Safety of Transesophageal Echocardiography to Guide Structural Cardiac Interventions

Freitas‐Ferraz, Afonso B.; Bernier, Martin; Vaillancourt, Richard; Ugalde, Paula A.; Nicodème, Frédéric; Paradis, Jean‐Michel; Champagne, Jean; O’Hara, Gilles; Junquera, Lucía; Val, David del; Muntané‐Carol, Guillem; O’Connor, Kim; Beaudoin, Jonathan; Rodés‐Cabau, Josep

doi:10.1016/j.jacc.2020.04.069

Cited by 126 publications

(74 citation statements)

References 26 publications

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“…CABG surgery remains the most frequently performed cardiac surgery in the United States. The wide variability in hospital TEE practice in CABG surgery, combined with new information regarding the safety profile for TEE, 20 is an opportunity for a future cluster randomized controlled trial comparing outcomes in normal ejection fraction CABG surgery patients with versus without TEE. Accordingly, if our findings were reproduced in a randomized study, increasing TEE in isolated CABG surgery could improve postoperative outcomes in the largest subset of cardiac surgery patients.…”

Section: Discussionmentioning

confidence: 99%

“…8,9 Transesophageal echocardiography (TEE) is an ultrasound-based cardiac imaging modality that may improve clinical outcomes after CABG surgery by permitting continuous interoperative hemodynamic monitoring, managing surgical complications related to cardiopulmonary bypass, [10][11][12][13][14][15][16][17][18] and facilitating surgical decision-making intraoperatively. 14,15,19 But it is unclear if TEE, a procedure that is not without risk, 20 improves postoperative outcomes after CABG surgery, because existing observational studies 14,15 are limited by an inability to account for the nonrandom selection of patients.…”

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confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

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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“…However, it is important to note that TEE and ICE come with their own risks, such as gastrointestinal bleeding, esophageal perforation, and trauma to the vocal cords with TEE (occurring in up to 1.2% of patients), and vascular complication with ICE. In fact, a recent report showed that the use of TEE for guiding structural heart disease interventions was associated with some degree of esophageal or gastric injury in the vast majority of patients, with more complex lesions (hematoma or laceration) accounting for 40% of cases 10 . Furthermore, the use of intraprocedural TEE requires general anesthesia, which otherwise would not be necessary for a large proportion of patients.…”

Section: Discussionmentioning

confidence: 99%

Utility of fluoroscopy alone for monitoring of intrathoracic bleeding complications during transvenous lead extraction

Issa

2021

Cardiovasc electrophysiol

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Background Transvenous lead extraction (TLE) carries a significant risk of major complications, namely bleeding into the pericardial sac or thoracic cavity. While echocardiographic imaging has been recommended for intraprocedural monitoring for those complications, no studies had examined the potential benefits of fluoroscopy alone as an alternative to echocardiography. The aim of this study was to evaluate the utility of fluoroscopy for monitoring intrathoracic bleeding complications during TLE. Methods This is a single‐center retrospective study of consecutive patients who underwent TLE of a pacemaker or ICD lead with fluoroscopy‐only monitoring. At the beginning of each TLE procedure, baseline fluoroscopic images were obtained for both lung fields and the cardiac silhouette. Similar images were acquired again when hypotension develops during the procedure. Results Fluoroscopy alone (without echocardiographic imaging) was used in 783 consecutive patients (54% women; average age, 71.5 ± 12.9 years) who underwent TLE. There were 93 patients (11.9%) who experienced significant hypotension. Fluoroscopy showed no obvious cause for hypotension in 63 patients. Right ventricular inversion was implied by fluoroscopy in 27 patients. Fluoroscopy detected new pericardial effusion in two patients and new right pleural effusion in one patient, which prompted halting the extraction procedure and therapeutic intervention. Additionally, routine fluoroscopic images revealed the development of an unsuspected new small left pleural effusion in one patient and a pericardial effusion in another. In‐hospital mortality rate was 0%. Conclusions In selected patients undergoing TLE, fluoroscopy can provide valuable information for identifying or excluding cardiovascular causes during periods of intraprocedural hemodynamic instability.

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“…The need for additional staff requirements significantly impedes the efficiency of the procedural workflow, increases cost, increases the risk of gastrointestinal injury, and may limit the primary operating physician's ability to collect anatomical and physiological information according to his or her discretion. 53 In light of the limitations of existing modalities for PDL detection, novel diagnostic tools capable of providing realtime, high-resolution 3D reconstructions of the LAA obtained by the operating physician and minimally affected by operator-and patient-factors are needed. New tools with the ability to generate 3D anatomical reconstructions may improve the measurement of the LAA, optimize device sizing, and possibly reduce PDL.…”

Section: Novel Strategies To Prevent and Detect Pdlmentioning

confidence: 99%

Peri-Device Leaks after Percutaneous Left Atrial Appendage Closure: Clinical Significance and Unmet Diagnostic Needs

et al. 2020

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Oral anticoagulation reduces the ischemic stroke risk in patients with nonvalvular atrial fibrillation (NVAF) but inherently increases the bleeding risk. Percutaneous left atrial appendage occlusion (LAAO) offers an alternative to long-term anticoagulation in patients at risk for cardioembolic events due to underlying atrial fibrillation. Although long-term clinical data remain limited, percutaneous LAAO appears to be a safe and effective means of reducing hemorrhagic stroke and non-procedural-related bleeding events compared to warfarin. Incomplete closure of the LAA resulting in a peri-device leak (PDL) is common after interventions targeting the LAA and has been variably associated with an increased risk of embolic stroke in patients following LAAO. However, the clinical significance of PDL remains unclear, in part, due to variability in the definitions used for PDL, modalities used for the detection of PDL, and the confounding impact of continuing therapeutic anticoagulation in patients found to have PDL on surveillance imaging. In the current review, we examine the association of PDL with ischemic stroke and systemic embolization and explore mechanistic considerations in the development of PDL as they pertain to the unmet need for improving the diagnostic assessment of PDL from an anatomic and physiologic perspective.

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Safety of Transesophageal Echocardiography to Guide Structural Cardiac Interventions

Cited by 126 publications

References 26 publications

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

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

Utility of fluoroscopy alone for monitoring of intrathoracic bleeding complications during transvenous lead extraction

Peri-Device Leaks after Percutaneous Left Atrial Appendage Closure: Clinical Significance and Unmet Diagnostic Needs

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