[HSF] preop echo vs. TEE

[Tea Acuff]

I have listened to the argument that MR may be missed on intraop TEE but have not changed my practice to do it. Seems like a lot of gratuitous echos to me. Put it in real dollars. What if you told every patient that It would be an extra $500 dollars from their pocket for "checking". How many patients would say yes? Would you? I do virtually all of my CABGs beating heat and if when I have finished I have significant MR or other worries I can go on pump knowing that it is probably not functional/ acute dysfunction. I must say that I have been misled coming off bypass with bad MR that resolves just waiting and some that worsens post op. (Don't anyone even bother to say that they have never seen the latter unless of course they never have a sternal infection either or are from Boston. Then I can just smile and nod back.) I use TEE on every case and this seems much more defensible that preop echo. All patients should expect that the surgeon fixes whatever cardiac problem he
 feels warranted at that moment of operation if a cardiac operation is planned and conducted. No test is perfect, no plan sacrosanct.  That is how I see it.
Tea


----- Original Message ----
From: Sherman Turnage <turnages at mac.com>
To: openheart-l at lists.hsforum.com
Sent: Wednesday, October 4, 2006 9:57:39 PM
Subject: [HSF] preop echo vs. TEE


Group:

In response to Dr. Levinson's comment below, I've seen a spectrum of  
situations. My partner and I have seen several patients who have had  
a preop transthoracic echo reporting mild MR. Even after anesthetic  
induction with attendant lower blood pressure, we have seen several  
patients with moderate to severe MR. The MR in these cases has  
generally been functional MR and presumed ischemic. Severity has been  
documented in most cases with pulsed wave doppler of the pulmonary  
veins. Even though the surgical consent hasn't listed mitral repair,  
our surgeon has placed a mitral ring, and the surgeon and myself  
explain to the patient postop that TEE is probably more sensitive in  
detecting MR and that we felt it was in the patient's best interest  
to perform the repair. Hal has discussed his observation of an  
annular diameter of > 40 mm as one indicator favoring mitral ring and  
before reading his postings I hadn't obtained that measurement. The  
other experience we have had is similar to my case yesterday. At the  
beginning of a redo CABG, the patient was noted to have mod-severe  
MR. We encountered multiple problems but ultimately got the patient  
regrafted successfully. Upon separation from CPB there was trivial MR  
indicating most of this MR was likely acute ischemic papillary muscle  
dysfunction.

While we appreciate the data supporting mitral repair, especially in  
sicker ventricles, there are a number of patients where we doubt  
whether the benefit of proceeding with a repair will outweigh the  
risk. Similarly, it is not entirely obvious to us whether all  
functional MR is ischemic and therefore whether improving coronary  
blood flow will in itself correct the MR. We find these cases of  
unexpected MR, particularly in relation to preop echo findings, the  
most challenging judgment calls to make. It would be interesting to  
hear some of the approaches members of the list take in evaluating  
these situations.

Thanks,

W. Sherman Turnage, MD
St. Augustine, FL


Mark Levinsons wrote:
For the past 2 years, I have asked that every CABG case get a preop
echo regardless of symptoms at presentation. MR or AI is often seen
and I have learned that if this is not corrected, some will present
in the near
future for another surgery in the setting of CHF and open grafts.

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