Conclusions
Despite the increasing popularization of the use of FEES, its efficacy
specifically in the setting of cardiac surgery has not been well
studied, and consequently is seldomly used.11 In a
2021 study, tracheal aspiration was found to be prevalent, costly to
patients, and associated with increased morbidity and mortality after
adult cardiac surgery.24 Given the high incidence of
dysphagia and concurrent silent aspiration and subsequent pneumonia in
cardiac surgery patients, demonstration of the efficacy of FEES in the
setting of cardiac surgery could play an important role in increasing
its utilization and improving health-related
outcomes.25
Postoperative dysphagia following cardiac surgery is common,
multifactorial, and is associated with increased morbidity and increased
LOS.3,6 FEES is a convenient tool for evaluating
dysphagia and has been shown to decrease the incidence of aspiration
pneumonia in other settings, but its use in postoperative cardiac
surgical care has not adopted as standard of
care.10,11 In our review of patients undergoing
durable LVAD implantation, patients that underwent FEES trended towards
shorter total hospital and post-implant LOS and lower postoperative
pneumonia and sepsis rates. In the entire LVAD cohort we had zero
30-day, and 5.6% 1-year mortality, and so FEES intervention did not
impact mortality. Mortality at 2 and 3 years were 5.6% and 16.7%,
respectively.
Dysphagia is a significant complication post cardiac surgery that
requires attention and mitigation. Risk factors for developing dysphagia
following cardiac surgery include TEE use, prolonged operative duration,
prolonged mechanical ventilation, New York Heart Association classes III
and IV, and larger endotracheal tube
size.1,2,4,5,9,24,26,27 TEE use was identified as an
independent predictor of dysphagia among 869 patients undergoing cardiac
surgery.5 In another study of operative duration and
dysphagia among 838 patients undergoing cardiac surgery, no patients who
were operated on for less than 4.5 hours developed dysphagia, suggesting
an association exists between operative duration and
dysphagia.4 Studies have also identified prolonged
mechanical ventilation as a risk factor for dysphagia among patients
undergoing cardiac surgery.1,2,4,5,9,26
Identifying dysphagia in patients early in the postoperative period may
also contribute to reduced adverse outcomes associated with dysphagia.
Though prior studies demonstrate FEES use in adult and pediatric
settings outside of cardiac surgical care is safe and effective for
evaluating dysphagia10–17, it has not been until
recently that studies have incorporated FEES to detect dysphagia in
cardiac surgery.28 In a prospective trial of adult
patients undergoing elective cardiac surgery, FEES was used as
confirmatory testing for patients failing a targeted swallow screen; the
study found the true incidence of dysphagia after cardiac surgery to be
significantly higher than previously
recognized.24,27,29 In a study of 60 patients with
dysphagia of various origin, FEES had high sensitivity and validity for
detection of dysphagia.30 Although the study was not
limited to patients undergoing cardiac surgery, the finding that FEES
has high sensitivity and validity for detecting dysphagia may explain
the higher incidence of dysphagia noted among LVAD patients undergoing
FEES in the current study despite comparable baseline risk factors with
the control group. These findings suggest that dysphagia may be
under-diagnosed without instrumentation, and early subclinical dysphagia
can be detected with FEES.
We believe that while our pilot study importantly contributes to
understanding how FEES can be integrated into LVAD surgery postoperative
care, it is limited due to small sample size and low event rates,
limiting our ability to draw conclusions that can be generalized beyond
the patients in the present study. We found reduced adverse clinical
outcomes following durable LVAD implantation; however, a larger
prospective study is warranted to delineate the significance of these
preliminary findings.