Leung J M, O'Kelly B, Browner W S, Tubau J, Hollenberg M, Mangano D T
Department of Anesthesia, University of California, San Francisco 94121.
Anesthesiology. 1989 Jul;71(1):16-25. doi: 10.1097/00000542-198907000-00004.
Regional wall motion abnormalities (RWMA) detected by intraoperative transesophageal echocardiography (TEE) are thought to be sensitive markers of myocardial ischemia. To assess the prognostic significance of RWMA as compared with other less costly technologies such as electrocardiography (ECG) and hemodynamic measurements [blood pressure (BP) and pulmonary artery (PA) pressure], 50 patients were prospectively studied who were undergoing elective coronary artery bypass graft (CABG) surgery using continuous TEE, ECG (Holter), and hemodynamic measurements during the prebypass, postbypass, and early postoperative intensive care unit (ICU) periods (first 4 h). Echocardiographic and ECG evidence of ischemia was characterized during each of these three periods and related to adverse clinical outcomes (postoperative myocardial infarction, ventricular failure, and cardiac death). Clinicians were blinded to the TEE and ECG information. The prevalence of myocardial ischemia during the perioperative periods was as follows: prebypass, 20% (TEE) versus 7% (ECG); postbypass, 36% (TEE) versus 25% (ECG); ICU 25% (TEE) versus 16% (ECG). Neither prebypass TEE ischemia nor ECG ischemia occurring in any of the three periods predicted adverse outcome. In contrast, postbypass TEE ischemia was predictive of outcome: six of 18 patients with postbypass TEE ischemia had adverse outcomes versus 0 of 32 without TEE ischemia (P = 0.001). Seventy-three percent of the echocardiographic ischemic episodes occurred without acute change (+/- 20% of control) in heart rate, BP, or PA pressure. The authors conclude that: 1) prebypass myocardial ischemia was relatively uncommon, 2) the incidence of ECG and TEE ischemia was highest in the postbypass period, and 3) postbypass RWMA were related to adverse clinical outcome.
术中经食管超声心动图（TEE）检测到的局部室壁运动异常（RWMA）被认为是心肌缺血的敏感标志物。为了评估RWMA与其他成本较低的技术（如心电图（ECG）和血流动力学测量[血压（BP）和肺动脉（PA）压力]）相比的预后意义，对50例接受择期冠状动脉旁路移植术（CABG）的患者进行了前瞻性研究，在体外循环前、体外循环后以及术后早期重症监护病房（ICU）期间（最初4小时）使用连续TEE、ECG（动态心电图）和血流动力学测量。在这三个时期的每个阶段，对缺血的超声心动图和ECG证据进行了特征描述，并与不良临床结局（术后心肌梗死、心室衰竭和心源性死亡）相关联。临床医生对TEE和ECG信息不知情。围手术期心肌缺血的发生率如下：体外循环前，TEE检测为20%，而ECG检测为7%；体外循环后，TEE检测为36%，而ECG检测为25%；ICU期间，TEE检测为25%，而ECG检测为16%。体外循环前TEE缺血以及在三个时期中的任何一个时期出现的ECG缺血均不能预测不良结局。相比之下，体外循环后TEE缺血可预测结局：18例体外循环后TEE缺血患者中有6例出现不良结局，而32例无TEE缺血患者中无不良结局（P = 0.001）。73%的超声心动图缺血发作发生时心率、BP或PA压力无急性变化（±对照值的20%）。作者得出结论：1）体外循环前心肌缺血相对少见；2）ECG和TEE缺血的发生率在体外循环后时期最高；3）体外循环后RWMA与不良临床结局相关。
