Transesophageal echocardiographic monitoring of myocardial ischemia during vascular surgery.

Transesophageal echocardiography (TEE) was used to detect segmental ventricular wall motion abnormalities (SWMAs) associated with ischemia in 49 high-risk patients who had 50 major vascular procedures, including 23 infrarenal aortic, five suprarenal aortic, 14 carotid, seven distal, and one axillofemoral reconstructions. A modified gastroscope tipped with an echocardiographic transducer was inserted into the esophagus and positioned behind the heart to obtain a reproducible cross-sectional view of the left ventricle at the level of the papillary muscles. Twelve patients (24%) had SWMA at baseline, probably representing areas of old infarction. Fourteen patients (28%) had new intraoperative SWMAs. Ten of 14 patients were successfully treated and wall motion was normalized. One of the four patients with persistent SWMA suffered a nonfatal subendocardial infarct; another patient suffered intraoperative cardiac arrest and died. No infarcts were documented in the 10 patients successfully treated. The mortality rate in the entire high-risk group was 6%. Alterations in ventricular wall motion were noted in almost 50% of high-risk patients undergoing major vascular surgery. Seventy-one percent of acute SWMAs were reversed without any evidence of myocardial infarction. TEE allowed early recognition of evolving myocardial ischemia and facilitated immediate and specific fluid and pharamcologic interventions. Continued application of this technique may reduce the incidence and morbidity of perioperative cardiac complications.