Intraoperative evaluation of myocardial viability by nitroglycerin-induced improvement in regional left ventricular function assessed by transesophageal echocardiography.

The aim of this study was to assess whether intraoperative transesophageal echocardiography with nitroglycerin infusion could identify viable myocardium. Twenty-eight patients with coronary artery disease with regional dysfunction underwent transesophageal echocardiography during bypass surgery. A transgastric left ventricular cross-sectional image at the midpapillary level was obtained and divided into four segments for wall motion analysis. Forty-four segments were graded as asynergic. Nitroglycerin was then given intravenously with an initial infusion rate of 1 microgram/kg/min, followed by an increase in dose up to 3 micrograms/kg/mini. Functional improvement with nitroglycerin was observed in 33 or 44 asynergic segments, while 11 remained unchanged. Follow-up transthoracic echocardiography was performed at 15.9 +/- 5.5 days after surgery. A segment was defined as viable when wall motion was better than or equal to severe hypokinesis at baseline or follow-up. Forty-three of 44 asynergic segments at baseline were defined as viable; these were the same segments demonstrating wall thickening with nitroglycerin. In particular, four of 5 akinetic segments at baseline demonstrated viability at follow-up, which had been predicted with nitroglycerin. Transesophageal echocardiography with nitroglycerin correctly identified viability (p < 0.05). No adverse hemodynamic effect was observed. Intraoperative transesophageal echocardiography with nitroglycerin appears to be a safe, noninvasive, feasible, and widely available method to identify myocardial viability under the condition supported by cardiopulmonary bypass.