The Bruce Rappaport School of Med-icine (Mr. Domany), the Technion

Objective: A cerebrovascular accident (CVA) is a devastating complication of coronary artery bypass grafting (CABG) and a major cause for morbidity and mortality. Aortic manipulation, cannulation, and clamping during CABG may lead to release of atheromatous material from the ascending aorta, which may cause a CVA. This study assessed the hypothesis that the use of intraoperative epiaortic ultrasonography (EAUS) would supplement imaging information with that derived from manual aortic palpation and influence the surgical decision-making approach accordingly. Methods: After undergoing a mid-sternotomy for CABG, 105 patients underwent EAUS with an 8-MHz transducer ordinarily used for conventional transthoracic echocardiography. The surgical strategy was decided on at three stages: preoperatively, after manual aortic palpation, and following EAUS. Results: The preoperative strategy had assigned 105 patients to the "touched aorta" group that was planned for either on-pump or off-pump CABG (OPCAB) with proximal anastomosis to the aorta. Pathologic lesions of the atheromatotic ascending aorta were evident in 40 patients (38%), with the lesions detected in 22 patients (21%) by both palpation and EAUS, and in 18 patients (17%) by EAUS alone. The planned surgical strategy was changed in 29 patients (28%): 25 patients (24%) were converted from on-pump CABG to OPCAB, and the EAUS influenced the choice of the aortic cannulation, cross-clamping, and proximal anastomosis site in 4 patients (4%). Among the changes in surgical decision making, changes in 11 patients (10%) were based on lesion detection by both manual palpation and EAUS; in 18 patients (17%), changes resulted from pathologic evidence provided by EAUS alone. Conclusions: This study showed EAUS to be more sensitive in detecting atherosclerotic lesions than manual intraoperative palpation of the ascending aorta. This investigation contributes new data on the effect of EAUS on intraoperative surgical approach in the era of OPCAB. The use of EAUS has emerged as an important tool in intraoperative decision making, and we recommend its use routinely in CABG procedures. (CHEST 2005; 127:60 -65) Key words: cerebrovascular accident; coronary artery bypass; epiaortic ultrasound Abbreviations: CABG ϭ coronary artery bypass grafting; CVA ϭ cerebrovascular accident; EAUS ϭ epiaortic ultrasonography; OPCAB ϭ off-pump coronary artery bypass; PVD ϭ peripheral vascular disease; TEE ϭ transesophageal echocardiography A dverse neurologic sequelae following coronary artery bypass grafting (CABG) are relatively common and are associated with substantial increases in mortality, length of hospitalization, and the need for intermediate or long-term care facilities. 1 Adverse cerebral outcomes have been reported to occur in 6.1% of these patients. Preoperative risk factors to develop ischemic stroke after CABG include age, preexisting cerebrovascular disease, and atherosclerosis of the ascending aorta. 2 Atheroscle