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.