Intraoperative Echocardiography in Low-Risk CABG Surgery

This trial will look at benefits and harms to two different treatments strategies in order to improve clinical outcomes. Intraoperative TEE is an ultrasound-based, imaging device that uses sound waves to look at the heart continuously during a heart surgery.

Inclusion criteria

• Scheduled to undergo isolated CABG surgery at a hospital within the UPenn Health System
• Age ≥18 years
• Ejection fraction ≥50%
• Transthoracic echocardiography within one year of scheduled surgery date
• Left heart catheterization within one year of scheduled surgery date
• English language fluency or facilitated via language interpreter
• Able to provide informed consent either in English or via a language interpreter
• Willing to comply with all study procedures

Exclusion criteria

• Documented valve (aortic, mitral, tricuspid, or pulmonic) disease (stenosis or regurgitation) moderate or greater.
• Any CABG surgery with either "possible" or "definite" aortic intervention listed as a planned part of the procedure. plan for either definite or possible surgical intervention.
• Any CABG surgery with either "possible" or "definite" valve repair/replacement listed as a planned part of the procedure.
• Having undergone any previous cardiac surgeries (i.e. scheduled with a "REDO" modifier).
• Proximal/critical left main coronary disease (e.g. greater than or equal to 90% stenosis).
• Preexisting anomalous coronary arteries
• Preexisting end-stage renal disease on hemodialysis
• Preexisting chronic kidney disease (CKD) stage 3, 4, or 5
• Stroke with residual focal neurological deficit(s) within 90 days of surgery
• Any of the following presurgical, mechanical circulatory support devices:

• Intraaortic balloon pump
• Percutaneous right ventricular assist device (RVAD)
• Impella
• Extracorporeal membrane oxygenation (ECMO)
• Absolute contraindication to echocardiography defined as one or more of the following documented conditions:

• Esophagectomy
• Esophagogastrectomy
• Esophageal trauma
• Any of these three relative contraindication to TEE:

• Esophageal varies
• Gastric bypass surgery
• Descending thoracic aortic aneurysm
• Severe pulmonary hypertension defined as:

• Pulmonary arterial pressure ≥60 mmHg
• Pulmonary vascular resistance (PVR) ≥3 Woods Units
• Hemodynamic instability after induction and following placement of an endotracheal tube will be defined as one or more of the following events or scenarios:

• Placement of an intraaortic balloon pump (IABP)
• Initiation of venoarterial extracorporeal membrane oxygenation (VAECMO)
• Placement of a right or left percutaneous mechanical circulatory support device
• Initiation of epinephrine infusion at a dose ≥ 6 mcg/min for a duration ≥5 minutes
• Initiation of norepinephrine at a dose ≥8 mcg/min for a duration ≥ minutes
• Initiation of phenylephrine infusion at a dose ≥100 mcg/min for a duration ≥ minutes
• Initiation of vasopressin infusion at a dose ≥0.04 units/min for a duration ≥ minutes