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

Abstract

Since the introduction of transesophageal echocardiography (TEE) to the operating room in the early 1980s (1,3,4), 1 its effectiveness as a clinical monitor to assist in the hemodynamic management of patients during general anesthesia and its reliability to make intraoperative diagnoses during cardiac operations has been well established (5–26). In recognition of the increasing clinical applications and use of intraoperative TEE, the American Society of Echocardiography (ASE) established the Council for Intraoperative Echocardiography in 1993 to address issues related to the use of echocardiography in the operating room. In June 1997, the Council board decided to create a set of guidelines for performing a comprehensive TEE examination composed of a set of anatomically directed cross-sectional views. The Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography has endorsed these guidelines and standards of nomenclature for the various anatomically directed cross-sectional views of the comprehensive TEE examination. This document, therefore, is the collective result of an effort that represents the consensus view of both anesthesiologists and cardiologists who have extensive experience in intraoperative echocardiography. The writing group has several goals in mind in creating these guidelines. The first is to facilitate training in intraoperative TEE by providing a framework in which to develop the necessary knowledge and skills. The guidelines may also enhance quality improvement by providing a means to assess the technical quality and completeness of individual studies. More consistent acquisition and description of intraoperative echocardiographic data will facilitate communication between centers and provide a basis for multicenter investigations. In recognition of the increasing availability and advantages of digital image storage, the guidelines define a set of cross-sectional views and nomenclature that constitute a comprehensive intraoperative TEE examination that could be stored in a digital format. These guidelines will encourage the industry to develop echocardiography systems that allow the quick and easy acquisition, labeling, and storage of images in the operating room, as well as a simple mechanism for side-by-side comparison of views made at different times. The following discussion is limited to a description of a method to perform a comprehensive intraoperative echocardiographic examination and does not address specific diagnoses, which is beyond the scope of a journal article. It describes how to examine a patient with “normal” cardiac structures to establish a baseline for later comparison. A systematic and complete approach ensures that unanticipated or clinically important findings will not be overlooked. Routinely performing a comprehensive examination also increases the ability to recognize normal structures and distinguish normal variants from pathologic states, thereby broadening experience and knowledge more rapidly. The description of the examination in the guidelines is based on multiple imaging plane (multiplane) TEE technology because it represents the current state of the art and is the type of system most commonly used. Compared with single plane or biplane imaging, multiplane TEE provides the echocardiographer with a greater ability to obtain images of cross-sections with improved anatomic orientation to the structures being examined (27–31). The writing group recognizes that individual patient characteristics, anatomic variations, pathologic features, or time constraints imposed on performing the TEE examination may limit the ability to perform every aspect of the comprehensive examination. Whereas the beginner should seek a balance between a fastidiously complete, comprehensive examination and expedience, an experienced echocardiographer can complete the recommended examination in <10 min. The TEE examination should be recorded on videotape or stored in a digital format so that individual studies can be archived and retrieved for review when necessary. The writing group also recognizes that there may be other entirely acceptable approaches and views of an intraoperative TEE examination, provided they obtain similar information in a safe manner. Patient Safety Although safe when properly conducted, in rare circumstances, TEE can cause serious and even fatal complications (32–37). An effort should be made to detect preexisting esophageal or gastric problems before performing TEE. Contraindications to TEE include esophageal stricture, diverticulum, tumor, and recent esophageal or gastric surgery. The TEE transducer should be inspected for defects and cracks in the waterproof covering before insertion. The mouth should be examined for preexisting injuries and loose teeth. The TEE probe may be inserted into an anesthetized, tracheally intubated patient with or without the use of a laryngoscope by displacing the mandible anteriorly and inserting the probe gently in the midline. Flexing the neck will help in some cases. If blind insertion of the probe is not easy, a laryngoscope can be used to expose the glottis and permit direct passage of the probe posteriorly into the esophagus. Once in the esophagus, the transducer should never be forced through a resistance. The tip of the transducer should be allowed to return to the neutral position before advancing or withdrawing the probe, and excessive force should never be applied when moving the transducer in the esophagus or flexing the tip with the control wheels. Cleaning and of the probe should be the with TEE, the transducer is first into the and the probe is to the imaging plane to obtain the cross-sectional This is by the image develop as the probe is by on the on the probe or the multiplane Although the most transducer and multiplane provided for cross-sectional of the image is based on the anatomic structures that It is that there is individual in the anatomic of the esophagus to the in some the esophagus is to the of the in it is to the This is into when of the cross-sectional views. is examined in multiple imaging and from more transducer An a or imaging the probe or the transducer to the imaging plane through the of a it to be examined and important for image quality and the of TEE. 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