Perioperative Transesophageal Echocardiography Research Articles

A female patient with cerebral ischemia after percutaneous kyphoplasty due to a paradoxical embolism via a persistent foramen ovale (PFO) - is a perioperative transesophageal echocardiography (TOE) helpful in the context of cardiac risk stratification?

Lehner, C.; Dieterich, F.; Matthes, T.; Reisig, F.; Knebel, J.; Büttner, J. Author Information

Simulation based teaching curriculum for perioperative transesophageal echocardiography for anesthesia residents: plotting a learning curve

Beth Israel Deaconess Medical Center, Department of Anaesthesiology and Pain Medicine, Boston, United States

Transcatheter Aortic Valve Replacement—Part 3: The Central Role of Perioperative Transesophageal Echocardiography

Transcatheter Aortic Valve Replacement—Part 3: The Central Role of Perioperative Transesophageal Echocardiography

Perioperative transoesophageal echocardiography: past, present & future

Perioperative transoesophageal echocardiography: past, present & future

Routine Peri-Operative Transoesophageal Echocardiography in Paediatric Cardiac Surgical Procedures

Introduction: Perioperative transoesophageal echocardiography (TOE) is recognised as a valuable diagnostic investigation for paediatric cardiac surgery, but is not performed on all cases in most centres. This study investigates the value of performing perioperative TOE for all procedures. Methods: All patients undergoing cardiac surgery between September 2011 and February 2012 had pre- and post-operative TOE studies. Demographic data, preoperative investigations, diagnosis and surgical procedure were documented prospectively. The influence of new diagnostic information determined by the pre-operative TOE on surgical procedure and the impact of post-operative TOE on subsequent surgical management was assessed. Results: Eighty-eight patients with median age 1.0 year (range; 4 days to 17.6 years) and weight 9.3 kg (range; 2.7–80 kg) were studied, with no TOE related complications. Twenty-five (28.4%) patients had cardiac catheters and four (4.5%) patients had cardiac magnetic resonance imaging as part of preoperative assessment. TOE was not possible in two (2.2%) cases. The preoperative TOE defined new information in six (7.0%) patients – new lesions identified in two; more detailed anatomic information which influenced surgical strategy in four. Post-operative TOE defined anatomical issues in five (5.8%) cases which resulted in further surgical intervention in four and a decision not to perform further surgery in one. The postoperative TOE findings did not differ from discharge assessments. Conclusions: This study demonstrates that perioperative TOE is an important adjunct for guiding surgical management. Performing TOE for every procedure is labour intensive, but the incidence of important findings which influenced management in this study, may support this strategy.

Left Ventricular Outflow Tract to Left Atrial Fistula After Aortic Valve Replacement

a posterior root enlargement to avoid patient prosthesis mismatch. The perioperative transesophageal echocardiography (TEE) showed only trace aortic regurgitation (AR) with no other abnormal findings. While the patient had been doing well during the postoperative period, he described palpitation episodes for 10 days. He had no fever or other constitutional symptoms. His examination revealed a normal prosthetic valve sound, 2/6° apical systolic murmur, and his other systemic findings were un-

小児用マルチプレーンプローベを用いた周術期経食道心エコー:乳幼児における先天性心疾患手術にもたらす影響

背景:周術期経食道心エコー(TEE)は体格の問題から乳幼児での使用や効果に制限があった. 目的:小児用マルチプレーンプローベ(PMP)を用いた周術期TEEの有用性について調査検討すること. 対象と方法:2007年以降に周術期TEEを試みた412例を使用プローベによりA群(PMP), B群(小児用バイプレーン), C群(成人用MP), D群(挿入不能)の4群に分類した. 年齢分布, 基礎心疾患, 手技追加の有無, 術後経過, 挿入不能理由とその影響について調査した. 結果:A群は0～4歳が86％(乳児33％), B群は5～9歳が57％, C群は15歳以上が70％, D群は乳児が83％であった. 手術手技追加はA群16例, C群6例で, B群に該当例はなかった. 単純心奇形はA群で35％, B群で94％, C群で48％であった. A群の手術手技追加は右室流出路再建7件, 房室弁再形成6件, 残存短絡閉鎖3件, 上大静脈狭窄解除1件であった. D群は心臓外疾患, 低体重が多く, 1例で術後15日で再手術を必要とした. 結語:複雑心奇形が多い乳幼児期の開心術においてPMPを用いたTEEの効用は大きく, 予後改善につながると考えられる.

Monitoring the Variation in Myocardial Function With the Doppler-Derived Myocardial Performance Index During Aortic Cross-Clamping

To investigate the effects of acute elevation in afterload on global (systolic and diastolic) myocardial function by performing serial intraoperative transesophageal echocardiograms during and after cross-clamp application on patients undergoing elective abdominal aortic aneurysm (AAA) surgery. A prospective observational study. A tertiary care university hospital. Patients undergoing elective AAA repair under general anesthesia (GA). The use of perioperative transesophageal echocardiography to calculate a tissue Doppler-derived myocardial performance index (MPI) during different stages of the surgery. Twenty consecutive patients scheduled for suprarenal AAA repair under GA were included in the study. Perioperative transesophageal echocardiography was performed after the induction of GA. MPI was calculated with Doppler tissue imaging as the sum of isovolumetric contraction and relaxation times divided by the ejection time before cross-clamping of the aorta and then 2, 10, and 20 minutes after cross-clamp application. A final MPI was measured after unclamping of the aorta. As compared with baseline, cross-clamp application initially worsened MPI within 2 minutes and then MPI improved to baseline after 10 minutes of cross-clamp application. The MPI improved significantly after unclamping of the aorta. The authors observed a temporal variation in global myocardial function after the application of a cross-clamp in the suprarenal position. There was transient deterioration of global myocardial function (the prolongation of MPI) 2 minutes after cross-clamp application, which improved within 10 minutes. Myocardial function returned to baseline after unclamping the aorta.

Perioperative Transoesophageal Echocardiography

New technologies are being introduced every day in the perioperative setting and perioperative practitioners will need to become increasingly familiar with transoesophageal echocardiography (TOE). TOE is used as a diagnostic tool during cardiac surgery in the operating theatre to direct the surgical procedure and to detect acute complications. TOE is also used to monitor cardiac function in patients undergoing non-cardiac surgery and in the intensive care unit (ICU) (Figure 1). The use of TOE is increasing in the cardiac catheterisation laboratory for percutaneous transcatheter procedures such as patent foramen ovale (PFO) closure, atrial septal defect (ASD) closure, aortic and mitral valvuloplasty, aortic valve implantation and mitral valve repair. Since the oesophagus is located directly behind the heart, TOE provides better image quality than transthoracic imaging for the assessment of posterior cardiac structures such as the mitral valve, left atrium and pulmonary veins.

Comprehensive Textbook of Perioperative Transesophageal Echocardiography, Second Edition.

Edited by Robert M. Savage, M.D., F.A.C.C., Solomon Aronson, M.D., F.A.C.C., F.C.C.P., F.A.H.A., F.A.S.E., and Stanton K. Shernan, M.D. Philadelphia, Lippincott Williams & Wilkins, 2011. Pages: 770. Price: $229.00.As the foreword indicates, the breadth of the second edition of Comprehensive Textbook of Perioperative Transesophageal Echocardiography is expansive, aptly mirroring the growth of echocardiography in perioperative medicine. For those of us striving to improve our echocardiography skills and improve patient care, this book will serve as a must-read, must-have reference. To reduce the burden of lugging around a heavy textbook, purchasers of each book gain access to an online version accessible from anywhere! The book covers everything a reader could want in an organized, well-thought-out manner. Filled with vibrant color illustrations and an extensive topic list, the text has a wonderful flow.Section 1 details the basics of perioperative echocardiography, starting with physics. This often-maligned topic is covered in detail, yet remains easy to read. Comprehensive illustrations help the reader along as the complex physics of echosonography are unwoven. Although the illustrations in this chapter are slightly busy, they appropriately convey the information needed. The text builds nicely on this basic knowledge by correlating the physical principles of ultrasound with real-life image pitfalls and artifacts in chapter 2 and image optimization in chapter 3. A section called Key Points at the end of each chapter succinctly summarizes important concepts. The book transitions smoothly from “machine” to “man” as the subsequent chapters of section 1 outline the anatomy of the heart, transesophageal echocardiography indications, and both the comprehensive and abbreviated transesophageal echocardiography examination before delving deeper into each area of the heart.Section 2 discusses the use of transesophageal echocardiography and transthoracic echocardiography in the critical care setting. Detailed evaluation of the patient with endocarditis and the use of rescue echocardiography in the intensive care unit are added to this edition as new chapters.Advanced applications of echocardiography are examined in section 3. From a new chapter on epiaortic imaging to chapters on congenital heart disease, as well as surgical considerations in valve and heart failure surgery, this section builds heavily on the basics. The level of detail and precision shines through as each chapter offers a wealth of information, clinical data, and images to support the echocardiographer through tough clinical scenarios. New chapters on strain echocardiography and three-dimensional echocardiography complete this section. It is a must-read for those working toward advanced certification in transesophageal echocardiography.With a text version, online version, 3 sections, 39 chapters, more than 60 contributing authors, 770 pages, and thousands of referenced articles, this text truly lives up to its name. It is comprehensive in every sense of the word. Yet, despite such a vast number of contributors and broad scope, it reads in a singular, focused manner. Topic after topic, it builds on the basics before advancing to an expanse of clinical application. I expect its readership will range from beginner to expert. For beginners, it is simple and easy to follow. For those already skilled, it is detailed and comprehensive. It is clearly informative for those seeking transesophageal echocardiography certification and those certified long ago. In short, it is well worth the asking price.*University of Chicago, Pritzker School of Medicine, Chicago, Illinois. jmarymont@northshore.org

Comprehensive Textbook of Perioperative Transesophageal Echocardiography, 2nd ed

Comprehensive Textbook of Perioperative Transesophageal Echocardiography, 2nd ed

Book Review: Comprehensive Textbook of Perioperative Transesophageal Echocardiography.

Book Review: Comprehensive Textbook of Perioperative Transesophageal Echocardiography.

Echo Didactics

Echo Didactics

Acute normovolemic hemodilution during CABG induces diastolic dysfunction: A perioperative transesophageal echocardiography study

Acute normovolemic hemodilution during CABG induces diastolic dysfunction: A perioperative transesophageal echocardiography study

Scholarly Productivity of United States Academic Cardiothoracic Anesthesiologists: Influence of Fellowship Accreditation and Transesophageal Echocardiographic Credentials on h-Index and Other Citation Bibliometrics

The h-index allows the evaluation of scholarly output in academics, but this bibliometric statistic has not been applied extensively to measure productivity in anesthesiology. The authors tested the hypothesis that the h-index is dependent on academic rank, American College of Graduate Medical Education (ACGME) accreditation of the training program, and National Board of Echocardiography credentials in perioperative transesophageal echocardiography (TEE) in United States academic cardiothoracic anesthesiologists. Observational. Internet analysis. United States academic cardiothoracic anesthesiologists. None. Faculty members from 30 randomly selected fellowship programs with or without accreditation were identified using the Society of Cardiovascular Anesthesiologists web site. The status of each faculty member's credentials in perioperative TEE was defined using the "verify certification" function on the National Board of Echocardiography web site. Publications, citations, citations/publication, and the h-index for each faculty member were obtained using Scopus. Two hundred fifty-nine cardiothoracic anesthesiologists (204 men and 55 women) were identified (8 instructors [3%], 123 assistant professors [48%], 56 associate professors [22%], 63 professors [24%], and 9 chairpersons [3%]). The average cardiothoracic anesthesiologist had an h-index of 6 ± 7 with 28 ± 46 publications, 499 ± 988 total citations, and 13 ± 18 citations per publication. The h-index increased significantly (p < 0.05) among ranks (instructors [1 ± 1], assistant professors [3 ± 3], associate professors [7 ± 5], professors [12 ± 8], and chairpersons [18 ± 13]). Significant differences in the number of publications and total citations also were observed among ranks. Differences in the h-index among ranks were observed regardless of program accreditation status or transesophageal echocardiographic credentials. Faculty members working in American College of Graduate Medical Education-accredited programs had more publications and citations and higher h-indices than their counterparts in programs that were not accredited. Except for program directors, the scholarly output of academic cardiothoracic anesthesiologists with or without transesophageal echocardiographic credentials was similar within each academic rank. The results show that the h-index increases progressively with academic rank and is dependent on fellowship program accreditation status but not transesophageal echocardiographic credentials in United States academic cardiothoracic anesthesiologists.

Comprehensive Textbook of Peri-operative Transesophageal Echocardiography (2nd edn)

Comprehensive Textbook of Peri-operative Transesophageal Echocardiography (2nd edn)

Diagnosing and understanding the mechanisms behind orthodeoxia syndrome

Orthodeoxia is a rare clinical syndrome characterized by deoxygenation in the upright position and relieved by recumbency. Our rounds illustrate how cardiovascular imaging and echocardiography can be used to diagnose the etiology of this syndrome with respect to its association with patent foramen ovale (PFO) and ascending aortic aneurysms. The rounds also demonstrate the use of peri-operative transesophageal echocardiography (TEE) in understanding the mechanisms contributing to the condition and aid in appropriately planning medical and surgical management.

Utility of Transesophageal Echocardiography During Severe Hypotension in Non-cardiac Surgery

Severe and refractory hypotension is an infrequent perioperative situation during non-cardiac surgery, but determining its etiology is essential for successful management and therapy. Adults undergoing non-cardiac surgery were prospectively enrolled in this study. Severe hypotension was defined as a drop from 30% of baseline systolic arterial pressure unresponsive to adequate fluids administration and to ephedrine, according to the anasthesiologist criteria. A multiplanar transesophageal echocardiography (TEE) probe was inserted, prior to any other invasive hemodynamic monitor. Forty two adults (68 ± 12 years) were studied, 84% during elective non-cardiac surgery. Abdominal (open and laparoscopic), thoracic and orthopaedic surgeries were performed most frequently. In all patients, TEE was useful for determining the etiology of severe hypotension. Hypovolemia was diagnosed in 18 patients (42%). Low ejection fraction (EF < 30%) was detected in 5 cases and was successfully treated with vasoactive drugs. Dynamic left ventricular outflow tract obstruction, associated with systolic anterior motion of the mitral valve, was diagnosed in 5 patients; in another 6 patients severe embolism was detected during hip and knee surgery. Myocardial ischemia causing persistent hypotension was detected in 5 patients; in 3 patients, cardiac tamponade was the etiology of severe hypotension. Two patients died; both had severe myocardial ischemia. Perioperative TEE was performed quickly, proving to be a useful technique in the context of hypotension during non-cardiac surgery. The heart and great vessels could be observed directly and functionally evaluated. Thus, the etiology of severe hypotension could be easily determined and managed.

Recommendations for transoesophageal echocardiography: update 2010

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations represent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing applications such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.

Case 4—2010Successful Use of Transesophageal Echocardiography After Esophagogastrectomy

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) commonly is used in the intraoperative management of patients undergoing cardiac surgery. Despite the increasing evidence that it generates new clinical findings in up to 40% of cases 1 Thys D.M. Echocardiography and anesthesiology successes and challenges. Anesthesiology. 2001; 95: 1313-1314 Crossref PubMed Scopus (17) Google Scholar , 2 Jneid H. Bolli R. Inotrope use at separation from cardiopulmonary bypass and the role of prebypass TEE. J Cardiothorac Vasc Anesth. 2004; 18: 401-403 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar and that surgical management is thereby altered in up to 25% of patients undergoing cardiac surgery, 3 Minhaj M. Patel K. Muzic D. et al. The effect of routine intraoperative transesophageal echocardiography on surgical management. J Cardiothorac Vasc Anesth. 2007; 21: 800-804 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar , 4 Eltzschig H.K. Rosenberger P. Loffler M. et al. Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery. Ann Thorac Surg. 2008; 85: 845-852 Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar its routine use in all cardiac surgical patients is not universal in the United States. 5 Morewood G.H. Gallagher M.E. Gaughan J.P. et al. Current practice patterns for adult perioperative transesophageal echocardiography in the United States. Anesthesiology. 2001; 95: 1507-1512 Crossref PubMed Scopus (32) Google Scholar Like most interventions, TEE is not risk free, and a variety of complications associated with its use have been reported, including esophageal mucosal tears and perforations, compression of airways and major vascular structures, 6 Kallmeyer I.J. Collard C.D. Fox J.A. et al. The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients. Anesth Analg. 2001; 92: 1126-1130 Crossref PubMed Scopus (364) Google Scholar cardiac arrhythmias, 7 Casta A. Brown D.W. Yuki K. Induction of supraventricular tachycardia during transesophageal echocardiography: An unusual complication. J Cardiothorac Vasc Anesth. 2008; 22: 592-593 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and injuries to other abdominal viscera. 8 Chow M.S. Taylor M.A. Hanson 3rd, C.W. Splenic laceration associated with transesophageal echocardiography. J Cardiothorac Vasc Anesth. 1998; 12: 314-316 Abstract Full Text PDF PubMed Scopus (21) Google Scholar Of these, esophageal injury has been the predominant type of complication noted in large observational studies of adverse sequelae of intraoperative TEE, 6 Kallmeyer I.J. Collard C.D. Fox J.A. et al. The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients. Anesth Analg. 2001; 92: 1126-1130 Crossref PubMed Scopus (364) Google Scholar , 9 Huang C.H. Lu C.W. Lin T.Y. et al. Complications of intraoperative transesophageal echocardiography in adult cardiac surgical patients—Experience of two institutions in Taiwan. J Formos Med Assoc. 2007; 106: 92-95 Abstract Full Text PDF PubMed Scopus (27) Google Scholar and, therefore, pre-existing esophageal pathology commonly is cited as a contraindication to its use. There are reports of successful use of TEE in other forms of esophageal pathology, such as Zenker diverticulum, 10 Ramjohn J. Paulus D.A. Use of transesophageal echocardiography in a patient with Zenker's diverticulum. J Cardiothorac Vasc Anesth. 2006; 20: 385-386 Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar but to date there are no reports of its use in patients with a previous esophagogastrectomy, and, therefore, the risks of injury to the reconstructed esophagus and the quality of imaging obtainable are unknown. Two patients with previous esophageal resection in whom high-quality intraoperative TEE images were obtained and who did not sustain any clinically evident injury to their reconstructed esophagus as a result are presented.