In adult patients who are undergoing open cardiac valve or proximal aortic surgery, the use of intraoperative transesophageal echocardiography (TEE) is linked to improved clinical outcomes, according to results of an analysis published in JAMA Network Open.

A matched, retrospective cohort study was conducted with the use of national registry data from the Society of Thoracic Surgeon (STS) Adult Cardiac Surgery Database (ACSD), which compared outcomes among individuals receiving cardiac valve or proximal aortic surgery with or without the use of intraoperative TEE. The researchers sought to explore the association between intraoperative TEE and clinical outcomes following cardiac valve or proximal aortic surgery.

STS ACSD data include over 90% of all hospitals in the United States that perform cardiac surgery. Participants in the study cohort comprised all patients aged 18 years or older who have received cardiac valve or replacement surgery or proximal aortic surgery from 2011 through 2019. All statistical analyses were conducted between October 2020 and April 2021. In this first all-patient, across-hospital, across-surgeon, matched comparison, each patient who did not receive a TEE was matched with a comparable patient who did receive a TEE while undergoing surgery. Strict matching criteria were used to guarantee that each of the matched pairs was as similar as possible.


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The study cohort included a total of 872,936 patients who were receiving valve or aortic surgery. Overall, 61.89% of the patients were men, 85.04% were White, and 7.28% were Black. The mean participant age was 65.61±13.17 years. In total, 81.5% of patients received a TEE and 18.5% of participants did not receive a TEE.

The primary study outcome was death within 30 days of surgery. Secondary outcomes included the composite of stroke or 30-day mortality and the composite of in-hospital reoperation for valve or coronary artery bypass graft reintervention or bleeding or 30-day mortality.

A total of 39,078 participants died within 30 days of surgery. Participants who received an intraoperative TEE experienced a significantly lower 30-day mortality compared with those who did not receive a TEE (3.92% vs 5.27%, respectively; odds ratio [OR], 0.73; 95% CI, 0.72-0.75; P <.001), a significantly lower incidence of stroke or
30-day mortality (5.63% vs 7.01%, respectively; OR, 0.79; 95% CI, 0.77-0.81; P <.001), and a significantly lower incidence of reoperation or 30-day mortality (7.31% vs 8.87%, respectively; OR, 0.81; 95% CI, 0.79-0.83; P <.001).

After matching, intraoperative TEE was significantly associated with a lower 30-day mortality vs no TEE (3.81% vs 5.27%, respectively; OR, 0.69; 95% CI, 0.67-0.72;P <.001), a significantly lower incidence of stroke or 30-day mortality (5.56% vs 7.01%, respectively; OR, 0.77; 95% CI, 0.74-0.79; P <.001), and a significantly lower incidence of reoperation or 30-day mortality (7.18% vs 8.87%, respectively; OR, 0.78; 95% CI, 0.76-0.80; P <.001).

A major limitation of this study is that its observational, nonrandomized design made the researchers unable to confirm a causal link between TEE and improved clinical outcomes. They were unable to completely eliminate residual confounding, especially among those participants who did not receive a TEE.

“These findings provide evidence to support the routine use of intraoperative TEE in all open cardiac valve and proximal aortic surgical procedures,” the researchers wrote.

Disclosure: None of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies.  

Reference  

MacKay EJ, Zhang B, Augoustides JG, Groeneveld PW, Desai ND. Association of intraoperative transesophageal echocardiography and clinical outcomes after open cardiac valve or proximal aortic surgeryJAMA Netw Open. Published online February 5, 2022. doi:10.1001/jamanetworkopen.2021.47820