Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery

Background: Coronary artery bypass graft (CABG) surgery is the most widely performed cardiac surgery in the United States. Transesophageal echocardiography (TEE) is frequently used in a variety of cardiac surgical procedures, but its clinical benefit in isolated CABG surgery is unclear, and guidelines remain indeterminate. The aim of this study was to compare clinical outcomes among patients undergoing isolated CABG surgery with versus without TEE in order to test the hypothesis that TEE would be associated with improved clinical outcomes after CABG surgery. Methods: A matched retrospective cohort study was conducted among Medicare beneficiaries undergoing isolated CABG surgery with versus without intraoperative monitoring using TEE in the United States. The primary analysis was a near/far instrumental variable match that paired hospitals with similar characteristics and patient populations but with opposing probabilities for using TEE in CABG surgery. Outcomes included 30-day mortality, a composite outcome of stroke or 30-day mortality, length of hospitalization, and incidence of esophageal perforation. Results: Of 114,871 patients undergoing isolated CABG surgery, 65,471 (57%) underwent TEE and 49,400 (43%) did not. Hospital-level instrumental variable matched analysis demonstrated that among the subset of 968 matched hospitals, TEE receipt was associated with lower 30-day mortality (3.7% vs 4.9%, P <.001), a lower incidence of the composite outcome of stroke or 30-day mortality (4.5% vs 5.6%, P <.001), no difference in length of hospitalization (10.32 vs 10.52 days, P =.26), and no difference in the incidence of esophageal perforation (0.01% vs 0.01%, P =.63). These results were replicated in surgeon-level and patient-level matched-pair instrumental variable analyses, and all analyses were robust to sensitivity analyses that tested for biases introduced by unmeasured confounding. Conclusions: The findings from this study suggest that TEE may offer a clinical benefit to cardiac surgical patients undergoing isolated CABG surgery.