2024 FSA Podium and Poster Abstracts
P105: THE IMPORTANCE OF INTRAOPERATIVE TEE DURING CABG: A MEDICALLY CHALLENGING CASE
Natalie A Schmidt, BA1; Austin Erney, MD2; George Luck, MD1; 1Florida Atlantic University College of Medicine; 2Jupiter Medical Center
Introduction: Coronary artery bypass graft (CABG) is an open-heart procedure indicated for coronary artery disease. Current ACA/AHA guidelines recommend performing aortic valve replacement (AVR) at the same time as CABG when there is moderate valvular disease. The procedure is performed traditionally utilizing a cardiopulmonary bypass pump (“on-pump”), which requires cannulization and clamping of the aorta. At the beginning of the procedure, the anesthesiologist is responsible for transesophageal echocardiography (TEE) and must inform the surgical team of any safety concerns before accessing the aorta.
Case Description: The patient is an 80-year-old gentleman who presented to the ED with chest pain for two weeks. He was found to have severe three-vessel coronary artery disease with moderate aortic stenosis as seen on a transthoracic echocardiogram. The patient was brought to the operating room for planned CABG and aortic valve replacement. Intraoperative transesophageal echocardiogram (TTE) performed by anesthesia revealed a grade 5 mobile atheroma in the distal aortic arch, close to the innominate takeoff. The anesthesiology team communicated this finding to the surgery team. A multidisciplinary discussion ensued as to how to proceed:
On-pump CABG with AVR?
Off-pump CABG alone?
Circulatory arrest with CABG and AVR?
The risk of neurovascular complication, the likelihood of requiring reoperation, the expertise of the surgeon, and the functional status of the patient were all considered. Ultimately, the decision was made to proceed with off-pump CABG without AVR.
Discussion: This case highlights the importance of the TEE in ensuring patient safety when a cardiopulmonary bypass is planned. Although most patients undergoing CABG will have a previous TTE, aortic disease can be missed. The discovery of a mobile atheroma presented an immediate safety concern as there was a high risk of embolization if the team had proceeded with cannulization of the aorta. Cardiothoracic anesthesiologists play a critical role in guiding management intraoperatively. Communication of TEE findings to the cardiac surgeon is essential and helps manage the best care for the patients.