The utility of transesophageal echocardiography and Doppler color flow imaging in patients undergoing cardiac valve surgery

Abstract

To assess the value of intraoperative transesophageal echocardiography during cardiac valve surgery, 154 consecutive patients who had a valve operation in conjunction with pre- and postcardiopulmonary bypass transesophageal imaging were studied. Prebypass imaging yielded unsuspected findings that either assisted or changed the planned operation in 29 (19%) of the 154 patients. Imaging immediately after bypass revealed unsatisfactory operative results that necessitated immediate further surgery in 10 (6%) of the 154 patients. Postbypass left ventricular dysfunction, prompting administration of inotropic agents, was identified in 13 patients (8%). Transesophageal echocardiography proved most useful when both two-dimensional and Doppler color flow imaging were employed in patients undergoing a mitral valve operation, where surgical decisions based on echocardiographic results were made in 26 (41%) of 64 cases. Postbypass echocardiographic findings identified patients at risk for an adverse postoperative outcome. Of 123 patients whose postbypass valve function was judged to be satisfactory, 18 (15%) had a major postoperative complication and 6 (5%) died, whereas of 7 patients with moderate residual valve dysfunction, 6 (86%) had a postoperative complication and 3 (43%) died (p less than 0.05 for both). Likewise, of 131 patients with preserved postbypass left ventricular function, 12 (9%) had a major complication and 7 (5%) died, whereas of 23 patients with reduced ventricular function, 17 (73%) had a postoperative complication and 6 (26%) died (p less than 0.05 for both). These data indicate that intraoperative transesophageal echocardiography is useful in formulating the surgical plan, assessing immediate operative results and identifying patients with unsatisfactory results who are at increased risk for postoperative complications.

Impact of routine use of intraoperative transesophageal echocardiography during cardiac surgery

“…Although the utility of intraoperative TEE for mitral valve repair is well recognized, 1 4 our study also suggests a considerable impact in valve replacement. These results confirm similar observations from Sheikh et al 3 They studied 154 patients, the majority undergoing mitral or aortic valve replacement, but with a substantial number of mitral valve repairs (26% of their patients). Prebypass TEE yielded unsuspected findings that assisted or changed the planned operation in 19% of the patients while post-bypass TEE revealed unsatisfactory results that required immediate reintervention in 6% of patients.…”

“…Postbypass left ventricular dysfunction, necessitating prompt administration of inotropic agents was identified in 13% of their patients. 3 Although we did not directly compare the impact of monitoring with TEE and PAC, intraoperative TEE has several potential advantages over PAC to monitor cardiac function during cardiac surgery. It provides an accurate and reliable assessment of intracavitary dimensions, global and regional right and left ventricular wall motion, valve function, and imaging of the great vessels.…”

A comparison of transoesophageal echocardiographic Doppler across the aortic valve and the thermodilution technique for estimating cardiac output

“…With respect to the recently discussed association between thermodilution determination of cardiac output in the initial care of critically ill patients and increase in mortality, less invasive techniques may be preferable. It is possible for TOE to provide an instantaneous diagnosis of hypovolaemia, qualitative assessment of contractility and valvular function in a very short time at the bedside [14,[18][19][20], permitting differentiation between cardiac and noncardiac causes of an acute haemodynamic derangement with a very low probability of morbidity [21]. Anaesthesia, 1999 ................................................................................................................................................................................................................................................ …”

Intraoperative Doppler color flow mapping for decision-making in valve repair for mitral regurgitation. Technique and results in 100 patients.

“…Figure 9 compares intraoperative prerepair Doppler assessment of mitral regurgitation with the preoperative angiographic assessment of mitral regurgitation in 95 patients performed a mean of 17 days (range, 0-173 days) preoperatively. In 45 patients, the results were identical; in 41 patients, there was a discrepancy of 1+; and in nine patients, there was a discrepancy of 2+. In two patients, no preoperative angiography was performed, and in three patients, the amount of mitral regurgitation on the angiogram could not be interpreted due to arrhythmias.…”