Intraoperative Echocardiography in Valvular Heart Disease: An Evidence-Based Appraisal
2010; Elsevier BV; Volume: 85; Issue: 7 Linguagem: Inglês
10.4065/mcp.2009.0629
ISSN1942-5546
AutoresHéctor I. Michelena, Martin Abel, Rakesh M. Suri, William K. Freeman, Roger L. Click, Thoralf M. Sundt, Hartzell V. Schaff, Maurice Enriquez‐Sarano,
Tópico(s)Aortic Disease and Treatment Approaches
ResumoIntraoperative (IO) transesophageal echocardiography (TEE) is widely used for assessing the results of valvular heart disease (VHD) surgery. Epiaortic ultrasonography (EAU) has been recommended for prevention of perioperative strokes. To what extent does high-quality evidence justify the widespread use of these imaging modalities? In March 2009, we searched MEDLINE (PubMed and OVID interfaces) and EMBASE for studies published in English using database-specific controlled vocabulary describing the concepts of IOTEE, cardiac surgery, VHD, and EAU. We found no randomized trials or studies with control groups assessing the impact of IOTEE in VHD surgery. Pooled analysis of 8 observational studies including 15,540 patients showed an average incidence of 11% for prebypass surgical changes and 4% for second pump runs, suggesting that patients undergoing VHD surgery may benefit significantly from IOTEE, particularly from postcardiopulmonary bypass IOTEE in aortic repair and mitral repair and replacement, but less so in isolated aortic replacement. Further available indirect evidence was satisfactory in the test accuracy and surgical quality control aspects, with low complication rates for IOTEE. The data supporting EAU included 12,687 patients in 2 prospective randomized studies and 4 nonrandomized, controlled studies, producing inconsistent outcome-related results. Despite low-quality scientific evidence supporting IOTEE in VHD surgery, we conclude that indirect evidence supporting its use is satisfactory and suggests that IOTEE may offer considerable benefit in valvular repairs and mitral replacements. The value of IOTEE in isolated aortic valve replacement remains less clear. Evidence supporting EAU is scientifically more robust but conflicting. These findings have important clinical policy and research implications. Intraoperative (IO) transesophageal echocardiography (TEE) is widely used for assessing the results of valvular heart disease (VHD) surgery. Epiaortic ultrasonography (EAU) has been recommended for prevention of perioperative strokes. To what extent does high-quality evidence justify the widespread use of these imaging modalities? In March 2009, we searched MEDLINE (PubMed and OVID interfaces) and EMBASE for studies published in English using database-specific controlled vocabulary describing the concepts of IOTEE, cardiac surgery, VHD, and EAU. We found no randomized trials or studies with control groups assessing the impact of IOTEE in VHD surgery. Pooled analysis of 8 observational studies including 15,540 patients showed an average incidence of 11% for prebypass surgical changes and 4% for second pump runs, suggesting that patients undergoing VHD surgery may benefit significantly from IOTEE, particularly from postcardiopulmonary bypass IOTEE in aortic repair and mitral repair and replacement, but less so in isolated aortic replacement. Further available indirect evidence was satisfactory in the test accuracy and surgical quality control aspects, with low complication rates for IOTEE. The data supporting EAU included 12,687 patients in 2 prospective randomized studies and 4 nonrandomized, controlled studies, producing inconsistent outcome-related results. Despite low-quality scientific evidence supporting IOTEE in VHD surgery, we conclude that indirect evidence supporting its use is satisfactory and suggests that IOTEE may offer considerable benefit in valvular repairs and mitral replacements. The value of IOTEE in isolated aortic valve replacement remains less clear. Evidence supporting EAU is scientifically more robust but conflicting. These findings have important clinical policy and research implications. Significant valvular heart disease (VHD) affects 13% of patients aged 75 years or older, has a national prevalence of 2.5%,1Nkomo VT Gardin JM Skelton TN Gottdiener JS Scott CG Enriquez-Sarano M Burden of valvular heart diseases: a population-based study.Lancet. 2006; 368: 1005-1011Abstract Full Text Full Text PDF PubMed Scopus (3135) Google Scholar and is primarily due to mitral regurgitation (MR). Intraoperative (IO) transesophageal echocardiography (TEE) is widely used to monitor patients undergoing VHD surgery. Landmark practice guidelines for the implementation of IOTEE2Task Force on Transesophageal Echocardiography Practice guidelines for perioperative transesophageal echocardiography: a report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists.Anesthesiology. 1996; 84: 986-1006Crossref Scopus (517) Google Scholar, 3Cheitlin MD Armstrong WF Aurigemma GP et al.ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography).Circulation. 2003; 108: 1146-1162Crossref PubMed Scopus (676) Google Scholar, 4Shanewise JS Cheung AT Aronson S et al.ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography.J Am Soc Echocardiogr. 1999; 12: 884-900Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar recommend its use in VHD surgery. The incidence of perioperative stroke in cardiac surgery has been estimated to range between 1% to 2% (Society of Thoracic Surgeons, 2007) and 4% to 5%.5Bucerius J Gummert JF Borger MA et al.Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients.Ann Thorac Surg. 2003; 75: 472-478Abstract Full Text Full Text PDF PubMed Scopus (486) Google Scholar Intraoperative TEE is superior to surgical palpation in detecting atheromas6Marschall K Kanchuger M Kessler K et al.Superiority of transesophageal echocardiography in detecting aortic arch atheromatous disease: identification of patients at increased risk of stroke during cardiac surgery.J Cardiothorac Vasc Anesth. 1994; 8: 5-13Abstract Full Text PDF PubMed Scopus (80) Google Scholar, 7Katz ES Tunick PA Rusinek H Ribakove G Spencer FC Kronzon I Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography.J Am Coll Cardiol. 1992; 20: 70-77Abstract Full Text PDF PubMed Scopus (416) Google Scholar; however, epiaortic ultrasonography (EAU) is more sensitive than IOTEE and has been recommended recently for use in patients at risk for stroke.8Glas KE Swaminathan M Reeves ST et al.Guidelines for the performance of a comprehensive intraoperative epiaortic ultrasonographic examination: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists: endorsed by the Society of Thoracic Surgeons.J Am Soc Echocardiogr. 2007; 20: 1227-1235Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Given the expansion in the use of these technologies, we sought to review the literature to determine the extent to which high-quality scientific evidence justifies their use. To what extent do IOTEE and EAU improve outcomes in patients undergoing VHD surgery? Randomized trials of test management using IOTEE or EAU and consecutive case series of IOTEE or EAU reporting patient-important outcomes were eligible. In their absence, observational, nonconsecutive series and case reports became eligible. To ensure that observational studies reflected mature learning curves associated with IOTEE, we chose arbitrarily to limit studies to those describing experience with more than 100 patients. In March 2009, we searched MEDLINE (PubMed and OVID interfaces) and EMBASE for studies published in English using database-specific controlled vocabulary describing the concepts of IOTEE, cardiac surgery, VHD, and EAU (Table 1).TABLE 1Literature Search Strategy PubMed (1980-2009) Core journals, human studies, all publication types, English languageSearch terms: transesophageal echocardiography, intraoperative, and cardiacHuman studies, all publication types, English languageSearch terms: epiaortic ultrasound and intraoperative OVID-MEDLINE (1950-2009) and EMBASE (1988 to 2009) All publication types, human adults, English languageSearch terms: TEE, intraoperative, heart valve surgery, outcome, heart valve diseases, aortic valve insufficiency, aortic valve stenosis, heart valve prolapse, mitral valve insufficiency, mitral valve stenosis, tricuspid valve insufficiency, tricuspid valve stenosis, heart valve prosthesis, cardiac surgical procedures, and heart valve prosthesis implantation Open table in a new tab For each study, we noted methodological quality, surgical indications, change in the surgery planned, rate of second pump run, morbidity and mortality, and complications from imaging. We contacted the authors of one study to clarify its methodological characteristics.9Grimm RA Stewart WJ The role of intraoperative echocardiography in valve surgery.Cardiol Clin. 1998; 16 (ix.): 477-489Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar For pooled analysis of IOTEE impact in VHD surgery, we chose studies reporting actual alterations in surgical (not medical) management, in which a single valve was addressed or in which a valve-by-valve breakdown of results was provided. For EAU in stroke prevention, we chose available randomized trials and nonrandomized controlled studies. Duplicates, reviews, commentaries, congenital and pediatric heart disease articles, and studies related to commercial valve brands or specific surgical techniques were eliminated. Of the remaining articles, 8 were appropriate for pooled analysis of the surgical impact of IOTEE in VHD9Grimm RA Stewart WJ The role of intraoperative echocardiography in valve surgery.Cardiol Clin. 1998; 16 (ix.): 477-489Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 10Bajzer CT Stewart WJ Cosgrove DM Azzam SJ Arheart KL Klein AL Tricuspid valve surgery and intraoperative echocardiography: factors affecting survival, clinical outcome, and echocardiographic success.J Am Coll Cardiol. 1998; 32: 1023-1031Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 11Click RL Abel MD Schaff HV Intraoperative transesophageal echocardiography: 5-year prospective review of impact on surgical management.Mayo Clin Proc. 2000; 75: 241-247PubMed Google Scholar, 12Eltzschig HK Rosenberger P Loffler 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: 845-852Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar, 13Mishra M Chauhan R Sharma KK et al.Real-time intraoperative transesophageal echocardiography–how useful? experience of 5,016 cases.J Cardiothorac Vasc Anesth. 1998; 12: 625-632Abstract Full Text PDF PubMed Scopus (115) Google Scholar, 14Nowrangi SK Connolly HM Freeman WK Click RL Impact of intraoperative transesophageal echocardiography among patients undergoing aortic valve replacement for aortic stenosis.J Am Soc Echocardiogr. 2001; 14: 863-866Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 15Shapira Y Vaturi M Weisenberg DE et al.Impact of intraoperative transesophageal echocardiography in patients undergoing valve replacement.Ann Thorac Surg. 2004; 78: 579-583Abstract Full Text Full Text PDF Scopus (49) Google Scholar, 16Sheikh KH de Bruijn NP Rankin JS et al.The utility of transesophageal echocardiography and Doppler color flow imaging in patients undergoing cardiac valve surgery.J Am Coll Cardiol. 1990; 15: 363-372Abstract Full Text PDF PubMed Scopus (130) Google Scholar (Table 2) and 6 for analysis of EAU impact on stroke prevention17Djaiani G Ali M Borger MA et al.Epiaortic scanning modifies planned intraoperative surgical management but not cerebral embolic load during coronary artery bypass surgery.Anesth Analg. 2008; 106: 1611-1618Crossref PubMed Scopus (55) Google Scholar, 18Gold JP Torres KE Maldarelli W Zhuravlev I Condit D Wasnick J Improving outcomes in coronary surgery: the impact of echo-directed aortic cannulation and perioperative hemodynamic management in 500 patients.Ann Thorac Surg. 2004; 78: 1579-1585Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 19Murkin JM Pathophysiological basis of CNS injury in cardiac surgical patients: detection and prevention.Perfusion. 2006; 21: 203-208Crossref Scopus (15) Google Scholar, 20Rosenberger P Shernan SK Loffler M et al.The influence of epiaortic ultrasonography on intraoperative surgical management in 6051 cardiac surgical patients.Ann Thorac Surg. 2008; 85: 548-553Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 21Trehan N Mishra M Kasliwal RR Mishra A Reduced neurological injury during CABG in patients with mobile aortic atheromas: a five-year follow-up study.Ann Thorac Surg. 2000; 70: 1558-1564Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 22Zingone B Rauber E Gatti G et al.The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke.Eur J Cardiothorac Surg. 2006; 29: 720-728Crossref PubMed Scopus (79) Google Scholar (Table 3). Five additional observational studies of the impact of IOTEE 23Forrest AP Lovelock ND Hu JM Fletcher SN The impact of intraoperative transoesophageal echocardiography on an unselected cardiac surgical population: a review of 2343 cases.Anaesth Intensive Care. 2002; 30: 734-741Google Scholar, 24Michel-Cherqui M Ceddaha A Liu N et al.Assessment of systematic use of intraoperative transesophageal echocardiography during cardiac surgery in adults: a prospective study of 203 patients.J Cardiothorac Vasc Anesth. 2000; 14: 45-50Abstract Full Text PDF PubMed Scopus (57) Google Scholar, 25Minhaj M Patel K Muzic D et al.The effect of routine intraoperative transesophageal echocardiography on surgical management.J Cardiothorac Vasc Anesth. 2007; 21: 800-804Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 26Ommen SR Park SH Click RL Freeman WK Schaff HV Tajik AJ Impact of intraoperative transesophageal echocardiography in the surgical management of hypertrophic cardiomyopathy.Am J Cardiol. 2002; 90: 1022-1024Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 27Qaddoura FE Abel MD Mecklenburg KL et al.Role of intraoperative transesophageal echocardiography in patients having coronary artery bypass graft surgery.Ann Thorac Surg. 2004; 78: 1586-1590Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar and 1 additional EAU study28Suvarna S Smith A Stygall J et al.An intraoperative assessment of the ascending aorta: a comparison of digital palpation, transesophageal echocardiography, and epiaortic ultrasonography.J Cardiothorac Vasc Anesth. 2007; 21: 805-809Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar were eligible. The remaining studies related to test accuracy,29Aklog L Filsoufi F Flores KQ et al.Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation?.Circulation. 2001; 104: I68-I75Crossref PubMed Scopus (314) Google Scholar, 30Bach DS Deeb GM Bolling SF Accuracy of intraoperative transesophageal echocardiography for estimating the severity of functional mitral regurgitation.Am J Cardiol. 1995; 76: 508-512Abstract Full Text PDF PubMed Scopus (101) Google Scholar, 31Chaliki HP Click RL Abel MD Comparison of intraoperative transesophageal echocardiographic examinations with the operative findings: prospective review of 1918 cases.J Am Soc Echocardiogr. 1999; 12: 237-240Abstract Full Text Full Text PDF Scopus (19) Google Scholar, 32Chaudhry FA Upadya SP Singh VP et al.Identifying patients with degenerative mitral regurgitation for mitral valve repair and replacement: a transesophageal echocardiographic study.J Am Soc Echocardiogr. 2004; 17: 988-994Abstract Full Text Full Text PDF Scopus (13) Google Scholar, 33Fanshawe M Ellis C Habib S Konstadt SN Reich DL A retrospective analysis of the costs and benefits related to alterations in cardiac surgery from routine intraoperative transesophageal echocardiography.Anesth Analg. 2002; 95: 824-827PubMed Google Scholar, 34Freeman WK Schaff HV Khandheria BK et al.Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: incidence and significance of systolic anterior motion.J Am Coll Cardiol. 1992; 20: 599-609Abstract Full Text PDF PubMed Scopus (136) Google Scholar, 35Gisbert A Souliere V Denault AY et al.Dynamic quantitative echocardiographic evaluation of mitral regurgitation in the operating department.J Am Soc Echocardiogr. 2006; 19: 140-146Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 36Grewal KS Malkowski MJ Piracha AR et al.Effect of general anesthesia on the severity of mitral regurgitation by transesophageal echocardiography.Am J Cardiol. 2000; 85: 199-203Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar, 37Ionescu AA West RR Proudman C Butchart EG Fraser AG Prospective study of routine perioperative transesophageal echocardiography for elective valve replacement: clinical impact and cost-saving implications.J Am Soc Echocardiogr. 2001; 14: 659-667Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 38Klein AL Obarski TP Stewart WJ et al.Transesophageal Doppler echocardiography of pulmonary venous flow: a new marker of mitral regurgitation severity.J Am Coll Cardiol. 1991; 18: 518-526Abstract Full Text PDF Scopus (179) Google Scholar, 39Monin JL Dehant P Roiron C et al.Functional assessment of mitral regurgitation by transthoracic echocardiography using standardized imaging planes: diagnostic accuracy and outcome implications.J Am Coll Cardiol. 2005; 46: 302-309Abstract Full Text Full Text PDF Scopus (94) Google Scholar, 40Morehead AJ Firstenberg MS Shiota T et al.Intraoperative echocardiographic detection of regurgitant jets after valve replacement.Ann Thorac Surg. 2000; 69: 135-139Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 41Neuman YM Brasch AV Kobal S et al.Comparison of transthoracic and intraoperative transesophageal color flow Doppler assessment of mitral and aortic regurgitation.Cardiology. 2003; 99: 145-152Crossref Scopus (15) Google Scholar, 42Saiki Y Kasegawa H Kawase M Osada H Ootaki E Intraoperative TEE during mitral valve repair: does it predict early and late postoperative mitral valve dysfunction?.Ann Thorac Surg. 1998; 66: 1277-1281Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 43Willett DL Hall SA Jessen ME Wait MA Grayburn PA Assessment of aortic regurgitation by transesophageal color Doppler imaging of the vena contracta: validation against an intraoperative aortic flow probe.J Am Coll Cardiol. 2001; 37: 1450-1455Abstract Full Text Full Text PDF Scopus (35) Google Scholar IOTEE-related outcomes,44Fix J Isada L Cosgrove D et al.Do patients with less than 'echo-perfect' results from mitral valve repair by intraoperative echocardiography have a different outcome?.Circulation. 1993; 88: II39-II48Google Scholar, 45O'Rourke DJ Palac RT Malenka DJ Marrin CA Arbuckle BE Plehn JF Outcome of mild periprosthetic regurgitation detected by intraoperative transesophageal echocardiography.J Am Coll Cardiol. 2001; 38: 163-166Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 46Schroder JN Williams ML Hata JA et al.Impact of mitral valve regurgitation evaluated by intraoperative transesophageal echocardiography on long-term outcomes after coronary artery bypass grafting.Circulation. 2005; 112: I293-I298Crossref PubMed Scopus (50) Google Scholar, 47Gillinov AM Cosgrove DM Blackstone EH et al.Durability of mitral valve repair for degenerative disease.J Thorac Cardiovasc Surg. 1998; 116: 734-743Abstract Full Text Full Text PDF PubMed Scopus (473) Google Scholar surgical quality control by IOTEE,48Applebaum RM Cutler WM Bhardwaj N et al.Utility of transesophageal echocardiography during port-access minimally invasive cardiac surgery.Am J Cardiol. 1998; 82: 183-188Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 49Bach DS Subvalvular left ventricular outflow obstruction for patients undergoing aortic valve replacement for aortic stenosis: echocardiographic recognition and identification of patients at risk.J Am Soc Echocardiogr. 2005; 18: 1155-1162Abstract Full Text Full Text PDF Scopus (23) Google Scholar, 50Lee KS Stewart WJ Lever HM Underwood PL Cosgrove DM Mechanism of outflow tract obstruction causing failed mitral valve repair: anterior displacement of leaflet coaptation.Circulation. 1993; 88: II24-II29PubMed Google Scholar, 51Mascagni R Al Attar N Lamarra M et al.Edge-to-edge technique to treat post-mitral valve repair systolic anterior motion and left ventricular outflow tract obstruction.Ann Thorac Surg. 2005; 79: 471-473Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 52Moisa RB Zeldis SM Alper SA Scott WC Aortic regurgitation in coronary artery bypass grafting: implications for cardioplegia administration.Ann Thorac Surg. 1995; 60: 665-668Abstract Full Text PDF Scopus (11) Google Scholar, 53Oh CC Click RL Orszulak TA Sinak LJ Oh JK Role of intraoperative transesophageal echocardiography in determining aortic annulus diameter in homograft insertion.J Am Soc Echocardiogr. 1998; 11: 638-642Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 54Weisenberg D Sahar Y Sahar G et al.Atherosclerosis of the aorta is common in patients with severe aortic stenosis: an intraoperative transesophageal echocardiographic study.J Thorac Cardiovasc Surg. 2005; 130: 29-32Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar IOTEE safety reports,55Kallmeyer IJ Collard CD Fox JA Body SC Shernan SK The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients.Anesth Analg. 2001; 92: 1126-1130Crossref PubMed Scopus (361) Google Scholar, 56Lennon MJ Gibbs NM Weightman WM Leber J Ee HC Yusoff IF Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients.J Cardiothorac Vasc Anesth. 2005; 19: 141-145Abstract Full Text Full Text PDF Scopus (126) Google Scholar and case reports.57Ducharme A Courval JF Dore A Leclerc Y Tardif JC Severe aortic regurgitation immediately after mitral valve annuloplasty.Ann Thorac Surg. 1999; 67: 1487-1489Abstract Full Text Full Text PDF Scopus (16) Google Scholar, 58Kumano H Suehiro S Shibata T Hattori K Kinoshita H Stuck valve leaflet detected by intraoperative transesophageal echocardiography.Ann Thorac Surg. 1999; 67: 1484-1485Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 59Masiello P Mastrogiovanni G Leone R et al.One leaflet immobilization after mitral valve replacement with a bileaflet prosthesis.J Heart Valve Dis. 1996; 5: 114-116Google Scholar, 60Tavilla G Pacini D Damage to the circumflex coronary artery during mitral valve repair with sliding leaflet technique.Ann Thorac Surg. 1998; 66: 2091-2093Abstract Full Text Full Text PDF PubMed Scopus (34) Google ScholarTABLE 2Studies Addressing the Specific Impact of IOTEE in VHD SurgeryaAVR = aortic valve replacement; CABG = coronary artery bypass graft; CPB = cardiopulmonary bypass; IOTEE = intraoperative transesophageal echocardiography; LVOT = left ventricular outflow tract; MVR = mitral valve replacement; NS = not specified; RWMA = regional wall motion abnormality; TVR = tricuspid valve replacement; VHD = valvular heart disease.ReferenceDesignYearNo. of patientsValve surgery (%)Pre-CPB impactbPre-CPB findings that altered the planned surgery. (%)Post-CPB findingsSecond pump run (%)Sheikh et al16Sheikh KH de Bruijn NP Rankin JS et al.The utility of transesophageal echocardiography and Doppler color flow imaging in patients undergoing cardiac valve surgery.J Am Coll Cardiol. 1990; 15: 363-372Abstract Full Text PDF PubMed Scopus (130) Google Scholar ProspectiveNonconsecutive1985-1988154 Mitral surgery (60) (repair [26])Aortic surgery (40) (repair [11])9 Residualregurgitation6.0 All mitral surgeryGrimm & Stewart9Grimm RA Stewart WJ The role of intraoperative echocardiography in valve surgery.Cardiol Clin. 1998; 16 (ix.): 477-489Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar RetrospectiveNonconsecutive1984-19964066 Mitral repair (75)Aortic repair (12)Tricuspid repair (13)NS Inadequate repairResidual regurgitation 7.0 Total5.0 Mitral1.8AorticcThis represented 14% of all aortic repairs, compared with 7% of all mitral repairs requiring a second pump run.0.2 TricuspidMishra et al13Mishra M Chauhan R Sharma KK et al.Real-time intraoperative transesophageal echocardiography–how useful? experience of 5,016 cases.J Cardiothorac Vasc Anesth. 1998; 12: 625-632Abstract Full Text PDF PubMed Scopus (115) Google Scholar ProspectiveNonconsecutive1993-19971356 Mitral (62) (repair or MVR)AVR (38)13Inadequate repair2.0 All mitral repairClick et al11Click RL Abel MD Schaff HV Intraoperative transesophageal echocardiography: 5-year prospective review of impact on surgical management.Mayo Clin Proc. 2000; 75: 241-247PubMed Google Scholar ProspectiveNonconsecutive1993-19972369 Mitral repair (36)MVR (18)AVR (30)Aortic repair (5)Other (11)14 Inadequate repairPerivalvular leakLVOT obstruction2.0 All mitral repairNowrangi et al14Nowrangi SK Connolly HM Freeman WK Click RL Impact of intraoperative transesophageal echocardiography among patients undergoing aortic valve replacement for aortic stenosis.J Am Soc Echocardiogr. 2001; 14: 863-866Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar RetrospectiveNonconsecutive1993-1996383AVR for aortic stenosis (100)7New RWMA0.0Shapira et al15Shapira Y Vaturi M Weisenberg DE et al.Impact of intraoperative transesophageal echocardiography in patients undergoing valve replacement.Ann Thorac Surg. 2004; 78: 579-583Abstract Full Text Full Text PDF Scopus (49) Google Scholar RetrospectiveNonconsecutive1999-2003352 MVR (47)AVR (43) TVR (10)29 Perivalvular leakImmobilized leaflet Coronary obstruction 4.0 Total2.0 MVR 1.7 AVR 0.3 TVRBajzer et al10Bajzer CT Stewart WJ Cosgrove DM Azzam SJ Arheart KL Klein AL Tricuspid valve surgery and intraoperative echocardiography: factors affecting survival, clinical outcome, and echocardiographic success.J Am Coll Cardiol. 1998; 32: 1023-1031Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar ProspectiveNonconsecutive1990s335Tricuspid surgery (100) (repair or replacement)6Failed repair4.0Eltzschig et al12Eltzschig HK Rosenberger P Loffler 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: 845-852Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar RetrospectiveNonconsecutive1990-20056525 MVR or repair (28)AVR or repair (25)Both (6)CABG + aortic (21)CABG + mitral (20)9 Inadequate mitral or aortic repair/replacementNew RWMA 3.0 Total1.2 MVR or repair0.6 AVR or repair0.2 Both0.3 CABG + aortic 0.7 CABG + mitralSummary1984-200515,540 Mitral surgery (56)Aortic surgery (36)Tricuspid surgery (8)11 (n=l 1,474)Abnormal valve result most common4.0a AVR = aortic valve replacement; CABG = coronary artery bypass graft; CPB = cardiopulmonary bypass; IOTEE = intraoperative transesophageal echocardiography; LVOT = left ventricular outflow tract; MVR = mitral valve replacement; NS = not specified; RWMA = regional wall motion abnormality; TVR = tricuspid valve replacement; VHD = valvular heart disease.b Pre-CPB findings that altered the planned surgery.c This represented 14% of all aortic repairs, compared with 7% of all mitral repairs requiring a second pump run. Open table in a new tab TABLE 3Studies Addressing the Specific Impact of IOTEE/EAU on Stroke PreventionaAo = aorta; AVR = aortic valve replacement; CABG = coronary artery bypass graft; CPB = cardiopulmonary bypass; EAU = epiaortic ultrasonography; IOTEE = intraoperative transesophageal echocardiography; MCA = middle cerebral artery; MVR = mitral valve surgery; NIH = National Institutes of Health; NYS = New York State; TCD = transcranial Doppler.ReferenceDesignYearNo. of patientsNo. of patients in randomization or control groupType of operationOutcome measuredResultsMurkin19Murkin JM Pathophysiological basis of CNS injury in cardiac surgical patients: detection and prevention.Perfusion. 2006; 21: 203-208Crossref Scopus (15) Google Scholar ProspectiveRandomized2003191 90 Ao palpation101 EAUCABGQuantification of MCA emboli by insonation47 vs 29 embolic counts (P<.05)Djaiani et al17Djaiani G Ali M Borger MA et al.Epiaortic scanning modifies planned intraoperative surgical management but not cerebral embolic load during coronary artery bypass surgery.Anesth Analg. 2008; 106: 1611-1618Crossref PubMed Scopus (55) Google Scholar ProspectiveRandomized2008113 58 Ao palpation55 EAUCABG Pre-CPB changesbChange in cannulation site, switch to off-pump procedure, avoidance of cross-clamp or change cross-clamp location, aortic arch atherectomy, and aorta repair.TCD emboliNIH Stroke ScaleIn-hospital mortality Pre-CPB change 12% vs 29% (P=.02)Embolic counts (P=.46)Stroke (P=.51)Death (P=.95)Trehan et al21Trehan N Mishra M Kasliwal RR Mishra A Reduced neurological injury during CABG in patients with mobile aortic atheromas: a five-year follow-up study.Ann Thorac Surg. 2000; 70: 1558-1564Abstract Full Text Full Text PDF Pub
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