© Copyright by ICR Publishers 2011 The Value of Intraoperative Transesophageal Echocardiography in Patients Undergoing Aortic Valve Replacement Daniel Weisenberg 1 , Alik Sagie 1 , Mordehay Vaturi 1 , Daniel Monakier 1 , Erez Sharoni 2 , Eyal Porat 2 , Yaron Shapira 1 1 The Dan Sheingarten Echocardiography Unit and Valvular Clinic, Department of Cardiology, 2 Department of Cardiothoracic Surgery, Rabin Medical Center, Beilinson Campus, Petah Tikva, affiliated with the Sackler School of Medicine, Tel-Aviv University, Israel During recent years, intraoperative transesophageal echocardiography (IOTEE) has become an integral part of the evaluation of patients undergoing valve surgery. Its role has been particularly important in valve repair surgery and surgery for infective endo- carditis, as recommended by the American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines for the management of patients with valvular heart disease (1). However, routine IOTEE for all patients undergoing valve surgery has gained only a grade IIC recommendation, namely supported by weaker evidence and expert consensus. Although, aortic valve replacement (AVR), per- formed mostly for severe aortic stenosis, is the most common valve operation currently carried out in developed countries (2), only minimal information is available regarding the impact of IOTEE in this setting. Hence, the present study was conducted to determine the impact of IOTEE on the management of a large cohort of patients referred for AVR (both isolated and combined with other procedures) at a tertiary referral medical center. Clinical material and methods Patients The departmental echocardiography database for patients undergoing AVR (mechanical or bioprosthetic valves) and who underwent IOTEE between April 1999 and September 2006 at the authors’ institution, was reviewed. Patients with infective endocarditis, aortic dissection, and those in whom a composite graft was implanted, were excluded from the study. All data Address for correspondence: Daniel Weisenberg MD, Echocardiography and Valvular Clinic, The Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah- Tiqva, 49100, Israel e-mail: wisnberg@zahav.net.il Background and aim of the study: While the role of intraoperative transesophageal echocardiography (IOTEE) in valve repair surgery is well documented, its value in patients undergoing valve replacement is debatable. The study aim was to assess the impact of IOTEE on the management of a large cohort of patients referred for aortic valve replacement (AVR). Methods: The departmental echocardiography data- base for patients undergoing AVR with IOTEE between April 1999 and September 2006 at the authors’ institution was reviewed. Patients with a diagnosis of infective endocarditis, aortic dissection, or those in whom a composite graft was implanted, were excluded from the study. Results: The study group included 604 patients (319 males, 285 females; mean age 70 ± 11 years) who underwent AVR for either predominant aortic steno- sis (n = 520; 86.1%) or aortic regurgitation (n = 84; 13.9%). Pre-pump IOTEE was performed in 440 patients (72.8%), and post-pump IOTEE in 586 (97.0%). Overall major preoperative findings influ- encing the operative plan were found in 106 of the 440 patients (24.1%); decisions regarding the mitral valve were the most frequent. The post-pump study revealed unexpected findings requiring a second pump run in 20 patients (3.4%), of whom nine cases (1.5%) applied to the replaced aortic prostheses (par- avalvular leak in five patients, coronary obstruction by an aortic bioprosthesis in two, and detection and closure of a pseudoaneurysm in the mitral-aortic fibrosa and incompetent bioprosthesis in one patient each). Eleven patients (1.8%) required a second pump run because of failed mitral/tricuspid repair or hemo- dynamic compromise. Conclusion: The main use of a routine application of IOTEE among patients undergoing AVR was to detect additional lesions preoperatively, and techni- cal failures postoperatively. The Journal of Heart Valve Disease 2011;20:540-544