% of the patients, respectively. Post-CPB graft revision was the most common change to the planned surgical procedure that was guided by TEE (Fig 7). The pre- and post-CPB changes in patients undergoing CABG and MV procedures are shown in Figure 8. In this subpopulation, the most frequent pre-CPB alteration was the omission of the planned MV procedure in 12.2% of the patients. After CPB, a revision of the MV (2.0%) was the most common surgical management changes influenced by TEE.
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New pre-CPB TEE diagnoses that altered the surgical plan occurred in 3.5% of the patients. Most commonly, a valve procedure was added, in 22 patients (1.1%). The most common decision post-CPB was to revise the performed procedure in 0.5% of the patients (data not shown).
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentFootnotesReferences |
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A comprehensive pre-CPB TEE examination allows the cardiac surgeon and anesthesiologist to validate the preoperative indication for surgery, and therefore to avoid an unnecessary intervention with its associated morbidity. In addition, newly identified pathologic findings can provide the opportunity to change the planned procedure, and possibly improve patient outcome or avoid an additional surgical procedure in the future. In our patient population, the most frequent pre-CPB finding that influenced surgical decision making was either undetected valve dysfunction or a change in the preoperatively diagnosed valve pathology. For example, a MV procedure was omitted in 12.2% patients scheduled for CABG and MV surgery.
Although the use of intraoperative TEE to diagnose MV pathology has never been specifically mandated as a "standard of care," guidelines and recommendations published by the American Society of Echocardiography, American Society of Anesthesiologists, and Society of Cardiovascular Anesthesiologists strongly support its use to guide surgical decision making by providing insight into the mechanism of mitral disease before repair [19, 20]. Such guidelines and recommendations have been developed based on numerous studies that have speculated on the purported reduction in perioperative morbidity associated with the use of TEE in cardiac surgical patients undergoing MV procedures [15, 20]. Similarly, TEE can be useful for the assessment of the tricuspid valve or AV for replacement or repair. For example, AV surgery was altered in 103 of the patients undergoing CABG, MV, or AV procedures (1.0%) in this study. Nonetheless, the decision to perform a valve procedure should not only be dictated by the presence or absence of valve dysfunction diagnosed by intraoperative TEE on surgical decision making among a selected group of patients undergoing a full spectrum of cardiac surgical procedures, but should also consider the patient’s comorbidity, the additional technical difficulty and morbidity in performing combined procedures, and the influence of hemodynamic changes associated with general anesthesia that may affect the echocardiographic grading of valve stenosis and regurgitation.
In addition to its utility as a valuable diagnostic tool in the pre-CPB period, intraoperative TEE also provides important post-CPB information [10]. The post-CPB TEE examination can provide a direct and immediate assessment of the surgical procedure, and therefore can expedite the decision to return to CPB when necessary. In our study, CPB had to be reinstituted in 4.1% of the patients undergoing MV surgery. Among patients undergoing combined CABG, AV, and MV procedures, this percentage was 1.3 %. Aortic valve repairs and replacements required revision in 0.7% of the total 1,610 patients scheduled only for an AV procedure. Alternatively, in the combined CABG, MV, AV procedures, there were no aortic valve replacement revisions necessary. In addition to its valuable role in valve surgery, TEE is also used as a continuous monitor of cardiac performance by permitting a direct assessment of ventricular volume and both regional and global function [21]. Moreover, TEE is very sensitive in detecting post-CPB myocardial ischemia and new regional wall motion abnormalities associated with possible graft kinking or occlusion [22]. In our study, a revision of previously placed grafts was required in 53 cases, 0.8% of the patients who underwent CABG, which is consistent with the results of Mishra and colleagues [15].
This study is the largest published investigation that has examined the influence of intraoperative TEE on surgical decision making in a diverse population of cardiac surgical patients. Nonetheless, because intraoperative TEE examinations were not performed in all patients, there was most likely a bias toward examining higher risk patients in whom a favorable impact of TEE was more likely to occur. Specific reasons why intraoperative TEE was not performed in the remaining 10,274 cardiac surgical patients were not available from the database. However, historically in our institution, intraoperative TEE has not been performed in patients undergoing only CABG who also had a preoperative ejection fraction of 40% or greater. In addition, a previously published study on the safety of a consecutive series of 7,200 patients from this group, reported that intraoperative TEE was not performed in 0.5% of these patients in whom it was contraindicated, and 0.18% of this population in whom esophageal insertion of the probe was unsuccessful [23]. Alternatively, our use of relatively conservative definitions for determining when the influence of intraoperative TEE on surgical decision making was significant may have actually contributed to lower incidences and an underestimation of impact in our study compared with some others reported in the literature [10]. Finally it is difficult to assess the true effectiveness and benefit of TEE on perioperative clinical outcomes, as this should ideally be accomplished in a prospective, randomized trial. Considering its expanding popularity and the accepted indications for intraoperative TEE, the practical and ethical limitations of conducting such a definitive study may be prohibitive.
In conclusion, the present study highlights the utility of intraoperative TEE for a large variety of cardiac surgical procedures. We have demonstrated that intraoperative TEE has the potential to significantly influence clinical decision making for more than 9% of cardiac surgical patients in our study population. However, as the the risk profile of cardiac surgical patients continues to shift toward higher risk populations predisposed to increased perioperative morbidity and mortality, the value of this important diagnostic tool and monitor of cardiac performance may increase substantially.
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