Real-Time Compared to Off-Line Evaluation of Segmental Wall Motion Abnormalities with Transesophageal Echocardiography Using Dobutamine Stress Testing

Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada.
Journal of cardiothoracic and vascular anesthesia (Impact Factor: 1.46). 09/2011; 26(2):191-6. DOI: 10.1053/j.jvca.2011.07.019
Source: PubMed


To compare real-time (on-line) monitoring of myocardial ischemia with transesophageal echocardiography (TEE) with off-line reviewing during a dobutamine stress test in patients undergoing coronary artery bypass grafting (CABG).
Prospective observational study.
Tertiary care university hospital.
Seventeen patients undergoing CABG.
TEE and electrocardiographic monitoring of myocardial ischemia during dobutamine stress testing.
Sixteen of 17 patients developed myocardial ischemia as diagnosed by TEE or electrocardiographic monitoring. On-line and off-line TEE detected myocardial ischemia in 11/17 and 12/17 patients, respectively. In total, 532 myocardial segments were analyzed at baseline and at peak dobutamine dose. The concordance between on-line and off-line assessments of segmental wall motion was poor at baseline and at peak dobutamine dose (κ = 0.28 and 0.29, respectively). The concordance for detecting myocardial ischemia (worsening in regional wall motion by ≥1 class or a biphasic response in any segment) was better between on-line and off-line analysis (κ = 0.60). There was no agreement between ST-segment monitoring and on-line TEE (κ = -0.27) and between 12-lead electrocardiogram and on-line TEE (-0.11). There was no agreement between ST-segment monitoring and off-line TEE (κ = -0.15) and between 12-lead electrocardiogram and off-line TEE (κ = -0.27).
Only a fair agreement exists between on-line and off-line analysis of myocardial ischemia during dobutamine stress testing in patients undergoing CABG. However, TEE misses up to one third of ischemic episodes and the present observations suggest using continuous electrocardiographic methods to complement TEE monitoring.

14 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the accuracy of new intraoperative regional wall motions abnormalities (RWMAs) detected by transesophageal echocardiography (TEE) to predict early postoperative coronary artery graft failure. A retrospective study. A tertiary care university hospital. Five thousand nine hundred ninety-eight patients who underwent coronary artery bypass graft (CABG) surgery. An evaluation of RWMAs recorded with intraoperative TEE before and after cardiopulmonary bypass (CPB) in patients who had coronary angiography for suspected postoperative myocardial ischemia based on electrocardiogram (ECG), CK-MB, troponin T, hemodynamic compromise, low cardiac output, and malignant ventricular arrhythmia. Sensitivity, specificity, positive and negative predictive values, odds ratio, 95% confidence interval, and chi-square analysis were used. Thirty-nine patients (0.7%) underwent early coronary angiography for the suspicion of early graft dysfunction. Of the 32 patients with diagnosed early graft dysfunction, 5 patients (15.6%) had shown new intraoperative RWMAs as detected by TEE, 21 patients (65.6%) had no new RWMAs, no report was available in 5 patients (15.6%), and 1 examination (3.1%) was excluded because of poor imaging quality. The sensitivity of TEE to predict graft failure was 15.6%, the specificity was 57.1%, and the positive predictive and negative values were 62.5% and 12.9%, respectively. The odds ratio and 95% confidence interval was 0.1190 (0.0099-1.4257) when TEE was positive compared with coronary angiography. No association was found between new RWMAs detected with TEE and graft failure as documented with coronary angiography (p = 0.106). In this retrospective study, RWMAs detected with TEE were of limited value to predict early postoperative CABG failure.
    No preview · Article · Mar 2012 · Journal of cardiothoracic and vascular anesthesia
  • [Show abstract] [Hide abstract]
    ABSTRACT: To assess if right ventricular (RV) dysfunction is associated with increased mortality after cardiac surgery. Post-hoc analysis of a single-center double-blind randomized controlled trial. University hospital. A total of 120 patients undergoing simple or complex valvular surgery. Patients were randomized to receive intravenous amiodarone or placebo intraoperatively. As secondary analysis, patients were divided into those requiring or not requiring postoperative inotropic agents. After cardiopulmonary bypass (CPB), there were significant increases in heart rate, cardiac index, systolic and mean arterial pressures, central venous pressure and pulmonary capillary wedge pressure with reduction in systemic vascular resistance (p<0.05). Right ventricular end-systolic area became larger in those without inotropes and tricuspid annular plane systolic excursion was reduced in all patients; mitral annular systolic velocities were higher in patients receiving inotropes. Both right- and left-sided Doppler signals were altered significantly after CPB, which may be attributed to increased filling pressure. Inotropic agents were required in 56 patients after CPB (47%). The use of inotropic agents was associated with increased left and right atrial velocities (p<0.05). There were no differences in postoperative complications between groups; however, the number of deaths at 6 years was increased in patients who received inotropes after CPB (p = 0.0247). The increases in right-sided dimensions after CPB are associated with reduction in RV function and increased biventricular filling pressure, suggesting worsening biventricular function and interventricular dependence. Inotropic medications were associated with unaltered RV dimensions and increased biatrial activity. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jan 2015 · Journal of Cardiothoracic and Vascular Anesthesia