Transoesophageal echocardiography in cardiac and vascular surgery: implications and observer variability

Transoesophageal echocardiography (TOE) has gained widespread acceptance am ong cardiac anaesthetists as a tool to facilitate peri-operative decision-m aking. This observational study analyses the impact of TOE and its inter-ob server variability on intra-operative patient management during cardiac and major vascular surgery. From lune 1996 to December 1998, standardized repo rts were obtained from I I anaesthetists in 1891 adult cardiac and vascular surgery patients undergoing routine biplane or multiplane TOE. Inter-obser ver variability and the difference between variables of interest were teste d using the chi-squared test or factorial analysis of variance as appropria te. TOE examinations were performed before and after the operation; 1673 (8 8.5%) patients underwent cardiopulmonary bypass (CPB), and 218 (11.5%) pati ents had surgery without CPB, including 42 (2.2%) coronary revascularizatio ns. In 923 patients (49%), TOE provided additional information that influen ced the patient's therapy. In 968 patients (51%), TOE had only minor or no impact on clinical decision-making. In two patients (0.10%) the scheduled o peration was not performed, and in another two patients the TOE examination led to major complications. Observer-dependent variables were: implication s of TOE for intra-operative decision-making (P<0.0001), estimation of imag e quality (P<0.0001), pre-operative left ventricular fractional area change (FAC) (P=0.0026), difference between pre-operative FAC and post-operative FAC (P=0.033), and requests for supervision (P<0.0001). There was no signif icant difference in the case mix between observers. TOE had an important im pact on intraoperative patient management. Inter-observer variability was s ignificant for several variables but not for the frequency of additional su rgical procedures.