Advanced (Comprehensive) TEE
Kathryn E Glas, MD, FASE, MBA
In 1999, Shanewise et al (1) published the landmark article on comprehensive
transesophageal echocardiography (TEE) examinations. That article became the
reference of choice for anyone in Anesthesiology learning TEE. The American
Society of Echocardiography (ASE) and the Society of Cardiovascular
Anesthesiologists (SCA) wrote this article together. In 2012, members of both
societies were once again brought together to update the guidelines. They were
once again co-published in each societies journal. The January 2014 reference is
listed below. (2)
The original article identified 20 TEE views intended to provide consistency in
image acquisition, reporting and quality assurance. Over the past 14 years, the use
of TEE for procedural and diagnostic indications has grown dramatically. The
original views were based on operative diagnostic examinations. Since then, TEE is
now used in a number of additional settings, and additional views have been
identified as in common use for specific diagnoses or interventions. The writing
group is intended to be a guide for both diagnostic examinations (for example,
evaluate for atrial thrombus or aortic dissection) and intraprocedural examinations
(surgical and catheter based).
The guideline document reviews the recommendations for training and certification
in both TEE and transthoracic echocardiography (TTE). This includes a listing of the
cognitive skills required for competence. The general indications for TEE are listed
as well. These include use of TEE in circumstances where TTE is non-diagnostic,
intraoperative and transcatheter procedures and critically ill patients in whom TTE
cannot provide the needed information and there is an expectation that the exam
will alter management. One common example of this is the unstable post-operative
cardiac surgery patient. Positive pressure ventilation and dressings frequently
prevent adequate TTE windows and TTE cannot always identify localized effusions
in this setting.
Since 1999, appropriate use has become an important aspect of many procedural
recommendations. In 2011, numerous societies developed appropriate use criteria
for many cardiac diagnostic procedures (3). The TEE criteria are listed in the
guideline document. TEE for cardiac surgical procedures meets the appropriate use
criteria. TEE for assessment of non-cardiac surgical patients with unexplained
hemodynamic instability or significant cardiac pathology as a monitoring tool is also
included as appropriate use.
The absolute and relative contraindications for TEE have changed over the years. In
particular, esophageal varices are now considered a relative contraindication based
on safe and successful use of TEE for monitoring of critically ill patients during liver
transplantation. A history of radiation to the neck and mediastinum warrants
consideration of the risk/benefit for the procedure given the increased risk of
esophageal injuries in this population. The absolute contraindications are:
perforated viscus, esophageal stricture, tumor, perforation or diverticulum or active
upper GI bleed. Table 7 lists the reported complications and incidence for TEE
based on large series published in cardiology and anesthesiology literature. Note in
particular reference 26- safety of TEE, published in JASE in 2010. (4)
The new guidelines include 8 additional views: mid-esophageal (ME) Five-chamber,
ME right Pulmonary vein, ME modified bicaval, ME Left atrial appendage (LAA),
upper esophageal (UE) pulmonary veins, transgastric (TG) right ventricle (RV) basal
and RV inflow-outflow and RV inflow. See below:
Many clinicians were already acquiring these views on a regular basis for numerous
indications. The ME 5 chamber could also be called an anterior 4 chamber in that
slight withdrawal of the probe brings the left ventricular outflow tract (LVOT) and
aortic valve (AV) in to view. The mitral leaflets are most likely A1 and P1 in this
view. The right PV view can be obtained at 0 degrees or at 90. Image 9 is an
example at 0 degrees and image 14 is about 90 degrees. Color and spectral Doppler
images are possible in both views. The modified bicaval view is obtained at an angle
closer to 90 degrees and includes the tricuspid valve as well as the coronary sinus.
The LAA view(s) are important for both diagnostic and interventional purposes.
Assessment for LAA thrombus is important in evaluation for cardiac source of
thrombus. Numerous interventional devices are now in clinical trial or approved for
use to occlude the LAA in patients with chronic atrial fibrillation for whom chronic
anticoagulation is problematic. At this time, there are two occluder devices, the
Watchman device and the Amplatzer plug. There is also the LARIAT device that
occludes the appendage via an external/pericardial approach.
The TG RV views by turning the probe toward the patients right from the
corresponding LV views. These views allow additional imaging of the TV and
pulmonic valve (PV). There is also improved imaging of the RV for functional
assessment and frequently appropriate alignment for spectral Doppler of the PV.
The guideline document also provides recommendations for imaging in adult
patients with congenital heart disease (CHD). There are now more adults with CHD
than children and these patients are coming to the operating room or interventional
suite for cardiac and non-cardiac surgical procedures. Currently most of the cardiac
procedures are Tetralogy of Fallot patients in need of TV and PV repair or
replacement. The number of single ventricle patients with Fontan physiology is
increasing.
References
1. Shanewise JS, CheungAT, Aronson S, Stewart WJ,Weiss RL, Mark JB, et al.
ASE/SCA guidelines for performing a comprehensive intraoperative
multiplane transesophageal echocardiography examination: recommendations
of the American Society of Echocardiography Council for Intraoperative
Echocardiography and the Society of Cardiovascular
Anesthesiologists Task Force for Certification in Perioperative Transesophageal
Echocardiography. Anesth Analg 1999;89:870-84.
2. Guidelines for performing a comprehensive transesophageal echocardiographic
examination: recommendations from the american society of echocardiography
and the society of cardiovascular anesthesiologists.
Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST,
Shanewise JS, Siu SC, Stewart W, Picard MH.
Anesth Analg. 2014 Jan;118(1):21-68.
3. American College of Cardiology Foundation Appropriate Use Criteria Task Force,
American Society of Echocardiography, American Heart As- sociation, American
Society of Nuclear Cardiology, Heart Failure Soci- ety of America, Heart Rhythm
Society, et al. ACCF/ASE/AHA/ASNC/ HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011
appropriate use criteria for echocardiography. A report of the American College
of Cardiology Foundation Appropriate Use Criteria Task Force, American Society
of Echocardiography, American Heart Association, American Society of Nuclear
Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for
Cardiovascular Angiography and Interventions, Society of Critical Care Medicine,
Society of Cardiovascular Computed Tomography, Society for Cardiovascular
Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr
2011;24:229-67.
4. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK. Safety
of transesophageal echocardiography. J Am Soc Echocardiogr 2010;23(11):111527.