Intraoperative Transesophageal Echocardiography: Review and Evolution

Abstract

increased frequency as well as in perioperative hemodynamic monitoring during noncardiac surgeries. Objectives: The aim of this analysis was to understand the evolution of the use of intraoperative TEE (iTEE) both in cardiac and noncardiac surgeries showing popular and challenging approaches in its use, and as a secondary goal, to understand the patterns to achieve competency. Methods: A literature review was carried out identifying relevant clinical studies published in last six years using the keywords listed below. Results: The quick acquisition of cardiac anatomy and function data give iTEE an importance in cardiac procedures that is undeniable, permitting refined diagnosis, detect unsuspected pathology, adjust both anesthetic and surgical plans and evaluate immediate surgical outcomes. Although, its use is less established in noncardiac surgery, the latest guidelines give an increasingly role for TEE in monitoring patients in high risk surgeries or in patients with several comorbidities that can compromise the hemodynamic status even in lower risk surgeries. iTEE is a multifaceted technical expertise and demonstration of competence is usually accomplished by successful conclusion of a training program and passing an examination. Restrictive factors to incorporating TEE proficiency into all anesthesia training include limited available equipment and trained operators. Conclusions: iTEE should be used as an auxiliary tool to have more comprehensive understanding of the patient's cardiovascular physiology and manage a most adequate anesthetic approach and surgical intervention. Meanwhile, it is advisable to have large systematic studies supporting its powerful value in both cardiac and noncardiac surgeries. Suitably, it is desirable an international adoption of TEE basic skills within anesthesia practice. Education is the most influential instrument to contribute in shifting the anesthesiology community’s standpoint of TEE use in daily clinical practice.

Full text

Intraoperative Transesophageal Echocardiography: Review and Evolution
Mariana Duque1 and Humberto S Machado1,2*
1Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Portugal
2Serviço de Anestesiologia, Centro Hospitalar do Porto, Portugal
*Corresponding author: Humberto S Machado, Serviço de Anestesiologia, Centro Hospitalar do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal, Tel:
+351-935848475; E-mail: hjs.machado@gmail.com
Received date: May 07, 2016; Accepted date: June 20, 2016; Published date: June 25, 2016
Copyright: © 2016 Duque M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Background: Presently, transesophageal echocardiography (TEE) is routinely used in adult cardiac surgery with
increased frequency as well as in perioperative hemodynamic monitoring during noncardiac surgeries.
Objectives: The aim of this analysis was to understand the evolution of the use of intraoperative TEE (iTEE) both
in cardiac and noncardiac surgeries showing popular and challenging approaches in its use, and as a secondary
goal, to understand the patterns to achieve competency.
Methods: A literature review was carried out identifying relevant clinical studies published in last six years using
the keywords listed below.
Results: The quick acquisition of cardiac anatomy and function data give iTEE an importance in cardiac
procedures that is undeniable, permitting refined diagnosis, detect unsuspected pathology, adjust both anesthetic
and surgical plans and evaluate immediate surgical outcomes. Although, its use is less established in noncardiac
surgery, the latest guidelines give an increasingly role for TEE in monitoring patients in high risk surgeries or in
patients with several comorbidities that can compromise the hemodynamic status even in lower risk surgeries. iTEE
is a multifaceted technical expertise and demonstration of competence is usually accomplished by successful
conclusion of a training program and passing an examination. Restrictive factors to incorporating TEE proficiency
into all anesthesia training include limited available equipment and trained operators.
Conclusions: iTEE should be used as an auxiliary tool to have more comprehensive understanding of the
patient's cardiovascular physiology and manage a most adequate anesthetic approach and surgical intervention.
Meanwhile, it is advisable to have large systematic studies supporting its powerful value in both cardiac and
noncardiac surgeries. Suitably, it is desirable an international adoption of TEE basic skills within anesthesia practice.
Education is the most influential instrument to contribute in shifting the anesthesiology community’s standpoint of
TEE use in daily clinical practice.
Keywords: Transesophageal echocardiography; Intraoperative;
Cardiac surgery; Noncardiac surgery
Introduction
Cardiovascular monitoring during a surgical procedure can be a
challenge for the anesthesiologist, especially if the patient has high
probability of hemodynamic instability.
e introduction of transesophageal echocardiography (TEE) in the
operating room (OR) represents a development of the management of
such patients, even in those who were not at risk, but suered from a
consequence or complication through the procedure. is technique
allows a direct and fast image of the heart and great vessels by using
high frequency ultrasound probes that improved the special resolution
due to the proximity between the transducer and the heart.
Invasive blood pressure monitoring is essential in intraoperative
management, but the accuracy of peripheral readings in comparison to
central measurements has been questioned. e role of this
intraoperative management tool became dicult to dene. It’s now
part of the decision-making process, providing determinant
information; TEE can change the surgical procedure, anesthetic plan,
conrm a suspected diagnosis, assist in positioning of intravascular
devices and may extend far for additional follow-up. Intraprocedural
TEE can be divided in surgical-based procedure and catheter-based
procedure [1-4].
However, its use during non-cardiac surgeries is less established, the
latest guidelines of the American Society of Anesthesiologists (ASA)
and Society of Cardiovascular Anesthesiologists (SCA) agreed that
TEE should be used in noncardiac surgery when patients have known
or suspected cardiovascular pathology that might result in
hemodynamic, pulmonary or neurologic compromise, and if experts
and equipment available in conditions of unexplained life-threatening
circulatory instability persists despite corrective therapy [1,3,5]. Yet,
the use of iTEE in noncardiac surgery won its own role here, since it is
now routinely an assessment tool in monitoring patients in high
instable risk surgeries.
Journal of Anesthesia & Clinical
Research Duque and Machado, J Anesth Clin Res 2016, 7:6
http://dx.doi.org/10.4172/2155-6148.1000634
Review Article JACR, an open access journal
J Anesth Clin Res
ISSN:2155-6148 Open Access Volume 7 • Issue 6 • 1000634

Objectives
e aim of this review is understand the evolution of the use of
intraoperative TEE both in cardiac and noncardiac surgeries and as a
secondary goal to understand the patterns to achieve competency.
Material and Methods
A literature review was carried out identifying relevant clinical
studies published aer 2010 covering a 6-year period from 2010 to
2016. PubMed and Google scholar were used to identify suitable
publication for inclusion. Transesophageal echocardiography,
transesophageal echocardiography in cardiac surgery and
transesophageal echocardiography in noncardiac surgery were the
used keywords.
Results
In 2014, ASA and SCA published the most recent guidelines to
perform a comprehensive TEE examination; the document does not
address basic perioperative TEE, which is a noncomprehensive
examination for intraoperative monitoring and evaluation of
hemodynamic instability. e last mentioned are especially for
intraoperative imaging and do not included some views important to
other applications of TEE. Another guidelines for practice developed
by ASE and SCA in 2010 provide the physician support in determining
the appropriate application of iTEE in order to improve the outcomes
based on the strength of supporting evidence [1,6].
e main indications to use iTEE are recommended for cardiac and
thoracic aortic surgery, catheter-based intracardiac procedures and
noncardiac surgery [6]. ese guidelines combined opinions from
experts, ASA members and literature review; it is clear that literature
in the past 5 years developed in a mode that iTEE is increasingly
expended for several other indications with evidence-based. us, the
authors of this work suggest a new paper addressing updated practice
guidelines.
Discussion
Cardiac surgery
TEE not only is a clinical benecial modality to inuence anesthetic
and surgical decision-making in cardiac surgery but also a cost-
eective one. Canty et al. found that TEE can predict le ventricular
distention, which is common in these surgeries [7]. In addition, the
assessment and management of LV diastolic diameter and area can be
used to diagnose hypovolemia and monitor uid therapy.
Perhaps one of the most valuable contributors of 3-dimension (3D)
TEE in the OR is the assessment of the le ventricle (LV). e accuracy
of LV volumes and function attained by TEE assemble those acquired
by cardiac magnetic resonance image (cMRI). As technology continues
to grow, LV volumes and ejection fraction became easy and quick
values analysed during surgery and early detection of wall motion
abnormalities, helped evaluating patient cardiac function status
intraoperatively [1,8].
Le ventricle (LV) mass is a commonly used predictor of
cardiovascular disease morbidity and mortality. During cardiac
surgery, LV mass can be calculated by multiplying the LV myocardium
volume by its weight through iTEE, permitting diagnose LV pathology,
such hypertrophic cardiomyopathy [8]. is is remarkably useful in
non-elective surgeries where cardiac abnormalities are found. In
addition, the assessment and management of LV diastolic diameter and
area can be used to diagnose hypovolemia and monitor uid therapy.
Evaluation of RV function should be routinely performed since it
has a very useful signicance predicting morbidity and mortality in
cardiac surgical patients, particularly in hypotension [1]. While gold
standards for RV function are cMRI and radionucleotide
ventriculography, TEE seems to be the most feasible tool to its
evaluation in the OR. 3D technology permits complete assessment of
RV volumes, anatomy, geometry and ejection fraction. With this
capability, it is expected that RV imaging and function become part of
a comprehensive TEE examination, emphasizing the inuence of this
evaluation [8,9]. Although, iTEE is not the gold standard for
pulmonary embolism (PE), echocardiographic ndings consistent with
acute PE are RV dysfunction an atypical wall motion abnormalities of
RV free wall [1].
Real time (RT) 3D TEE can accurately assess location, attachment
and size of intracardiac masses as atrial and ventricular septal defects,
simplifying surgical planning [10-12]. Myxomas are the most common
cardiac tumors and may arise in any of the four cardiac chambers,
usually in the le atrium (LA). Observing the relation between LA and
mitral valve (MV) it is possible to predict dysfunction when tumors are
large enough or their location covers MV area [13]. Yamagushi and
Koide reported a case in which a masked mitral regurgitation was only
detected aer tumor resection; nevertheless it permitted support
decision-making for appropriate MV procedure [14]. e authors
reinforced the idea that TEE should be used continually to evaluate the
possible presence of MV dysfunction before and aer tumor resection.
In addition, Dharmalingam and Sahajanandan demonstrated a shiing
in surgical plan in a man with right atrial myxoma, highlighting the
importance of TEE characterizing cardiac masses [15]. TEE performed
intraoperatively gave specic information’s about the attachment and
extent of the myxoma. Among valvular masses, the most known are
infective endocarditis vegetations’, in which TEE is recommended for
surgical cases, rening surgical manage [16,17].
Mitral valve surgery
Surgical repair of the mitral valve is being progressively
implemented to treat severe mitral regurgitation, which is an excellent
treatment option with low-risk and high durability. One of the
strongest indications for iTEE is evaluation MV during repair or
replacement. e MV apparatus, function and the pathological
segments are evaluated under general anesthesia, as well as other risk
factors that can be assessed for surgical repair and correct placement of
the cannulas used for CPB in minimally MV repair surgery [18,19].
When a nonsystemic approach is used to assess mitral valve
morphology, like in perioperative period, there is good agreement
between TEE and surgical ndings [20].
Considering postoperative evaluation of MV repair or replacement,
3D TEE has been shown to simplify visualization of the entire
structure of the new articial valve and its function. Qualitative
imaging of 3D TEE is more suitable to visualize anatomy and locating
pathologies whereas quantitative analysis of 2-dimension (2D) TEE is
more accurate for measurements and quantifying severity. In addition,
color Doppler 3D TEE can show the right location of paravalvular MR,
helpful for transcatheter closure of leaks with immediate surgical
correction. It is necessary to exclude mitral stenosis, and assess
ventricular function [8,9,18,19,21-25]. Even some echocardiographic
Citation: Duque M, Machado HS (2016) Intraoperative Transesophageal Echocardiography: Review and Evolution. J Anesth Clin Res 7: 634.
doi:10.4172/2155-6148.1000634
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ISSN:2155-6148 Open Access Volume 7 • Issue 6 • 1000634

variables are recently identied as independent risk predictors of
procedural failure [26].
As new minimally invasive and even o-pump techniques for MV
repair/replacement become well known, the role of TEE turns out to be
essential for monitoring these less invasive approaches since simplies
the surgery, improves outcomes and is highly rewarding [18].
Aortic valve surgery
For several years, TEE is used to see immediate results and, if
necessary, for reintervention to improve the adequacy of prosthetic
valve in percutaneous valve implantation [27]. Besides that, iTEE is
routinely performed aer cardiopulmonary bypass (CPB) to evaluate
the adequacy of aortic valve (AoV) repair in adult population. AoV
repair is an alternative approach to valve replacement with the
advantages of eliminating the need of long-term anticoagulation and
prosthetic-related complications such thromboembolic events and
endocarditis. However, during aortic valve replacement, TEE allows
sizing the annulus and conrming satisfactory function aer
implantation.
A pre-repair TEE usually focuses on anatomy and function of the
AoV, planning the viability of the AoV procedure. An immediate post-
repair evaluation provides important information about the quality of
the surgical repair (coaptation’s level relative to the annulus and length
of cusp coaptation) and mechanisms of any residual aortic
insuciency (AI). In some cases, the amendment of contributing
lesions should be done concurrently to guarantee a suitable result. If
the repair is considered inadequate, an echographic image of the valve
is absolutely critical and will guide the surgeon to correct the causes of
residual AI during re-evaluation, or if the repair is no longer
reasonable, and the decision to replace the valve may be made [28-30].
Coronary surgery
e utility of TEE in revascularization surgery should be considered
to rene preoperative diagnosis, detect new unsuspected pathology,
manage both anaesthetic and surgical plans appropriately and evaluate
surgical results [6]. Evidences show that iTEE is the most sensitive
method in the diagnosis of myocardial ischemia, detecting segmental
wall abnormalities less than a minute aer inadequate myocardial
perfusion, preventing an unsuccessful revascularization. In addition, it
can also detect incidental cardiac conditions that may require surgical
intervention. e detection of these alterations modies the
therapeutic conduct [31,32].
In patients undergoing coronary artery bypass graing,
atherosclerotic disease can lead to perioperative complications. Several
studies showed that the severity of the atheroma found in iTEE is
strongly related to stroke and other negative outcomes aer coronary
artery surgery [33]. Nowadays, literature is more oriented in
preoperative evaluation of patients, so their risk factors can be
promptly added to surgical and anaesthetic planning.
Even in something as rare as coronary aneurisms, TEE could detect
intraoperatively dilations of these vessels and equally helped to
approach complications during these techniques [34,35].
Aortic surgery
iTEE should be used routinely in thoracic aortic surgery [6].
Currently, TEE is considered the rst-line exam in the diagnosis of
thoracic aortic dissection (AD) in hemodynamic instable patients; true
and false lumens can be dicult to distinguish and so the presence of
blood ow in true lumen and slow or absence of ow in false lumen
can be perceived through TEE colour Doppler. It has proven
specically valuable for choosing the landing site for the proximal stent
by clarifying areas of atheroma and calcication that would otherwise
not be perceived by angiography and could interfere with stent
adhesion. iTEE is highly useful during endovascular treatment in
complicated descending AD. It allows identify true and false lumens by
guide wiring entrance, false lumen thrombosis and anterograde and
retrograde ows, evaluate correct stent-gra positioning, possible leaks
and small re-entry tears, all critical evidence with prognostic
implications [6,28,36-38]. Orihashi et al. in a recent case report showed
that TEE besides being useful in stent guidance during open stent gra
procedure, it also was a valuable tool for diagnosing a stent migration
occurred intraoperatively [39]. It looks intuitive to think of TEE as an
accurate check-up tool in operative period.
Although recent guidelines recommend TEE for any aortic surgery
involving the ascending, arch, or proximal descending aorta, it has not
been used universally. Little is known about the impact of TEE in the
management of AD. In literature, some studies have been performed
that showed its role even in abdominal aorta. In abdominal aneurysm
surgery, acute AD is an atypical and fatal complication that can
develop during open repair of an abdominal aortic aneurysm.
Kainuma et al. reported a case describing the usefulness of TEE for the
diagnosis and operative decision-making during the management of
an acute AD [40]. TEE revealed the existence and extension of the
dissection, presence of AR and absence of myocardium and coronary
involvement as well as pericardial eusion. orsgard et al., in a
retrospective study showed that TEE data led to a change in planned
surgery in 39% of the patients in acute type-A AD. According to the
previous literature, this number is a little higher (6-30%) but it is
specic for this surgery and it can be as high as in other emergent
surgery procedures, entirely distinctive of the complete data that is
required in an elective surgery patient [41].
Pediatric and congenital heart disease surgery
As in adult population, iTEE in infants who undergo cardiac
surgery is a valuable tool that conrms diagnosis by other imaging
devices and can identify additional pathological disorders. Before
surgical correction, TEE conrms diagnosis and aer surgical repair
assesses correct x and detects remaining lesions. A recent study
showed that in almost 6,5% of the patients undergoing surgery for
congenital heart disease (CHD), iTEE changed surgical plan and
allowed immediately repair of surgical abnormalities [42,43].
TEE is used in several dierent surgical procedures in CHD such
atrial septal defect (ASD), ventricular septal defect (VSD), valve
replacement, atrioventricular canal, combined ASD and VSD or
combined VSD and pulmonary stenosis, valve reconstruction,
subaortic stenosis resection, reoperation and neo-natal surgery, Fontan
procedure, Tetralogy of Fallot (TF), Ebstein anomaly and even in
extracardiac procedures [42].
In pediatric population, TEE has adverse eects too. Compression
of the airway leading to desaturation and hemodynamic instability are
the most common side eects in younger patients and trauma during
insertion and extubation, especially in neonates. Technological
advances permitted the accessibility of pediatric probes in surgeries for
CHD in children. e use of these probes is limited in small infants
weighing less than 5 kg, but a weight-based algorithm can help
determine neonates at risk for iTEE probe insertion failure. It has been
Citation: Duque M, Machado HS (2016) Intraoperative Transesophageal Echocardiography: Review and Evolution. J Anesth Clin Res 7: 634.
doi:10.4172/2155-6148.1000634
Page 3 of 7
J Anesth Clin Res
ISSN:2155-6148 Open Access Volume 7 • Issue 6 • 1000634

suggested that smaller TEE probes might benet this patient
population, once some heart diseases need intervention right aer
birth. Small probes with 5mm could be used in neonates with less than
2.5 kg [42,44]. Zyblewski et al. established that the use of new
multiplane micro-TEE provided high quality, useful diagnostic images
without hemodynamic or ventilation compromise in small infants
undergoing cardiac operations [45]. e innovation is especially
important with the growing trend towards complete repair of complex
structural heart disease in toddlers [44].
In a high-risk surgery as TF correction, iTEE revolutionized cardiac
evaluation during the procedure, assessing primary anomalies,
immediate surgical revision, residual defects and hemodynamic
monitoring. TEE improved clinical outcomes in these patients [46].
Although well described in adult population, TEE predictors of
aortic regurgitation (AR) aer AoV surgery may not be appropriate in
pediatric population, given the disparities in underlying diseases. Stern
et al. studied which intraoperative post-CPB TEE variables could
predict higher risk of early reoperation for recurrent AR in children
with congenital aortic valve disease [29]. ey found that higher risk
was present with coaptation asymmetry, measured through the
dierence in percentage between short-axis coaptation lengths. is
parameter is a simple calculation in standard TEE view, strengthening
the value of TEE in decision-making process. e information could
lead to a return to bypass to improve coaptation symmetry and so
preventing reintervention in these children. Still, since this was a small
group study, a larger sample size studies could corroborate these nds.
In congenital mitral valve disease, Song et al. demonstrated the
utility of iTEE in MV replacement, which diagnosed an incorrectly
placed prosthetic valve permitting proper implantation aer
reinitiating CPB [47].
Transesophageal echocardiography plays also a crucial role in
performing minimally invasive surgical closure of cardiac defects,
showing more accuracy about real dimension of the defect than
transthoracic echocardiography [48].
Non cardiac surgery
e questions faced in the OR during a noncardiac surgery are
rather distinctive. TEE can be an important tool for patients with
signicant comorbidities or if hemodynamic instability is anticipated
or occurs intraoperatively [49].
Hemodynamic instability and quick changes in volume are serious
complications. e impact of direct visualization of cardiac structures
has the potential to provide quickly important information on
cardiovascular function relevant to hemodynamic management. In
complex noncardiac procedures such has liver transplantation, due to
surgical manipulation or blood loss, the probability of hemodynamic
instability is high and so iTEE can add important information to
patients managing.
Moreover, hypotension and arrhythmias are frequently associated
with hemodynamic instability. e rst one can be due to cardiac
failure, hypovolemia or reduced peripheral resistance (RPR). Even in
acute blood loss, RPR can be existent along with signs of hypovolemia.
Consequently, evaluations of cardiac output and cardiac preload are
important factors in intraoperative examining. Many of these variables
demonstrate good correlation when compared with more invasive
techniques, even in the case of detecting acute hemodynamic changes;
TEE is superior to pulmonary artery catheter [37].
To show an original and astute use of this device in noncardiac
surgery, in 2014 it was described a rare case report of which an external
masse (transplanted liver) caused a cardiac compression resulting in
several episodes of supraventricular tachycardia immediately aer the
transplant. is symptomatic myocardial compression by the liver was
guided and conrmed via RT-TEE imaging with a successful
resolution [50]. Even in obstetric surgery, Cho et al. reported a rare
case of abrupt hemodynamic instability in a woman during a vaginal
hysterectomy, iTEE was performed and a right atrium thrombus was
identied [51].
In the case of neurosurgery, the sitting position (SP) has been an
important approach to improve surgical eld, however the risks are not
negligible. While TEE is the most sensitive modality for detecting air
in the right atrium, sitting position is relatively safe without TEE and
TEE does not change outcomes. Additionally TEE is cumbersome
given where the patient and surgeon are positioned [1,52].
Liver transplantation
Patients undergoing orthotopic liver transplantation (LT) may
present cardiac dysfunction from cirrhotic cardiomyopathy or pre-
existing coronary artery disease. In addition, patients are at risk of
hemodynamic instability due to several causes, blood loss, obstructed
inferior vena cava ow, increased workload, embolization, and
reduced systemic vascular resistance. ese circumstances can be
assessed by TEE and make a dierence in patient’s outcome, creating
an opportunity to identify early and prevent future complications [49].
Concerns about these conditions may refrain anesthesiologists from
practice intraoperative TEE. Nevertheless, in patients with pulmonary
hypertension, RV dysfunction can be a complication during surgery
and it is recommended to perform a basic iTEE, allowing quick
determination of cardiac status and therapeutic attitudes [1]. Recent
guidelines listed esophageal varicose veins, coagulopathy,
thrombocytopenia and recent upper gastrointestinal bleeding as
contraindications to use TEE, however literature considered that it is
relatively safe despite the risk of varicose veins haemorrhage [53]. A
recent retrospective study about iTEE in orthotopic LT showed that it
was relatively safe procedure in patients with documented
esophagogastric varicose veins and coagulopathy, with a low incidence
of major hemorrhagic complications (0,43%) [54]. e grade of the
varicose veins seems to be related to the probability of bleeding,
although grade IV is an absolute contraindication, in grades I and II
TEE has been performed safely [55,56]. In addition, a contemporary
retrospective study in University of California, population of 433
patients with model for end-stage liver disease (MELD) score 25 or
higher demonstrated that iTEE was not associated with major
gastroesophageal and hemorrhagic complications during LT [57].
Nevertheless, there are some methods that decrease the risk of
varicose veins rupture during iTEE in liver transplantation, such as
experienced operators with strict vigilance, gastroenterology
consultant and correction of coagulopathy before the TEE procedure
[1,6,58].
Considering the great dimension of this surgery, hemodynamic
patterns are very important to monitor, and TEE has shown accuracy
to determine essential changes, such stroke and end diastolic volumes,
wall abnormalities, air embolism, shunts, eusions and valvular
pathologies. Inuence of TEE on uid therapy during liver
transplantation is also well documented in literature, up to 50% in
some series [59]. Although transgastric views are limited, the short axis
Citation: Duque M, Machado HS (2016) Intraoperative Transesophageal Echocardiography: Review and Evolution. J Anesth Clin Res 7: 634.
doi:10.4172/2155-6148.1000634
Page 4 of 7
J Anesth Clin Res
ISSN:2155-6148 Open Access Volume 7 • Issue 6 • 1000634

view gives a better assess to the circumference of the le ventricle by
overpassing posterior retraction of the stomach [60].
e less invasive option to monitor cardiac output is arterial pulse
waves analysis but this measurement cannot be reliable during liver
transplantation. With the currently technology available, TEE has been
the most direct measurement of cardiac lling, oering the benet of
identifying also a variety of other diagnosis that can alter surgical
procedure and change the patient’s outcome [61].
Training and competencies
Echocardiography is a multifaceted technical expertise and the
restrictive factor is the availability of trained operators and equipment.
Dobbs et al. conducted a large international web survey to better
understand global practice of iTEE in adult cardiac surgery. e results
corroborate that the main barriers to the use of iTEE in 27 countries
were the lack of resources (equipment and personnel) [62]. However,
TEE is being used more oen and by more qualied personnel than in
previous studies. ese results are a call to order to establish basic TEE
training programs among novices anesthesiologists as well as among
non-skilled seniors, permitting a new generation of physicians who
dominate this technique and know how to take advantage in clinical
practice of its potential.
Demonstration of competence in iTEE is usually accomplished by
successful conclusion of a training program and passing an
examination [36].
It is recommended to follow current existing accreditation pathway
if one requests to acquire TEE competence. In cardiac surgery,
advanced level of echocardiography is required, full diagnostic skills
with Doppler modes domain and 3D imaging. Yet, it is possible to a
trainee who spends a year in cardiac anesthesia training programme
develop required skills to perform a full TEE examination if the
equipment can be made accessible. Basic perioperative TE training is
mostly dedicated on intraoperative monitoring, whereas advanced
training aims on specic diagnoses [63,64].
e European Society of Echocardiography together with the
European Association of Cardiac Anaesthesiologists oers a
certication in TEE through a two-component evaluation, a multiple-
choice examination and the submission of a logbook of 125 PTE exams
performed personally in 1-year period. From these studies 15 cases are
selected randomly and posterior graded by external examiners. e
maintenance of certication requires at least 50 TEEs per year (25 to
basic certication) and continuing medical education.
e demands for advanced or director level are not specied in
these consensus, but in the ASA and SCA guidelines for training in
perioperative echocardiography require 150 and 300 performed TEEs,
in advance and director levels, respectively [1,6,64].
New technology allowed the conception of echocardiographic
simulators; several studies have been shown an important role in
future training of echocardiography skills without routine access to
patient environment, demonstrating superior learner outcomes. ese
platforms are especially important to TEE-naïve since improves
expertise, speed learning and comfort with TEE [65-69].
Conclusions
Transesophageal echocardiography information can be very
valuable in intraoperative period providing or restoring hemodynamic
stability. It should be used as an auxiliary tool to have more
comprehensive understanding of the patient's cardiovascular
physiology and manage a most adequate surgical intervention. With
low risk depending together of experienced skilled operator and
patient’s anatomy and comorbidities, it is an important perioperative
tool that can changes patient’s outcome.
Systematic large sets studies are recommendable for access its role in
noncardiac surgery, especially since it has been promising in
monitoring patients in liver transplantation. Accordingly, it is desirable
the adoption of transesophageal echocardiography basic skills within
anesthesia practice worldwide.
e crucial worth of iTEE is how the information obtained is
interpreted and used to alter the patient management. e risks and
benets should always be considered. Anesthesia and surgical teams
should operate together in order to promptly analyze the evidence and
act in accordance with the best interest of the patient.
Once expert and skilled, the anesthesiologist increases his position
in perioperative medicine, contributing with vital clinical evidence for
anesthetic-surgical procedure.
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ISSN:2155-6148 Open Access Volume 7 • Issue 6 • 1000634