Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac Surgery

MacKay, Emily J.; Groeneveld, Peter W.; Fleisher, Lee A.; Desai, Nimesh D.; Gutsche, Jacob T.; Augoustides, John; Patel, Prakash A.; Neuman, Mark D.

doi:10.1053/j.jvca.2018.07.040

Cited by 17 publications

(11 citation statements)

References 42 publications

(58 reference statements)

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“…Receipt of TEE was defined using CPT codes for TEE (93312-93315, 93317, 93318, 93320, 93321, and 93325) present in the Medicare Part B (physician) claims. 16,17 Dependent Variables (Outcomes)…”

Section: Exposure Variablementioning

confidence: 99%

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Transesophageal Echocardiography, Mortality, and Length of Hospitalization after Cardiac Valve Surgery

MacKay

Neuman

Fleisher³

et al. 2020

Journal of the American Society of Echocardiography

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Background: Despite recommendations regarding the use of intraoperative transesophageal echocardiography (TEE), there is no randomized evidence to support its use in cardiac valve surgery. The purpose of this study was to compare the clinical outcomes of patients undergoing open cardiac valve repair or replacement surgery with and without transesophageal echocardiographic monitoring. The hypothesis was that transesophageal echocardiographic monitoring would be associated with lower 30-day mortality and shorter length of hospitalization. Methods: In this observational retrospective cohort study, Medicare claims were used to test the association between perioperative TEE and 30-day all-cause mortality and length of hospitalization among patients undergoing open cardiac valve repair or replacement surgery between January 1, 2010, and October 1, 2015. Baseline characteristics were defined by inpatient and outpatient claims. Medicare death records were used to ascertain 30-day mortality. Statistical analyses included regression models and propensity score matching. Results: A total of 219,238 patients underwent open cardiac valve surgery, of whom 85% underwent TEE. Patients who underwent TEE were significantly older and had greater comorbidities. After adjusting for patient demographics, clinical comorbidities, surgical characteristics, and hospital factors, including annual surgical volume, the TEE group had a lower adjusted odds of 30-day mortality (odds ratio, 0.77; 95% CI, 0.73 to 0.82; P < .001), with no difference in length of hospitalization (<0.01%; 95% CI, À0.61% to 0.62%; P = .99). Results were similar across all analyses, including a propensity score-matched cohort. Conclusions: Transesophageal echocardiographic monitoring in cardiac valve repair or replacement surgery was associated with lower 30-day risk-adjusted mortality, without a significant increase in length of hospitalization. These findings support the use of TEE as routine practice in open cardiac valve repair or replacement surgery.

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Section: Exposure Variablementioning

confidence: 99%

“…3 In previous work, we have observed that the use of TEE is lower among US patients undergoing aortic valve replacement surgery compared with mitral valve repair or replacement surgery. 16 One possible explanation for this disparity is the relative lack of evidence to support the use of TEE in aortic valve compared with mitral valve surgery.…”

Section: Highlightsmentioning

confidence: 99%

Transesophageal Echocardiography, Mortality, and Length of Hospitalization after Cardiac Valve Surgery

MacKay

Neuman

Fleisher³

et al. 2020

Journal of the American Society of Echocardiography

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“…Although the use of TEE in cardiac valve surgery is relatively uniform nationwide, 21 this is not the case in isolated CABG surgery. 22 Thus, the limitations of previous observational work could be addressed by performing an instrumental variable analysis that leverages the highly variable practice pattern differences in TEE use for CABG surgery across hospitals or surgeons to approximate the design of a cluster-randomized trial within the framework of an observational study by using a near/far matching, a matched-pair instrumental variable study design.…”

mentioning

confidence: 99%

Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery

MacKay

Zhang

Heng

et al. 2021

Journal of the American Society of Echocardiography

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Background: Coronary artery bypass graft (CABG) surgery is the most widely performed cardiac surgery in the United States. Transesophageal echocardiography (TEE) is frequently used in a variety of cardiac surgical procedures, but its clinical benefit in isolated CABG surgery is unclear, and guidelines remain indeterminate. The aim of this study was to compare clinical outcomes among patients undergoing isolated CABG surgery with versus without TEE in order to test the hypothesis that TEE would be associated with improved clinical outcomes after CABG surgery.Methods: A matched retrospective cohort study was conducted among Medicare beneficiaries undergoing isolated CABG surgery with versus without intraoperative monitoring using TEE in the United States. The primary analysis was a near/far instrumental variable match that paired hospitals with similar characteristics and patient populations but with opposing probabilities for using TEE in CABG surgery. Outcomes included 30-day mortality, a composite outcome of stroke or 30-day mortality, length of hospitalization, and incidence of esophageal perforation.Results: Of 114,871 patients undergoing isolated CABG surgery, 65,471 (57%) underwent TEE and 49,400 (43%) did not. Hospital-level instrumental variable matched analysis demonstrated that among the subset of 968 matched hospitals, TEE receipt was associated with lower 30-day mortality (3.7% vs 4.9%, P < .001), a lower incidence of the composite outcome of stroke or 30-day mortality (4.5% vs 5.6%, P < .001), no difference in length of hospitalization (10.32 vs 10.52 days, P = .26), and no difference in the incidence of esophageal perforation (0.01% vs 0.01%, P = .63). These results were replicated in surgeon-level and patient-level matched-pair instrumental variable analyses, and all analyses were robust to sensitivity analyses that tested for biases introduced by unmeasured confounding. Conclusions:The findings from this study suggest that TEE may offer a clinical benefit to cardiac surgical patients undergoing isolated CABG surgery.

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“…Recent evidence suggests that even in the United States, TEE use in recommended cases is far from 100%. 25 This quality gap highlights the need for all physicians involved in the care of cardiac surgical patients to become critically aware of barriers to the use of TEE for cases in which it is unequivocally helpful. This study by Wang et al 11 is a valuable first step in determining how to implement and expand the use of intraoperative TEE worldwide.…”

mentioning

confidence: 99%

Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac Surgery

Cited by 17 publications

References 42 publications

Transesophageal Echocardiography, Mortality, and Length of Hospitalization after Cardiac Valve Surgery

Transesophageal Echocardiography, Mortality, and Length of Hospitalization after Cardiac Valve Surgery

Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery

Intraoperative Transesophageal Echocardiography for Cardiac Surgery: Experience in China

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