Intraoperative epiaortic ultrasound scanning guides operative strategies and identifies patients at high risk during coronary artery bypass grafting

Objective: Epiaortic ultrasound (EU) reliably reveals ascending aortic atherosclerosis (AAA), allowing strategies to minimize the risk of embolization or plaque disruption during coronary artery bypass grafting. Our objective was to delineate if EU-guided intervention improved outcomes. Methods: Patients undergoing coronary artery bypass grafting (2004-2007) were categorized by EU grade (grade 1-2 [mild] vs. 3-5 [moderate/severe]) and the use of an aortic clamp. A propensity score estimated probability of clamp use was based on 45 risk factors. Multiple logistic regression models measured the association between outcomes-death, stroke, myocardial infarction, and major adverse cardiac and cerebrovascular events (MACCE)-and the primary variables (grade and clamp use), adjusted for propensity score. Results: Grade was available in 4278 patients. Patients with grade 3 to 5 AAA had an increased risk of death (adjusted odds ratios (AOR) 3.11; P < 0.001), stroke (AOR 2.12; P < 0.001), and MACCE (AOR 2.58; P < 0.001). Aortic clamping (any clamp, all grades) led to a higher risk of stroke (AOR 2.77; P = 0.032). EU altered aortic manipulation in 530 patients (12.4%). In this group, patients with high grade aortas had similar rates of death, stroke or MACCE, when compared with patients with low-grade aortas. Conclusions: EU alters surgical strategy. Patients with grade 3 to 5 AAA are at increased risk of death, stroke, and MACCE compared with patients with grade 1 to 2 AAA. Clamping the aorta (any grade) increases the risk for stroke. Aortic clamping should be avoided in patients with grade 3 to 5 AAA, but EU may minimize morbidity and mortality if a clamp must be used.