Impact of Intraoperative Transesophageal Echocardiography on Surgical Decisions in 12,566 Patients Undergoing Cardiac Surgery Holger K. Eltzschig, MD,

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Impact of Intraoperative Transesophageal Echocardiography on Surgical Decisions in 12,566 Patients Undergoing Cardiac Surgery Holger K. Eltzschig, MD, PhD, Peter Rosenberger, MD, Michaela Löffler, MD, John A. Fox, MD, Sary F. Aranki, MD, Stanton K. Shernan, MD The Annals of Thoracic Surgery Volume 85, Issue 3, Pages 845-852 (March 2008) DOI: 10.1016/j.athoracsur.2007.11.015 Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Overview of surgical procedures performed in 12,566 cardiac surgical patients who underwent intraoperative transesophageal echocardiography examination. *Other types of procedures (n = 1,947). (ASD = atrial septal defect repair; AV = aortic valve replacement or repair; CABG = coronary artery bypass grafting; MV = mitral valve replacement or repair; TMLR = transmyocardial laser revascularization; VAD = ventricular assist device placement; VSD = ventricular septal defect repair.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Percent transesophageal echocardiography (TEE) performed per year. Overview of TEE (open bars) performed per year in 12,566 cardiac surgical patients who underwent intraoperative TEE examination. (Black bars = surgeries.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Changes in 3,835 patients undergoing isolated coronary artery bypass graft surgery. Impact of before (pre-) and after (post-) cardiopulmonary bypass (CPB) intraoperative transesophageal echocardiography (TEE) on surgical decision making in 3,835 patients undergoing isolated coronary artery bypass graft surgery. (An = aneurysm; ASD = atrial septal defect; AV = aortic valve; MV = mitral valve; Rx = resection; Thr = Thrombus; TVP = tricuspid valve repair; VAD = ventricular assist device; VSD = ventricular septal defect.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Changes in 1,610 patients undergoing aortic valve replacement (AVR). Impact of before (pre-) and after (post-) cardiopulmonary bypass (CPB) intraoperative transesophageal echocardiography on surgical decision making in 1,610 patients undergoing aortic valve surgery. (An = aneurysm; Ao = descending thoracic aorta; ASD = atrial septal defect; AVP = aortic valve repair; CABG = coronary artery bypass grafting surgery; MV = mitral valve; MVR = mitral valve replacement; Rx = resection; Thr = thrombus; TV = tricuspid valve repair; Ventr DysFx = ventricular dysfunction; VSD = ventricular septal defect.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Changes in 1,823 patients undergoing mitral valve replacement (MVR) or repair (MVP). Impact of before (pre-) and after (post-) cardiopulmonary bypass (CPB) intraoperative transesophageal echocardiography on surgical decision making in 1,823 patients undergoing MVR or MVP. (An = aneurysm; ASD = atrial septal defect; AV = aortic valve; CABG = coronary artery bypass graft surgery; Desc Ao = descending thoracic aorta; LV = left ventricle; MV = mitral valve; RA = right atrium; Rx = resection; Thr = thrombus; TVP = tricuspid valve repair.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Changes in 407 patients undergoing aortic valve replacement (AVR) plus mitral valve replacement (MVR) or repair (MVP). Impact of before (pre-) and after (post-) cardiopulmonary bypass (CPB) intraoperative transesophageal echocardiography on surgical decision making in 407 patients undergoing combined AVR and MVR or MVP. (An = aneurysm; ASD = atrial septal defect; AV = aortic valve; CABG = coronary artery bypass graft surgery; MV = mitral valve; Rx = resection; Thr = thrombus; TVP = tricuspid valve repair.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Changes in 1,360 patients undergoing coronary artery bypass graft surgery (CABG) plus aortic valve (AV) surgery. Impact of before (pre-) and after (post-) cardiopulmonary bypass (CPB) intraoperative transesophageal echocardiography on surgical decision making in 1,360 patients undergoing combined CABG and AV surgery. (An = aneurysm; Ao: descending thoracic aorta; ASD = atrial septal defect; AVP = aortic valve repair; AVR = aortic valve replacement; MV = mitral valve; Rx = resection; Thr = thrombus; TVP = tricuspid valve repair.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Changes in 1,325 patients undergoing coronary artery bypass graft surgery (CABG) plus mitral valve (MV) surgery. Impact of before (pre-) and after (post-) cardiopulmonary bypass (CPB) intraoperative transesophageal echocardiography on surgical decision making in 1,325 patients undergoing combined CABG and MV surgery. (An = aneurysm; Ao = descending thoracic aorta; Asc Ao = ascending thoracic aorta; ASD = atrial septal defect; AV = aortic valve; LA = left atrium; Rx = resection; Thr = thrombus; TVP = tricuspid valve repair.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 9 Changes in 259 patients undergoing coronary artery bypass graft surgery (CABG) plus mitral valve (MV) plus aortic valve (AV) surgery. Impact of before (pre-) and after (post-) cardiopulmonary bypass (CPB) intraoperative transesophageal echocardiography on surgical decision making in 259 patients undergoing combined CABG and AV and MV surgery. (Ao = descending thoracic aorta; ASD = atrial septal defect; TMLR = transmyocardial laser revascularization; TVP = tricuspid valve repair.) The Annals of Thoracic Surgery 2008 85, 845-852DOI: (10.1016/j.athoracsur.2007.11.015) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions