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Intraoperative TEE in CABG Patients
Quick Takes
- Intraoperative TEE (IOTEE) during planned isolated CABG was associated with lower odds of operative mortality, with the greatest risk reduction among patients with higher STS risk scores.
- The use of IOTEE also was associated with increased odds of a concomitant but unplanned mitral, aortic, tricuspid, or pulmonic valve procedure instead of planned isolated CABG.
Study Questions:
Is there an association between intraoperative transesophageal echocardiography (IOTEE) during isolated coronary artery bypass grafting (CABG) on clinical decision making and post-CABG mortality?
Methods:
In a retrospective cohort study, the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify patients with planned isolated CABG between January 1, 2011 and June 30, 2019. The exposure variable of interest was the use of IOTEE during CABG compared to no IOTEE. The primary outcome was operative mortality. The association between IOTEE and unplanned valve surgery also was assessed.
Results:
Of 1,255,860 planned isolated CABG procedures across 1,218 centers, 676,803 (53.9%) had IOTEE. The percentage of patients with IOTEE increased over time from 39.9% in 2011 to 62.1% in 2019 (p trend < 0.0001). CABG patients who underwent IOTEE had lower odds of operative mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.91-0.99; p = 0.025), with heterogeneity across STS risk groups (p interaction = 0.015). IOTEE was associated with increased odds of an unplanned mitral, aortic, tricuspid, or pulmonic valve procedure instead of planned isolated CABG (adjusted odds ratio, 4.98; 95% confidence interval, 3.98-6.22; p < 0.0001).
Conclusions:
IOTEE during planned isolated CABG was associated with lower operative mortality, particularly among higher-risk patients; as well as greater odds of an unplanned valve procedure. The authors concluded that these findings support the use of IOTEE to improve outcomes for isolated CABG among high-risk patients.
Perspective:
IOTEE is widely utilized among patients undergoing valvular and thoracic aortic surgical procedures. This retrospective cohort study using the STS Adult Cardiac Surgery Database found that the use of IOTEE during planned isolated CABG was associated with increased odds of altering the surgical plan to include a previously unplanned valve procedure; and, importantly, was associated with lower odds of operative mortality. The reduction in mortality risk was highest among patients with STS risk score >8%, but still reached statistical significance among patients with STS risk score of 4-8%. The mechanism of risk reduction might be attributable to the identification and treatment of concomitant valvular pathology and/or to the use of IOTEE to identify and treat left or right ventricular systolic dysfunction, ischemia, pericardial effusion, or aortic injury. This study supports the routine use of IOTEE at least among patients with higher STS risk scores undergoing planned isolated CABG.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Diagnostic Imaging, Echocardiography, Echocardiography, Transesophageal, Heart Valve Diseases, Myocardial Ischemia, Pericardial Effusion, Risk Factors, Risk Reduction Behavior, Secondary Prevention, Ventricular Dysfunction
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