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Original Articles: Cardiovascular

Invited Commentary

Department of Anesthesiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9202

(Email: philip.greilich{at}utsouthwestern.edu).

Eltzschig and colleagues [1] are to be commended for providing the cardiac surgery community with compelling evidence for the benefits of intraoperative TEE. The experience summarized in this report of 12,566 patients validates what most of us have experienced since TEE was introduced to the cardiac surgical suite. The increase in TEE utilization (35% to 84%) over the 15-year span in this study mirrors that of our institution and likely reflects the perception that intraoperative TEE improves patient outcome. This perception was reinforced by the observation that the surgical plan was changed in over 9% of all patients in this series and in over 14% in those undergoing CABG/valve procedures. In fairness, one has to bear in mind that this was a selected (likely to benefit from TEE) group of patients that reflected only 53% of the cardiac surgical population at the Brigham during the study period. That being said, I still believe this report justifies the additional resources needed (equipment, experienced echocardiographers) to support a dedicated intraoperative TEE service.

The use of a change in the surgical procedure as the primary endpoint was not ideal. Clearly, reductions in patient morbidity, mortality and/or resource utilization with intraoperative TEE use would be preferable. The authors were careful, however, to make sure this surrogate endpoint was as robust as possible. First, they included only those intraoperative TEE findings that were "new" despite a comprehensive preoperative assessment. Second, they only included unplanned changes in the surgical procedure. Finally, they excluded any decision(s) (IABP, type of pharmacological support, etc) that might have been made based on hemodynamic measurements.

The magnitude of this large retrospective analysis provides an excellent resource for the design of future, randomized, controlled trials examining the potential benefits of intraoperative TEE on clinical outcome. The interdisciplinary (cardiology, surgery, anesthesiology) nature of this type of research makes it logistically challenging, yet potentially high in clinical impact. Hopefully, the study will be used to help secure the resources needed to provide high quality intraoperative TEE services and drive scientific investigation of this powerful intraoperative technology.

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1. Eltzschig HK, Rosenberger P, Löffler M, Fox JA, Aranki SF, Shernan SK. Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery Ann Thorac Surg 2008;85:845-853.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Greilich, P. E. Search for Related Content PubMed PubMed Citation Articles by Greilich, P. E. Related Collections Cardiac - other Related Article