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Although transesophageal ultrasound was first reported in the 1970s, the advent of phased array transducers and flexible transesophageal probes in the early 1980s enabled improved visualization of cardiac structures. Transesophageal echocardiography has become a commonly used imaging modality in a wide range of settings including the cardiac operating theatre, the intensive care unit, the interventional laboratory, as an outpatient procedure, and as a monitoring or rescue device in patients who have or are expected to have unexplained cardiovascular instability. Recently, the development and widespread availability of real-time 3-dimensional echocardiography has expanded the role of TEE in the guidance of complicated cardiac surgical procedures and catheter-based cardiac interventions such as transcatheter aortic valve replacements (TAVR). Objectives: Identify the significant anatomy views used in intraoperative echocardiography. Describe the indications for intraoperative echocardiography. Recall the clinical significance of intraoperative echocardiography. Discuss interprofessional team strategies for improving care coordination and communication to advance the use of intraoperative echocardiography and improve outcomes. Access free multiple choice questions on this topic.

Although transesophageal ultrasound was first reported in the 1970s, the advent of phased array transducers and flexible transesophageal probes in the early 1980s enabled improved visualization of cardiac structures.[1] Transesophageal echocardiography (TEE) has become a commonly used imaging modality in a wide range of settings including the cardiac operating theatre, the intensive care unit, the interventional suit, as an outpatient procedure, and as a monitoring or rescue device in patients who have or are expected to have unexplained cardiovascular instability. TEE is able to provide excellent ultrasonic imaging compared to transthoracic echocardiography (TTE) because of the proximal location of the esophagus next to the heart and great vessels, and avoidance of the lungs and ribs as impediments to imaging. In addition, TEE is more practical than TTE during most surgeries and especially during cardiac surgical operations because of the need to avoid the sterile operating field.[2][3] For these reasons, TEE is superior to TEE during cardiac surgery, for certain diagnosis, and for many catheter-based cardiovascular interventions. Recently, the development and widespread availability of real-time 3-dimensional echocardiography has expanded the role of TEE in the guidance of complicated cardiac surgical procedures and catheter-based cardiac interventions such as transcatheter aortic valve replacements (TAVR).[4]

Although transesophageal ultrasound was first reported in the 1970s, the advent of phased array transducers and flexible transesophageal probes in the early 1980s enabled improved visualization of cardiac structures.[1] Transesophageal echocardiography (TEE) has become a commonly used imaging modality in a wide range of settings including the cardiac operating theatre, the intensive care unit, the interventional suit, as an outpatient procedure, and as a monitoring or rescue device in patients who have or are expected to have unexplained cardiovascular instability. TEE is able to provide excellent ultrasonic imaging compared to transthoracic echocardiography (TTE) because of the proximal location of the esophagus next to the heart and great vessels, and avoidance of the lungs and ribs as impediments to imaging. In addition, TEE is more practical than TTE during most surgeries and especially during cardiac surgical operations because of the need to avoid the sterile operating field.[2][3] For these reasons, TEE is superior to TEE during cardiac surgery, for certain diagnosis, and for many catheter-based cardiovascular interventions. Recently, the development and widespread availability of real-time 3-dimensional echocardiography has expanded the role of TEE in the guidance of complicated cardiac surgical procedures and catheter-based cardiac interventions such as transcatheter aortic valve replacements (TAVR).[4] The Society of Cardiovascular Anesthesiologists (SCA) and the American Society of Echocardiography (ASE) published a first set of guidelines for the performance of a comprehensive intraoperative TEE exam in 1999. The aim of these guidelines was to define a standard examination for the purposes of training, consistency, storage, and quality. These guidelines contain a set of twenty TEE views that were primarily designed for intraoperative use although they have been widely adopted outside of the operating room.[5] These guidelines were updated in 2013 to now include an expanded 28 standard views as well as 3-dimensional imaging.[6][6] In addition, a set of basic perioperative TEE guidelines were also published in 2013 that included 11 standard views. The SCA and the ASE realized that the availability and use of TEE as a monitoring and diagnostic rescue tool outside of cardiac surgery had dramatically increased. Therefore, a basic set of guidelines that were intended for use in general operating rooms by non-cardiac anesthesiologists were developed.[7]

The Society of Cardiovascular Anesthesiologists (SCA) and the American Society of Echocardiography (ASE) published a first set of guidelines for the performance of a comprehensive intraoperative TEE exam in 1999. The aim of these guidelines was to define a standard examination for the purposes of training, consistency, storage, and quality. These guidelines contain a set of twenty TEE views that were primarily designed for intraoperative use although they have been widely adopted outside of the operating room.[5] These guidelines were updated in 2013 to now include an expanded 28 standard views as well as 3-dimensional imaging.[6][6] In addition, a set of basic perioperative TEE guidelines were also published in 2013 that included 11 standard views. The SCA and the ASE realized that the availability and use of TEE as a monitoring and diagnostic rescue tool outside of cardiac surgery had dramatically increased. Therefore, a basic set of guidelines that were intended for use in general operating rooms by non-cardiac anesthesiologists were developed.[7] Many practicing physicians that utilize TEE become certified in its use by the National Board of Echocardiography. This requires passing a test and the completion of several other requirements including a certain number of personally performed TEE exams.[7][6]

Although transesophageal echocardiography (TEE) has the reputation of a safe imaging modality, it does carry the risk of complications that range from mild to potentially life-threatening. The physical insertion and manipulation of the TEE probe in the intraoperative setting can cause a variety of gastric, esophageal, and oropharyngeal complications. According to several large studies, the overall rate of TEE related complications ranged from 0.2% to 1.4%. Intraoperative TEE does carry slightly different risks in comparison to TEEs performed in the ambulatory setting because patient's that undergo TEE in the operating room (OR) are typically under general anesthesia and have received neuromuscular blocking agents. These patients are unable to swallow and potentially protest dangerous probe manipulations. In addition, the TEE probe is often kept inserted for a prolonged period in the operating room, particularly in patients undergoing cardiac surgery. Despite these challenges, the rate of TEE related compilations appears to be similar in the ambulatory and operating room settings. Many of the gastrointestinal injuries related to TEE may not present until after the first twenty-four hours and may have previously led experts to underestimate the overall risk of TEE related complications. TEE related injuries include: Laceration of lip Loose or chipped tooth Tongue ulceration Laceration of the oropharynx Dysphagia Odynophagia Pharyngeal edema Vocal cord palsy or paralysis Gastritis Stomach ulceration Esophagitis Esophageal perforation Mallory-Weiss tear Dysrhythmias Compression of the mediastinal structures Inadvertent extubation[6][13][9]

Although transesophageal echocardiography is a relatively safe modality, it is an invasive procedure and does carry the risk of infrequent but potentially life-threatening complications. Therefore, it should only be performed by qualified, trained physicians. Cardiologists, anesthesiologists and critical care physicians who demonstrate their competence in echocardiography by completion of a training program and achieving a passing score on a certifying exam, can safely perform the procedure. Improving health professional understanding of how to utilize TEE to evaluate and treat patients can lead to better patient outcomes.