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Does transesophageal echocardiography improve postoperative outcome in patients undergoing coronary artery bypass
M Kato1, Y Nakashima, J Levine
1Albert Einstein College of Medicine/Montefiore Medical Center, Department of Anesthesiology, Bronx, NY 10461.
Insights
Transesophageal echocardiography (TEE) detected more ischemic episodes after coronary artery bypass grafting (CABG) surgery. Early detection of these events using TEE guided timely interventions, improving patient outcomes and reducing adverse events.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Imaging
Background:
- Postoperative myocardial infarction (MI) and adverse outcomes are significant concerns following coronary artery bypass grafting (CABG).
- Transesophageal echocardiography (TEE) offers real-time visualization of cardiac function during surgery.
- Electrocardiogram (ECG) is a standard method for detecting myocardial ischemia.
Purpose of the Study:
- To investigate the incidence and characteristics of ischemic episodes detected by TEE during CABG.
- To determine the relationship between TEE-detected ischemia and postoperative MI and adverse clinical outcomes.
- To evaluate the utility of TEE in guiding intraoperative management and improving patient outcomes.
Main Methods:
- Prospective study involving 50 patients undergoing CABG.
- Continuous monitoring using TEE and ECG to detect ischemic episodes.
- Correlation of ischemic events with intraoperative interventions and postoperative outcomes.
Main Results:
- 30% of patients experienced TEE-defined ischemic episodes in the post-cardiopulmonary bypass (CPB) period, compared to 8% pre-CPB.
- 19 patients (34%) had ECG-detected ischemic episodes post-CPB.
- TEE-guided interventions, including graft revision and intra-aortic balloon pump insertion, improved regional wall motion abnormalities in 73% of patients with post-CPB ischemia.
Conclusions:
- TEE is effective in detecting a higher incidence of ischemic episodes in the post-CPB period compared to the pre-CPB period.
- Post-CPB ischemia detected by TEE is associated with adverse outcomes, suggesting issues with graft quality or myocardial protection.
- TEE serves as a valuable tool for early detection of cardiac issues during CABG, enabling timely interventions and improved patient management.
Abstract:
The incidence and characteristics of ischemic episodes as detected by transesophageal echocardiography (TEE) and their relationship to postoperative myocardial infarction (MI) and adverse clinical outcome were studied in patients undergoing coronary artery bypass grafting (CABG). Seventeen of 50 patients had 21 TEE-defined ischemic episodes: 4 patients (8%) had 4 ischemic episodes in the pre-cardiopulmonary bypass (CPB) period, and 15 patients (30%) had 17 ischemic episodes in the post-CPB period, whereas 19 patients had 20 ECG ischemic episodes: 3 patients (6%) had 3 ischemic episodes in the pre-CPB period and 17 (34%) had 17 ischemic episodes in the post-CPB period. In 14 patients, ischemic episodes were detected by both TEE and ECG. Clinicians were made aware of the TEE data and appropriate treatments were undertaken during ischemic episodes: of the 15 patients with TEE-defined post-CPB ischemia, 4 had an additional saphenous vein graft placed, 8 had an intra-aortic balloon pump (IABP) inserted, 3 were given sublingual nifedipine, and 13 received nitroglycerin. These treatments resulted in improvement in regional wall motion abnormalities (RWMA) by the end of surgery in 11 of the 15 patients (73%), including the 4 with postoperative MI and 2 who died with cardiogenic shock. The authors conclude that: (1) significantly more patients had TEE-defined ischemic episodes in the post-CPB period (30%) than in the pre-CPB period (8%); (2) a poor graft and/or inadequate myocardial protection were strongly suggestive of post-CPB ischemia, which was significantly related to adverse outcome; and (3) TEE was a useful tool enabling detection of problem areas at an early stage and timely and appropriate treatment to support and sustain patients.