Seminars TOE in Non Cardiac PDF

Transesophageal Echocardiography
and Noncardiac Surgery
Seminars in Cardiothoracic
and Vascular Anesthesia
Volume 12 Number 4
December 2008 265-289
2008 SAGE Publications
10.1177/1089253208328668
http://scv.sagepub.com
hosted at
http://online.sagepub.com
Feroze Mahmood, MD, Angus Christie, MD, and Robina Matyal, MD

The use of transesophageal echocardiography (TEE) for
monitoring during cardiac and noncardiac surgery has
increased exponentially over the past few decades. TEE
has evolved from a diagnostic tool to a monitoring device
and a procedural adjunct. The close proximity of the
TEE transducer to the heart generates high-quality
images of the intracardiac structures and their spatial
orientation. The use of TEE in noncardiac and critical
care settings is not well studied, and the evidence of the
benefits of its use in these settings is lacking. Despite
the widespread availability of TEE equipment in US
hospitals, less than 30% of anesthesiologists are formally
trained in the use of perioperative TEE. In this review,
the safety and indications of TEE are reviewed and
detailed analysis of the best available evidence in this
regard is presented. Landmark trials evaluating the use

of TEE and its therapeutic impact in noncardiac surgical setting are critically reviewed. This article details recommendations to familiarize anesthesiologists with TEE
technology to exploit it to its fullest potential to achieve
better patient monitoring standards and eventually
improve outcome. Training of greater numbers of anesthesiologists in TEE is needed to increase awareness of
the indications and contraindications. Until relatively
inexpensive TEE equipment is available, the initial cost
of equipment acquisition remains a significant prohibitive factor limiting its widespread use.
esophageal stethoscope for intraoperative use was

combined with the esophageal echo probe to develop
a TEE probe, and M-mode images were obtained and
left ventricular (LV) dimensions were measured.2
The design of the probe was further improved, and
the results of the first intraoperative application for
continuous ventricular monitoring were published in
1980.3 The initial uses of TEE were limited to monitoring of LV dimensions and visualization of intracardiac air bubbles, but with the development of the
phased array transducer, 2-dimensional images were
also generated.2,4-6 Further developments (eg, biplane
and multiplane imaging and the incorporation of
color flow and spectral Doppler) literally revolutionized cardiac imaging and monitoring.2
The role of intraoperative TEE has evolved from a
diagnostic tool to a monitoring device and a procedural adjunct. The close proximity of the TEE transducer to the heart generates high-quality images of
the intracardiac structures and their spatial orientation. With the availability of Doppler information, the
valvular disorders (stenosis and regurgitation) could
he use of transesophageal echocardiography

(TEE) for monitoring during cardiac and noncardiac surgery has increased exponentially
over the past few decades. Initially, TEE was used as
an alternative to transthoracic echocardiography
(TTE) for patients with limited echo windows,
and the imaging was limited to M-mode analysis of
cardiac structures.1 Since the introduction of
esophageal echocardiography in the mid-1970s,
modern TEE equipment and techniques have
evolved and overcome many technological and
methodological hurdles. The initial attempts to
develop a practical esophageal probe were almost
abandoned due to the difficulty encountered by
volunteers in swallowing the probe.2 Later, an
From Beth Israel Deaconess Medical Center, Harvard Medical
School, Boston, Massachusetts (FM, RM); Department of
Anesthesiology and Pain Medicine, Maine Medical Center,
Portland, Maine (AC).
Address correspondence to: Angus Christie, MD, Department of
Anesthesiology and Pain Medicine, Maine Medical Center,
Portland, ME 04102; e-mail: chrisa9@spectrummg.com.
Keywords: transesophageal echocardiography; transthoracic echocardiography; noncardiac surgery
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
also be diagnosed, and the response to therapy

followed over time. The intraoperative application of
TEE was limited to cardiac surgical procedures. The
use of TEE in noncardiac and critical care settings is
not well studied, and the evidence of the benefits of
its use in these settings is lacking. The scarcity of evidence of benefit is mainly due to the lack of any relevant trials specifically designed to answer the
question of benefit. Despite the widespread availability of TEE equipment in US hospitals, less than 30%
of anesthesiologists are formally trained in the use of
perioperative TEE.7-9 The preference of anesthesiologists for TEE over other hemodynamic monitors is also
strongly influenced by their formal training in perioperative TEE.7 Hence, the paucity of literature favoring
the use of TEE in noncardiac surgical settings is perhaps a function of the lack of familiarity, training, and
interpretive skills of the clinicians involved.
In this review, the safety and indications of TEE
will be reviewed and detailed analysis of the best
available evidence in this regard will be presented.
Landmark trials evaluating the use of TEE and its
therapeutic impact in noncardiac surgical setting
will also be critically reviewed. This article will also
make recommendations to familiarize the anesthesiologists with TEE technology to exploit it to its
fullest potential to achieve better patient monitoring
standards and eventually improve outcome.
Safety Profile of Transesophageal

Echocardiography
Since its earliest application in the operating room
(OR), TEE has enjoyed a remarkable safety profile.
Major complications associated with the passage of
the probe through the esophagus are rare, and there
are very few absolute contraindications to the performance of TEE.10 Presentation of esophageal injury
after a TEE examination can be as early as within 24
hours to as long as 8 days after the injury.11 The presence of esophageal abnormalities (eg, stricture and
cardiomegaly) has been suggested to be important
predisposing factors in these case reports. The
American Society of Anesthesiologists/ Society of
Cardiovascular Anesthesiologists (ASA/SCA) practice
guidelines for perioperative TEE also recommend the
performance of TEE in the context of indications,
contraindications, and peculiar circumstances.12 The
benefits of performing a perioperative TEE examination have to be weighed against the potential risks.
The other available intraoperative monitors (eg,

central venous pressure and pulmonary artery
catheter), which can be used for similar information,
are not only more invasive but also of questionable
value.13-16 There are also no large randomized trials
addressing the benefits of perioperative TEE in terms
of outcome in cardiac or noncardiac surgery. Hence,
it is difficult to accurately assess the riskbenefit
ratio of TEE specifically as a monitor during noncardiac surgery. However, the extremely low risk of serious complications and the enormous diagnostic
potential overwhelmingly favor the use of TEE.10
Indications During Noncardiac Surgery

The ASA practice guidelines acknowledge that the
reductionist approach to assessment of the evidence
of the efficacy of TEE may underscore its true usefulness.12 The guidelines recommend appropriateness
criteria for performing perioperative TEE in the context of the condition of the patient, the risks of the
procedure, and the specific circumstances.12 The category I indications (supported by strongest evidence)
of TEE in noncardiac surgical circumstances are
severe, life-threatening unexplained hypoxia, and
hypotension.12 The evidence supporting the use of
TEE for monitoring of ischemia is considered supportive and not conclusive (ie, a category II indication), and expert opinion favors the use of TEE during
procedures with risk of hemodynamic instability.
TEE and category II indications. The broader application of TEE outside the cardiac OR is limited due to
its high initial cost, training requirements, and the
lack of appreciation of the depth and accuracy of the
information available. TEE is able to provide instantaneous anatomical images in the context of function
to provide a unique functional cardiovascular assessment,17 hence making it an ideal monitoring modality. The application of perioperative TEE to allow
practitioners to perform a comprehensive hemodynamic assessment and evaluation of the cardiovascular system outside the cardiac ORs is not addressed.17
Even when used in its most basic fashion, the information provided by TEE has been shown to influence decision making independent of the presence of
central venous pressure monitoring in cardiac as well
as noncardiac surgery.17-20 Whereas the broad assessment of the cardiac function may be considered adequate for a basic-level echocardiographer, more
TEE and Noncardiac Surgery / Mahmood et al
sophisticated techniques can be employed by

advanced practitioners to exploit this modality to its
fullest potential.21
The applications of perioperative TEE for noncardiac surgery are restricted merely for diagnosis and
management of life-threatening disorders in a majority of the cases.12 The use of TEE as a consult service only during acute life-threatening emergencies
explains its utility as a category I indication. The
choice to use TEE for elective hemodynamic monitoring by anesthesiologists is largely determined by
their level of training and familiarity in using TEE.7 In
a recent survey, only about 50% of cardiac anesthesiologists in Canada and 23% of anesthesiologists in the
United States had specific training for performing
intraoperative TEE.7,8 Until recently, specific TEE
training was not an integral part of the cardiac anesthesia fellowship training. Hence, the lack of evidence supporting a therapeutic impact during
high-risk noncardiac surgery is due to the limited
availability and interpretive skills of anesthesiologists.
Myocardial ischemia. Intraoperative, automated, continuous ST segment analysis is a more sensitive monitor of ischemia than visual assessment of ST
segments.22-24 The occurrence of perioperative ST segment changes is also associated with higher incidence
of ischemic postoperative events.25 However, ischemic
ST segment changes demonstrate a significant time
delay after the sudden occlusion of coronary arteries.
The response of myocardium to sudden ischemia is
manifested as diastolic dysfunction initially, followed
by wall motion abnormalities (WMAs), then electrocardiogram (EKG) changes, and finally clinical symptoms.26 Thus, TEE has the ability to detect and
diagnose ischemia before any other ischemia monitor,
and it can detect WMAs within a few seconds of coronary occlusion, implying that ischemia is detected
even before tissue markers of cell damage are released
into circulation.27,28 Although the transgastric shortaxis view is considered the view of choice for ischemia
detection, visualization of myocardial walls from multiple midesophageal views further increases the ability
to detect WMAs with TEE.29
The accuracy of early detection of WMAs by
TEE is questioned because of the lack of a true gold
standard reference ischemia monitor for comparison. It is difficult to differentiate the ischemic
WMAs from the nonischemic false-positive WMAs
on the basis of ST segment changes, which are themselves an imperfect ischemia monitor.12 Predictably,
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intraoperative WMAs as detected by TEE have

shown weak concordance with intraoperative ST segment changes.12,30 The incidence of WMAs detected
by TEE is 27% to 100% when there is EKG evidence
of ischemia and 56% to 85% when there is no evidence of ischemia on EKG.12 Despite the high sensitivity and early detection, the intraoperative
occurrence of WMAs has shown a poor correlation
with postoperative myocardial infarction as detected
by enzyme assays.31,32 Intraoperative TEE has other
limitations as well. Intraoperative TEE monitoring of
ischemia is intermittent, and the 2 most stressful
parts of the procedure (ie, induction of and emergence from anesthesia) are not monitored.30 Second,
due to the segmental nature of myocardial blood supply, it is possible to miss ischemic WMAs if the
appropriate myocardial walls and segments are not
monitored.33 Also, sudden changes in after-load have
been known to cause nonischemic WMAs due to
regional conduction delays.34-36 Due to the lack of
availability of an automated system, intraoperative
assessment of WMAs remains a qualitative assessment, with a high interobserver variability even for
very severe WMAs.30 However, the previous studies
of sensitivity and specificity of perioperative TEE
have significant limitations. The investigators used
either monoplane or biplane TEE probes, monitoring
was intermittent, and WMA analysis was done offline on VHS tapes, and only the transgastric midpapillary short-axis view of the left ventricle was viewed
and recorded.31,32,37-40 The aforementioned factors
tend to complicate ischemia monitoring with perioperative TEE. Despite visualizing the territory of all
major coronary vessels, it is only the middle segments
of the myocardium that are visualized in the transgastric short-axis view. Off-line analysis with cine-loop
is more accurate than tape review, and multiplane
imaging allows for more comprehensive assessment
of myocardial walls.38 There is also the question of
the WMAs that occur during induction and are considered as baseline WMAs after induction, thus
potentially decreasing the sensitivity of TEE for
ischemia detection.31,39
TEE provides a unique perspective of monitoring
myocardial function and provides more quantifiable
monitoring parameters of ischemia than EKG
changes.12 The higher sensitivity and lack of correlation of perioperative WMAs with postoperative
myocardial infarction should be viewed as a favorable
factor.31,32 Early detection of myocardial ischemia
can lead to earlier interventions (eg, anti-ischemia
268
therapy and more vigilant care) to improve outcome.

Although direct evidence of a favorable outcome of
perioperative TEE in noncardiac surgery is lacking, it
can be indirectly extrapolated from the benefits of
early ischemia detection and management.12
TEE Preload Assessment

Left ventricular preload is physiologically the length
of sarcomeres at the end of diastole and is primarily
determined by volume.12 Left ventricular end-diastolic diameter (LVEDD), as measured by TEE,
allows a rapid assessment of LV preload. Because
the available evidence at that time was anecdotal
case reports, the ASA practice guidelines for TEE
have termed the TEE hemodynamic evaluation, at
best, as qualitative.12 However, they have also termed
TEE as more practical and useful than the pulmonary artery catheter for hemodynamic evaluation.12
Because TEE can be inserted quickly, without sterile
technique, and provides a real-time anatomical
functional assessment of LV, it is an ideal modality
to quickly assess the LV preload.
In addition to providing a baseline preload assessment, TEE allows the practitioner to observe the
response to preload alterations. It is now established
that the LVEDD can be used to dynamically follow
the response to fluid therapy. The lack of increase in
LVEDD can identify patients who are responding to
repeated fluid boluses with increased stroke volume
and cardiac output.41-43 This parameter is applicable
even in those patients who have depressed ejection
fraction and WMAs.41 TEE can also be used to accurately assess left ventricular end-diastolic pressure
(LVEDP). Combinations and ratios of transmitral
pulse wave Doppler (PWD), transmitral flow propagation velocity (Vp), and mitral annular tissue velocities
can be used to accurately predict LVEDP. Nomura et
al42 have demonstrated a correlation between early
transmitral deceleration slope and pulmonary capillary wedge pressure (PCWP) in patients with ejection
fraction <35%. Similarly, a sensitivity and specificity
of 100% for a transmitral deceleration time of 120
ms and PCWP 20 mm Hg has been reported in
patients with depressed systolic function with simultaneous Doppler and cardiac catheterization studies.44 Ratios of transmitral PWD-derived early filling
(E) velocity to Doppler tissuederived early mitral
annular descent (E) velocity (E/E), or the ratio of E
velocity to Vp (E/Vp) can also be used to accurately
predict a range of LVEDP.45,46 The Doppler estimation

of LVEDP and PCWP has shown greater correlation
with invasively derived pressures in patients with
moderately depressed systolic function than in
patients with normal systolic function.44-46 Doppler
tissue imaging of the mitral annulus is less dependent
on the loading conditions and is more accurate than
the PWD transmitral flow velocities for the estimation of LVEDP and PCWP in patients with normal
systolic function.42,47
Hence, TEE provides an accurate assessment of
LV preload assessment and can be used dynamically to
follow the response to fluid resuscitation during noncardiac surgery. It has been shown that intensivists
with basic training in echocardiography can diagnose
and interpret hypovolemia with TEE and can initiate
corrective therapies.48 It is well established that intraoperative TEE can provide far more information than
mere end-diastolic dimensions for preload assessment.
Due to the lack of automation on most available
equipment, the acquisition and interpretation of
Doppler-derived data requires significant training and
experience. Intraoperative TEE can provide timely,
accurate, and reliable hemodynamic evaluation during
noncardiac surgery, which has the potential to initiate
goal-directed therapy. In the era of cost containment
and outcome-driven monitoring protocols, intraoperative TEE has the potential to be a viable alternative to
other more invasive monitors (eg, PA catheter).
Comprehensive Ventricular
Function Assessment
Systolic function. A combination of 2-dimensional and
Doppler interrogation of both left ventricle (LV) and
right ventricle (RV) provides a comprehensive (systolic and diastolic) ventricular functional assessment.
Blood supply territory of all the major coronary vessels can be seen in the transgastric midpapillary shortaxis view of the LV, and an instantaneous assessment
of LV systolic function and WMAs can be made.29,49
Quantitative assessment of LV function can be made
with geometric modeling of the LV with either the
Teicholz formula or Simpsons method of discs.49,50
Due to multiple assumptions made about the geometry of the LV and the time-consuming nature of the
mathematical calculations, these formulae are not
routinely used, and visual estimation of systolic function by an experienced observer has been shown to
correlate well with these objective measures.51
Determination of ventricular stroke volume and

cardiac output is one of the most commonly used
methods of systolic functional assessment. Cardiac
output measurement was initially attempted with TEE
using PWD interrogation of pulmonary artery, but
adequate imaging could not be obtained in a quarter
of the patients.52 Earlier studies investigating cardiac
output measurement with monoplane TEE probes
required significant probe manipulation for image
acquisition, but still showed good correlation with
thermodilution-derived cardiac output.52-55 With the
advent of multiplane TEE probes, positioning the
probe in the deep transgastric position has allowed
more accurate alignment of PWD with the aortic outflow in a greater percentage of cases.56-58 Multiplane
TEEderived cardiac output has been shown to reliably measure cardiac output in the OR as well as
changes in cardiac output with varying hemodynamics.59,60 More recent developments allow for automated cardiac output calculation with flow calculation
at multiple sites as well 3-dimensional reconstruction
of end-diastolic and end-systolic LV volumes.61,62
An accurate measurement of cardiac output is
dependent on the alignment of the Doppler beam with
the aortic flow, and there is potential for significant
underestimation of cardiac output.60 The estimates of
the accuracy and reproducibility of TEE-derived cardiac output are based on comparison with the pulmonary artery catheterderived thermodilution cardiac
output, which is itself an imperfect standard.54,63,64 This
technique is also based on the assumptions of an
instantaneous triangular unchanging aortic valve orifice during systole, which actually may not be triangular and may vary with varying flow rate.60,65
Diastolic function. Diastolic dysfunction may occur as
a result of either impaired relaxation or due to
decreased compliance.66 Most patients with coronary
artery disease and varying degrees of systolic dysfunction have diastolic dysfunction,67 and it is possible for
patients with normal systolic function to have isolated diastolic dysfunction.68 The difference in symptoms with equal degrees of systolic dysfunction can
be explained with differences in diastolic properties of
LV.69 Diastolic dysfunction in the general community
is as common as systolic dysfunction, and the incidence of congestive heart failure (CHF) increases
with increasing severity of diastolic dysfunction.70
The presence of diastolic dysfunction with or without
CHF has been shown to be associated with all-cause
269
morbidity and mortality.70-72 The prevalence of diastolic dysfunction increases with age, and almost 50%
of patients with CHF have been shown to have normal systolic function.46 Although Doppler assessment
of diastolic filling abnormalities has been used to
assess survival and prognosis, its specific application
to evaluate preoperative risk has thus far been limited.73-76 The lack of appreciation for diastolic dysfunction as a risk factor for postoperative outcome
may be due to the absence of a universal method of
classification and diagnosis of diastolic function and
dysfunction.46 Most studies evaluating the use of
echocardiography in noncardiac surgery have limited
the assessment to ventricular systolic function or
WMAs.77-80 Also, due to the unique history of disease
progression, most patients scheduled for elective
high-risk noncardiac surgery have coronary artery disease and an equivocal pseudo-normal Doppler filling pattern.46,81 Furthermore, general anesthesia is
associated with rapid alterations of loading conditions, which makes the traditional Doppler assessment of diastolic function more challenging and
frequently inconclusive.82 Traditionally, anesthesiologists have used PCWP as a marker of LVEDP, which
has been shown to be an unreliable indicator of the
diastolic properties of LV.83 Left ventricular filling
during diastole is a complex sequence of events, and
the application of Doppler has greatly increased the
understanding of diastole.66,84 With the use of Vp and
Doppler tissue imaging, it is possible to assess the
events of diastole and their abnormalities (relaxation
and compliance, respectively).46,66,84,85
A history of CHF has also been demonstrated to
be an independent predictor of 30-day postoperative
mortality and hospital readmission after major noncardiac surgery.86 Similarly, perioperative interventions (eg, -adrenergic antagonists and pulmonary
artery catheters) have not been associated with any
improvement of postoperative outcome in these
patients,67 but may have actually caused more complications.87 This may be because we have so far been
unable to identify the patients truly at risk and
attributed the presence of CHF to systolic dysfunction only. Xu-Cai et al88 found that patients with a
history of CHF and normal systolic function (ie, presumed diastolic dysfunction) had longer length of
stay and higher readmission rate after vascular surgery than patients with CHF and abnormal systolic
function and controls. Recently, investigators have
demonstrated changes in diastolic function of LV
270
with abdominal aortic cross-clamp application independent of systolic function.82,89 Similarly, Phillip
et al90 have reported that more than 50% of geriatric
patients undergoing cardiac and noncardiac surgery
had preoperative diastolic dysfunction with normal
systolic function. They concluded that a comprehensive LV functional assessment should include evaluation of both systolic and diastolic properties. If risk
stratification is limited to systolic function alone, a
significant proportion of patients with diastolic dysfunction who are at risk for postoperative adverse
events would not be identified. TEE provides us with
the ability to diagnose the presence of diastolic dysfunction and assess its severity. This information can
be especially useful in fluid titration for patients with
moderate to severe diastolic dysfunction.
Myocardial performance index. Systole and diastole are
both energy-dependent processes. A truly comprehensive myocardial functional assessment would include
an assessment of systolic and diastolic performance.
Traditionally, an ejection fraction of >55% has been
considered to be an evidence of a normal, global ventricular function and excludes diastolic function as a
determinant of myocardial function. Myocardial performance index (MPI), also referred to as the Tei
index, is a Doppler-derived index of global myocardial
function.91,92 It was originally described by Tei et al91 as
an echocardiographic measure of global (systolic and
diastolic) LV function. The correlation of this index
with invasively derived constants of relaxation and
contraction has been validated with simultaneous cardiac catheterization and Doppler echo studies.92
Because both isovolumetric relaxation and contraction time (IVRT and IVCT) are energy dependent,
they are directly related to dP/dt and +dP/dt, respectively.91,93 The sum of IVCT and IVRT would be an
estimate of the global myocardial function (systolic
and diastolic). A ratio of IVCT and IVRT with heart
rate or the ejection time (ET) eliminates their dependence on heart rate. The result is the sum of IVCT and
IVRT, divided by the ET. A prolonged MPI signifies
that either the IVCT or IVRT are prolonged or ET is
shortened (ie, the forward cardiac output is too low).
The Tei index has been shown to be prognostic of poor
outcomes in patients presenting with acute myocardial
infarction, dilated cardiomyopathy, and cardiac amyloidosis and has been used for risk stratification in this
patient population.91,93,94 Although MPI was initially
measured with TTE, TEE has also been validated to
measure MPI.95,96 The main advantages of the use of
MPI to assess myocardial function are the simplicity

of the technique, evaluation of both systolic as well as
diastolic function, and lesser dependence on loading
conditions. Before the widespread use of echocardiography, the measurement of IVCT/IVRT was
only possible during invasive cardiac catheterization
procedures. The availability of spectral pulse wave
Doppler has made it possible to measure these time
intervals with a high degree of precision. Use of MPI
as a means of assessment of global LV function should
make it an excellent monitoring modality during highrisk noncardiac surgery. When a patient demonstrates
a prolonged MPI, it is possible to measure IVCT and
IVRT and diagnose which specific part of the cardiac
cycle is affected and, therefore, make therapeutic
interventions.
Application of TEE for

Specific Clinical Situations
The intraoperative applications of TEE for noncardiac surgery have ranged from vascular surgery to
assessment during laproscopic surgery. The category
I indications for TEE for noncardiac surgery, which
are well established and known, have been discussed
earlier. The utility of TEE for specific clinical situations has been extensively reviewed by Maslow
et al.97 We will briefly describe the clinical application of TEE in the context of specific scenarios.
Vascular Surgery (Table 1)

Patients undergoing vascular procedures are at high
risk for perioperative cardiac complications due to the
invasive nature of the procedure as well as the prevalence of coronary artery disease in this population.98
As noted earlier, TEE has been investigated as a monitor of myocardial ischemia, particularly patients at
high risk.31,37,39,99,100 Furthermore, it has been shown
to be a valuable guide for fluid resuscitation in major
vascular surgery.101 In addition to ischemic cardiac
complications, patients undergoing thoracic and
abdominal aortic surgery are at risk for spinal cord,
renal, and mesenteric ischemia. Several investigators
have used TEE to image blood flow in at-risk organ
vascular beds following surgical repair.102-104 In emergent vascular surgery, the subpopulations of traumatic aortic disruption and dissection provide a
difficult set of circumstances requiring rapid diagnosis and treatment. TEE provides a quick, accurate,
mobile diagnostic tool with which to image the aorta.

Several authors have evaluated TEE in the diagnosis
of traumatic aortic injury.105-117 Again, it has been
demonstrated that TEE is highly accurate and facilitates diagnosis and treatment of traumatic aortic disruption, with the caveat that TEE is limited in its
ability to image the distal ascending aorta, aortic arch,
and branch vessels.110,113 Acute aortic dissections,
both type A and type B, benefit from the use of TEE
in the diagnosis and definitive management.104,118-120
Review of the literature illuminates the increasing use
and benefit of TEE in vascular surgery.
Endovascular Surgery (Table 2)

Endovascular aortic repair (EVAR) was introduced in
the early 1990s. Since that time, the use of endovascular prostheses has grown rapidly. The growth of
intraoperative TEE has paralleled that of EVAR. The
value of TEE in identifying aortic pathology, localization of the landing zone, and demonstration of successful deployment has been demonstrated in
dissections and traumatic disruptions of the aorta as
well as aneurysmal disease.121-134 Furthermore, TEE
and contrast-enhanced ultrasound have been shown
to be more sensitive than angiography in revealing
endoleaks and thromboexclusion.121-133
Trauma (Table 3)
Early diagnosis and treatment of traumatic injury is
crucial in enhancing survival and limiting the associated morbidity. The concept of the golden hour
was demonstrated during World War I and has been
the cornerstone of trauma medicine since that time.
Patients presenting with both penetrating and blunt
chest trauma are at the highest risk for morbidity
and mortality.135 Rapid, accurate diagnosis, triage,
and definitive management have fueled improving
mortality, and TEE provides the ideal platform.
Blunt chest trauma has a high incidence of traumatic aortic injury and cardiac contusion. Aortic
injury can range from intramural hematoma to complete transection and exsanguination. Although the
specific criteria for diagnosis of contusion are vague
and changing, TEE in conjunction with TTE, serial
myocardial enzymes, and serial ECGs is a valuable
diagnostic tool.111,136-142a TTE has been shown to be
valuable in the immediate diagnosis of cardiac rupture.143 Although it has not been investigated, TEE
271
with its better image quality and enhanced diagnostic capabilities should be of equal or more benefit in
managing these patients.
Like all clinical scenarios, the use of TEE has
limitations in trauma. The possibility or presence of
cervical spine injuries can increase the risk of further
destabilizing the cervical spine with probe placement. Additionally, maxillofacial injuries and stabilizing equipment around the skull and face can make
probe placement and image acquisition very difficult.
Transplant Surgery (Table 4)

Both TTE and TEE are used in the initial evaluation
of cardiac functional status in patients listed for
organ transplantation. These patients have experienced end-stage organ failure as the result of complex disease processes. These same processes have a
detrimental effect on cardiac anatomy and function.
Furthermore, the procedures are often complicated
by large fluid shifts and hemodynamic perturbations. TEE provides information that complements
data provided by invasive hemodynamic monitoring
in the management of complex patients.
Several authors have investigated the use of TEE
in liver and lung transplantation.144-154 Although liver
patients have an increased risk of complications due
to coagulopathy and esophageal varices, TEE has
been used successfully with a low complication
rate.154 Although there is no doubt about the clinical
benefit in this patient population, however, consideration of elevated risk is essential to the safe application of TEE, which should be considered on an
individual basis.
Patients with end-stage pulmonary disease presenting for lung transplantation also benefit from
intraoperative TEE. Evaluation of ventricular function, volume status, and surgical anastomoses are
easily and accurately performed with TEE.
Additionally, delineation of unknown anatomy may
result in additional surgical intervention. Gorscan
et al155 identified pulmonary artery thrombi, patent
foramen ovale, and both atrial and ventricular septal
defects. These defects were repaired at the time of
transplantation, most likely improving the postoperative and intensive care of these patients.
Other applications of TEE in transplant patients
include cardiac donor screening and the use of
dobutamine stress echocardiography in the preoperative evaluation of renal transplant patients.
272
Table 1.
Author
Year
Population
(n)
Gillespie 1994
et al101
22
Harpole
et al99
1989
23
Goarin
2000
et al108
209
Godet
1994
et al102
17
Iafrati
1993
et al100
17
Konstadt 1995
et al134
81
London
et al31
1990
156
Smith
et al39
1985
60
Voci
1999
et al104
Use of Transesophageal Echocardiography in Vascular Surgery
Surgical
Procedure
Infrarenal AAA
repair
Observations
Observational study investigating the correlation

between pulmonary artery occlusion pressure
(PAOP) and left ventricular end-diastolic area
(LVEDA) by TEE. A weak positive correlation
between PAOP and LVEDA (0.37) was found.
AAA repair
Significant changes in ejection fraction (EF),
end-diastolic volume (EDV), end-systolic
volume (ESV), and mean arterial pressure
(MAP) associated with cross-clamping. These
changes resolved with unclamping of the aorta.
Traumatic
TEE and aortography are equivalent for major
aortic injury
aortic injury (sensitivity 97%, specificity 100%).
TEE is more accurate than angiography
(sensitivity 98% vs 83%, specificity 100% both)
in minor aortic injury.
AAA repair
Spinal cord images of good quality were obtained
in all patients. TEE was unable to visualize the
spinal cord beyond T10-11. It is not likely to be
effective in monitoring artery of Adamkiewicz.
Thoracoabdominal The goal was to evaluate TEE as monitor of
aortic aneurysm
myocardial ischemia and ventricular volume,
compared with PAC. PAC failed to recognize 6
severe hemodynamic alterations: 5 patients were
hypovolemic and hyperdynamic, 1 has
congestive heart failure
Elective cardiac
Fourteen (17%) of 81 patients had significant
surgery
atherosclerotic disease as diagnosed by epiaortic
scanning. TEE has 100% negative predictive
value, but only 34% positive predictive value.
Sensitivity 100%, specificity 60%.
Noncardiac
20% of patients with new or worsened episodes
>1 hour
(44) of segmental wall motion abnormality
(SWMA). Most limited to hypokinesis (55%),
but akinesis (36%) and dyskinesis (9%) also
occurred. Most SWMA occurred in patients
undergoing aortic surgery.
Carotid
endarterectomy
Type B aortic
dissection
TEE Conclusions
TEE valuable
adjunct to guide
fluid resuscitation.
Not focus of
investigation.
TEE is an accurate
diagnostic tool for
traumatic aortic
injury.
Possible to visualize
thoracic epidural
catheter.
TEE significantly
affected management
in 9 patients.
TEE is very sensitive but

mildly specific for
detection of aortic
atherosclerosis.
Continuous TEE
monitoring for
ischemia had low
yield. Forty percent of
SWMA not associated
with clinical events or
hemodynamic
changes. Poor
correlation with
postoperative cardiac
events.
Not focus of
investigation.
30% incidence of new or worsened segmental wall

motion abnormality. No postoperative
myocardial infarction in any patient studied
Case report demonstrating ability to measure blood
Unusual to image the
flow in the anterior spinal artery following repair
spinal arteries.
of descending thoracic aorta with vascular
Improved software
prosthesis.
will improve imaging.
May have clinical
benefit if patients had
risk for spinal cord
ischemia.
(continued)
273
Table 1. (continued)
Author
Year
Population
(n)
Taams
1988
et al120
30
Smith
1995
et al105
Surgical
Procedure
Observations
Aortic dissection
(15)/aortic
aneurysm (15)
In dissection subpopulation, TEE was more likely

(77% vs 33%) than angiography to determine
entry site. Computed tomography (CT) inferior
to both methods. In aneurysm subpopulation,
false negatives associated with CT and
angiography. TEE had no false positives with
respect to concomitant aortic dissection.
101
Blunt chest
trauma
Nienaber 1993
et al118
110
Suspected aortic
dissection
Study successfully completed in 93 of 101 patients.

Twelve percent (11 of 101) demonstrated
rupture of the aorta at the level of the isthmus.
Findings confirmed at surgery or autopsy.
Evaluation of MRI, CXR, CT, TTE, and TEE as
initial diagnostic tools for suspected aortic
dissection. All patients had 2 imaging tests at
random.
Orihashi 1998
et al103
12
Eisenberg 1992
et al37
332
Sommer 1996
et al119
49
Aorta
Celiac, superior mesenteric, left and right renal

arteries imaged in majority of patients.
Noncardiac
vascular
332 men at high risk for CAD; 111 (39%)

identified as having intraoperative myocardial
ischemia be either TEE, continuous 2-lead
ECG, or 12-lead ECG.
Suspected aortic
dissection
Sensitivity in detection of thoracic aortic dissection

was 100% for all techniques. Specificity was
100%, 94%, and 94% for spiral CT, multiplanar
TEE, and MRI. The sensitivities of assessment
of aortic arch vessel involvement for spiral CT,
multiplanar TEE, and MRI were, respectively,
93%, 60%, and 67%, and specificity was 97%,
85%, and 88%.
TEE Conclusions
TEE is a rapid and
accurate diagnostic
tool to evaluate
thoracic aortic
pathology. Rapidity
essential in
dissection, which has
associated 2% mortal
ity per hour.
TEE is a highly sensitive
and specific diagnostic
tool for detection of
thoracic aortic injury.
TEE suggested for
hemodynamically
unstable patients.
MRI to be used in
hemodynamically
stable patients.
Transgastric
echoangiography
potential method to
evaluate blood flow
following procedures
on abdominal aorta.
TEE and 12-lead added
little incremental
value in identifying
patients at high risk
for perioperative
ischemic outcomes.
Multiplanar TEE is as
valuable as CT and
MRI in detection of
thoracic aortic
dissection. Spiral CT
is superior to both
multiplanar TEE and
MRI for evaluation of
aortic arch vessel
involvement.
NOTES: TEE = transesophageal echocardiography; PAC = pulmonary artery catheter; AAA = abdominal aortic aneurysm; MRI =
magnetic resonance imaging; TTE = transthoracic echocardiography; CAD = coronary artery disease; ECG = electrocardiogram;
CXR = chest x-ray.
Obstetrics
Obstetrical anesthesia is generally performed under
regional anesthesia. However, emergent cesarean section and nonobstetrical surgery in pregnant patients
require general anesthesia. These patients may benefit
by intraoperative TEE in certain situations. A review of
the literature shows that TEE in obstetrical patients is

well described.156-170 The clinical scenarios range from
pregnant women undergoing electrophysiology procedures to the parturient with pulmonary hypertension
or congenital heart disease to cardiopulmonary resuscitation following amniotic fluid embolism.
274
Table 2.
The Use of Transesophageal Echocardiography in Endovascular Surgery
Authors
Year
Population
(n)
Orihashi
et al121
2000
16
Swaminathan 2003
et al122
Swaminathan 2007
et al123
Fattori
et al124
2000
25
Rocchi
et al125
2004
42
Rapezzi
et al126
2001
22
GonzalezFajardo
et al127
2002
12
Koschyk
et al128
2005
42
van der
Starre
et al129
2004
Observations
TEE Conclusions
Aorta examined for atheromatous disease. TEE assists placement of endovascular graft and
TEE useful in measuring aortic diameter
provides immediate evaluation of deployed
for sizing graft. There were no
prosthesis. TEE assessment of endoleak and
complications related to TEE.
thromboexclusion the same as CT and
angiography (sensitivity 100%, specificity 100%).
Thoracic aorta was well visualized. Primary TEE valuable for (1) identifying aortic pathology, (2)
aortic disease identified in all patients.
confirming guidewire in true lumen, (3) aiding in
After deployment of endograft, both distal stent graft positioning, and (4) complementing
and proximal ends identified. No TEE
angiography for the determination of endoleaks.
complications; 1 hemorrhagic
Furthermore, TEE useful in evaluation of
complication from arterial access.
cardiac function and volume status.
TEE imaging of proximal aortic arch is
TEE should not be used as the sole imaging
limited. Difficulty placing the probe.
modality in endovascular repair; it complements
Change in character of spontaneous
angiography in determination of endoleaks and
echocontrast may signal occlusion of
thromboexclusion of the aneurysm.
aneurysm and endoleak.
TEE essential in determining graft landing TEE suitable for use throughout procedure. TEE
zone in 16 (62%) patients. TEE
complemented angiography in providing optimal
measurements prevented graft sizeaortic
procedural results. After deployment, TEE
mismatch in 4 patients. Distal landing
appears more sensitive than angiography in
zone change in 12 patients due to
determining endoleaks.
presence of atheromatous disease.
TEE used to confirm wire in true lumen
TEE algorithm is an easy tool to facilitate
and position graft. After deployment,
endovascular treatment of Stanford type B
appearance of spontaneous echocontrast dissection. TEE provided additional information
is suggestive of closure of the primary
from angiography in 16 (%) patients that was
intimal tear. If unsuccessful, color
critical in successful operation. The 5 endoleaks
Doppler imaging used to further guide
determined by CT at discharge were previously
stenting.
identified by TEE.
TEE identified the guidewire in the false TEE provided information that resulted in a
lumen in 2 of 7 dissections. In one third
procedural change in 13 (59%) patients.
of patients with aneurismal disease, the
Procedure was successful in all patients;
proximal landing site was changed after
complications avoided due images provided by
TEE detected atheromatous disease.
TEE.
Color Doppler echocardiography
demonstrated 7 endoleaks compared
with angiography (P = .02).
No complications due to the use of TEE
TEE is an essential adjunct to fluoscopy in the
were observed. TEE clearly identified
placement of endovascular grafts. TEE identifies
dissection in flap in all patients.
the intimal tear, establishes closure of tear with
Endoleaks were identified in 6 patients
graft, and detects endoleaks.
by TEE; angiography only demonstrated
3 leaks.
TEE and intravascular ultrasound (IVUS) TEE in conjunction with angiography provides
are superior to angiography in
useful information in the endovascular treatment
determining multiple entry sites and
of Stanford type B dissection.
demonstrating decreased flow in the
false lumen after stent deployment. TEE
superior to IVUS and angiography in the
detection of endoleaks.
An 87-year-old with Stanford type A
Endovascular graft placed successfully in the
dissection refused open surgical
ascending aorta. After deployment, TEE
treatment; opted for endovascular repair. demonstrated flow to both coronary arteries in
TEE demonstrated moderate AI,
addition to the arch vessels. TEE essential in
pericardial and pleural effusions, and
placement of prosthesis in ascending aorta.
normal contractility.
(continued)
275
Authors
Year
Population
(n)
Napoli
et al130
2004
30
Dobson
et al131
2004
Dobson
et al132
2006
Moskowitz
et al133
1999
Observations
TEE Conclusions
Study goal to investigate the use of

Investigation used ultrasound, not TEE. Use of
contrast-enhanced ultrasound to detect
contrast agents probably likely to improve imaging
endoleaks in patients who had undergone with TEE as well.
endovascular abdominal aortic aneurysm
repair. Patient population had enlarging
aneurysm without evidence of endoleak.
Traumatic disruption of descending aorta TEE prevented inadvertent placement of
was treated with endovascular graft.
endovascular graft in pseudoaneurysm.
TEE demonstrated stent introducer
entering the pseudoaneurysm; not
evident on fluoroscopy.
Traumatic disruption of descending aorta Appearance of echo contrast outside of the graft
was treated with endovascular graft.
lumen provided definitive evidence of endoleak.
TEE identified endoleak that was not
Balloon dilation eliminated endoleak. Use of
seen with angiography. Echo contrast
echocontrast important in providing best
(Definity) administered as an adjunct.
procedural results.
Visualization of aortic disease accomplished TEE improves repair by identifying pathology,
in all patients with TEE. After
assisting in placement, confirming aneurysm
deployment, TEE confirmed proper
isolation, and monitoring cardiac function. TEE
placement and exclusion of blood flow.
should not replace fluoroscopy but rather
complement it.
NOTES: TEE = transesophageal echocardiography; CT = computed tomography.
Critical Care (Table 5)

The critically injured patient provides a unique set of
conditions to challenge physician management. The
combination of mechanical ventilation, invasive hemodynamic monitoring, multiple infusions, and surgical
wounds limit the ability to transport the patients for
diagnostic procedures. TEE is ideal for the critical
care setting as it is versatile, accurate, and rapid.
Furthermore, multiple studies have questioned the usefulness of invasive hemodynamic monitoring.171-178
Practice guidelines179 support the use of echocardiography in patients with critical illness. Indications
for the application of TEE include evaluation of hemodynamic instability due to structural or functional
impairment, diseases of the pericardium, sources of
emboli (both cerebral and peripheral), and endocarditis. Additionally, TEE can facilitate the differential
diagnosis of hypoxemia (ie, intracardiac shunting,
intrapulmonary shunting, or pleural effusions).
Since the introduction of TEE into clinical practice, numerous authors have investigated the impact in
the critical care patient.18,171-178,180-195 Some studies
have reported that TEE has provided additional diagnostic information in more than 75% of patients and
altered therapeutic plans in more than 50% of patients.
Orthopedics (Table 6)
As the demographics continue to change, older and
sicker patients are presenting for an increasing number of total joint procedures. A significant body of literature demonstrates the utility of intraoperative
TEE in the setting of orthopedic procedures.196-214
Furthermore, patients will continue to present emergently for femoral and pelvic fractures requiring
hemiarthroplasty or total arthroplasty. We believe that
intraoperative TEE will be of benefit in providing necessary functional cardiac assessment as well as guiding therapy during the actual surgical procedure.
Additionally, patients undergoing spinal instrumentation211,213 also provided medically challenging
cases as a result of their disease processes. Intraoperative TEE has provided complementary information to invasive hemodynamic monitors.
Therapeutic Impact of TEE

There are only a few studies in the literature that have
looked at the therapeutic impact of TEE. In part this
because it is very difficult to define therapeutic
impact. Some have defined therapeutic impact as
276
Table 3.
Authors
Year
Population
(n)
Ahrar
et al110
1997
89
Saletta
et al113
1995
114
Shapiro
et al114
1991
19
Frazee
et al137
1986
291
Helling
et al139
1989
68
Mattox
et al135
1985
204
Ellis and
Bender117
1991
Beggs
et al136
1987
40
Plummer
et al
1992
49
Schiavone
1991
et al143
Garcia1998
Fernandez
et al138
Mollod and
Felner141
1996
134
16
An Overview of Transesophageal Echocardiography Use in Trauma

Observations
Nineteen percent (17 of 89) had 24 ruptured
aortic arch branch vessels. The safety of TEE
in patients with cervical spine injuries. Failure
rate approaches 8% in patients with maxofacial
injuries.
TEE failed to identify 3 patients with aortic
transaction diagnosed with angiography.
TEE abnormal in 12 patients. Abnormalities

included valvular insufficiency, pericardial
effusion, and segmental wall motion
abnormalities.
TTE, serial ECG, CK-MG used to evaluated blunt
chest trauma. Forty percent incidence of
cardiac contusion.
Forty-nine patients (72%) were found to have
abnormal ECG, TTE, or CK-MB. Evaluation of
patients with blunt chest trauma should be
multifaceted.
Blunt and penetrating injury to the heart is
associated with high mortality. Rapid assessment
including TTE improves diagnostic accuracy.
A 34-year-old male involved in motor vehicle
accident. TEE and later autopsy revealed avulsed
tricuspid valve, pericardial effusion and
tamponade, and an intimal tear in the
descending thoracic aorta.
TTE, serial ECGs, and CPK isoenzyme
determination evaluated in blunt chest trauma.
Nine patients (23%) had abnormal
echocardiograms; no correlation with ECG
changes or presence of CPK. TTE should
complement other diagnostic modalities in blunt
chest trauma.
Patients with penetrating cardiac injury were either
evaluated with (28) or without (21) TTE.
Survival in TTE group was 100% versus 57.1%
in the nonecho group. Average time to diagnosis
15.5 (TTE) versus 42.4 (nonecho).
Case series highlighting the utility of TTE to
diagnosis cardiac rupture after trauma.
Sixty-six (56%) patients had TEE findings due to
blunt chest trauma. There was an association
with abnormal ECGs and elevated peak serum
CK-MB levels.
Variety of pathologic conditions including
intracardiac shunts, valvular pathology, foreign
bodies, aortic ruptures, and segmental wall
motion abnormalities (SWMAs) 2 to coronary
artery laceration.
TEE Conclusions
If TEE is the primary imaging modality
in blunt chest trauma, approximately
20% of injuries will be missed or
improperly evaluated. Furthermore,
facial and cervical injuries may limit
the use of TEE in trauma patients.
TEE had a sensitivity of 63% and a
specificity of 84% for aortic rupture.
Caution on using TEE as sole
diagnostic modality in blunt chest
trauma.
TEE provides a rapid assessment of
cardiac structure and function as
well as evaluation of aorta and
mediastinum.
None
None
None
None
None
None
None
TEE can be routinely and safely used
to evaluate cardiac injuries after
blunt chest trauma.
TEE is a safe, efficient, and accurate
method to evaluate cardiac and aortic
pathology following blunt chest
trauma.
(continued)
277
Table 3.(continued)
Authors
Year
Population
(n)
Goarin
et al107
1997
28
Patients with severe blunt chest trauma, confirmed

traumatic aortic injury (TAI), and TEE performed
by trained physician. Study group compared
with 30 patients without TAI.
Sparks
et al115
1991
11
Vignon
et al116
1995
32
Eleven underwent aortography with 6 positive

results. TEE was positive in 3 of 11 patients,
confirmed at surgery. Remaining 8 patients
demonstrated no aortic morbidity.
Thirty-two patients with suspected traumatic
disruption of aorta (TDA) prospectively
underwent TEE. TEE results compared with
results of aortography, surgery, or necropsy.
Minard
et al112
1996
34
Examination unsuccessful in 5 patients. In the

remaining patients, 4 true positives, 20
true-negatives, 2 false-positives, 3 false-negatives.
Sensitivity and specificity of TEE were 57% and
91%, respectively.
Weiss
et al142
1996
22
Karalis
et al111
1996
105
Goarin
et al108
2000
209
Hiatt
et al140
1988
73
Retrospectively, reviewed charts of patients with

TEE-diagnosed cardiac contusion. Contusion
patients had a higher mortality, 27% versus 9%
(P < .001). ECGs were nondiagnostic in 73% of
patients with cardiac contusions. Right
ventricular contusions are twice as common as
left ventricular contusions.
TTE performed on 105 patients with blunt chest
trauma. Twenty TEEs performed on patients
with suboptimal TTE. Thirty-one patients (30%)
diagnosed with myocardial contusion. Eight of
31 (26%) developed cardiac complications
compared with 2 of 74 patients (3%) with
normal echo findings.
Blunt trauma patients suspected of having
traumatic aortic injury underwent TEE and
angiography. TEE (sensitivity 98%, specificity
100%) more accurate than angiography
(sensitivity 83%, specificity 100%) in minor
aortic injury. Equivalent for major aortic injury.
TTE, continuous ECG, serial ECG, and peak
CK-MB levels used to evaluate severity of injury.
Patients with an abnormal TTE had higher peak
CK-MB, numbers of associated injuries, and
Injury Severity Scores. Patients with normal
TTE and ECG do not require invasive
monitoring.
Observations
TEE Conclusions
TEE can diagnosis traumatic aortic
injury with some limitations.
Additionally, TEE allows diagnosis
of additional conditions associated
with trauma: myocardial contusion,
hemopericardium, hypovolemia, and
valvular insufficiency.
TEE is a useful technique in the
diagnosis of descending aortic
rupture.
Sensitivity and specificity of TEE for
the diagnosis of TDA were 91% and
100%, respectively. TEE should be
considered the first-line imaging
modality for the evaluation of
patients with suspected pathology of
the thoracic aorta.
Compared with aortography, sensitivity
89% and specificity 100%, TEE is
less accurate. TEE should not
replace aortography as the gold
standard for diagnosis of traumatic
disruption of the aorta.
TEE examinations are safe with
excellent quality images. TTE
examinations are often inadequate
in blunt chest trauma patients.
TEE is valuable when TTE images are

suboptimal and aortic injury is
suspected.
TEE is an accurate diagnostic tool for

traumatic aortic injury.
None
NOTES: TEE = transesophageal echocardiography; TTE = transthoracic echocardiography; ECG = electrocardiogram; CPK =
creatinine phosphokinase; CK-MB = creatinine phosophokinase (MB fraction); TDA = traumatic disruption of the aorta.
278
Table 4.
A Limited Review of Transesophageal Echocardiography in Transplant Surgery
Authors
Year
Population
(n)
Stoddard
et al162
1992
24
De Wolf
et al147
1993
20
Gorcsan
et al155
1995
48
Prah
et al151
1994
Ellis
et al148
1989
16
Suriani
et al154
1996
100
Harley
et al149
1996
OConnor 2000
et al150
Observations
TEE Conclusions
TTE technically difficulty in 7 (29%) patients.

Of those 7, 5 patients had abnormal
examinations, segmental wall motion
abnormalities (SWMAs) and concentric LV
hypertrophy. One technically adequate TTE
failed to diagnose a bicuspid aortic valve.
Pulmonary artery catheter (PAC) with fast
response thermistor as well as TEE was
used to evaluate RV function during
orthotopic liver transplantation. No patient
had pulmonary hypertension in the study.
RV function was within normal during all
stages of transplantation.
All patients underwent left and right heart
catheterization, TTE, and radionucleotide
ventriculography. TEE revealed additional
findings in 12 (25%) patients. Findings
include pulmonary artery thrombi, patent
foramen ovale (PFO), atrial septal, and
ventricular septal defects.
Case 1: TEE demonstrated increased RA size,
decreased RV function, and fibrinous
material on the tricuspid valve and PAC. TEE
visualization demonstrated increasing clot,
progressive RV failure, and ultimately
biventricular failure. Case 2: Increased PA
pressures initiated TEE examination. TEE
demonstrated clot in RA. -Amino-caproic
acid infusion discontinued with resultant
decrease in PA pressure. Similar episode 2
hours later. TEE again demonstrated clot in RA.
Four (25%) patients demonstrated paradoxical
movement of interventricular septum
consistent with RV failure. Additionally, 3
(19%) demonstrated right-to-left divergence
of interatrial septum and RA enlargement.
TEE is a valuable adjunct to TTE when TTE

studies are technically inadequate in the
screening of cardiac donors. TEE may
eliminate the need for cardiac
catheterization or direct surgical inspection.
TEE indicated for monitoring in 62 patients, 41

of whom had relevant findings. TEE used for
diagnostic purposes in 38, which confirmed
the diagnosis in 14. Major impact on
intraoperative patient management in 11% of
patients.
High PCWP and low MAP are often treated
with inotropes. TEE demonstrated low LV
volume with high PCWP, thus patients treated
with fluid resuscitation, not inotropes.
Case 1: Extreme hypotension indicated an
emergent TEE, which demonstrated RA
thrombus occluding the tricuspid valve.
Emboli surgically removed. Case 2: TEE
performed for suspected PE. Fibrinous
strands in RA, RV, and PA, across PFO, and
on all valves. Urokinase infusion initiated.
Used TEE to evaluate RV function;

investigation not focused on TEE value.
TEE is a useful adjunct in the preoperative

evaluation of patients with severe pulmonary
hypertension undergoing lung
transplantation. Accurate anatomic
knowledge is essential for successful lung
transplantation. TEE provides high-resolution
images of cardiovascular anatomy.
TEE provides accurate, real-time
information in the diagnosis of
hemodynamic collapse in patients
undergoing orthotopic liver
transplantation.
TEE clearly identified patients with RV wall

motion abnormalities, RV failure, and
thromboembolism. TEE demonstrated that
RV failure may be responsible for the
hemodynamic instability associated with
orthotopic liver transplantation.
It is safe to perform TEE on liver transplant
patients. TEE is efficient in providing
information that otherwise would not have
been discovered, and it is a useful monitor
during hemodynamic instability. Potential
for significant impact on patient
management.
TEE-guided therapy important in patient
management.
TEE essential in providing accurate diagnosis

of hypotension, prompting a change in the
medical management of the patients.
(continued)
Table 4.
Authors
Year
Population
(n)
Krenn
et al152
2004
10
Michel1997
Cherqui
et al153
Suriani
1996
et al154
18
(continued)
Observations
TEE Conclusions
TEE-measured left ventricular shortening

fraction demonstrated evidence of maintained
myocardial contractility. Hemodynamic
changes during OLT may be due to fluid shifts.
All 13 RPA anastomoses visualized; none of 9
LPA anastomoses visualized; all pulmonary
vein anastomoses visualized.
Review article recognizing the use of TEE in
organ transplantation. Accurate tool for
diagnosing RV decompensation and failure,
volume status, and pulmonary arterial and
venous anastomoses in lung transplant.
Article also addresses TEE in liver transplant.
Valuable for left and right ventricular
function and volume, as well as abnormal
cardiac anatomy.
279
TEE useful monitor of contractility in

patients undergoing liver
transplantation.
TEE provides immediate evaluation of
vascular anastomoses, thus allowing
immediate surgical correction if abnormal.
TEE should be used in organ transplantation.
Both lung transplant and liver transplant
patients benefit from TEE-guided
intraoperative management.
NOTES: TEE = transesophageal echocardiography; LV = left ventricle; RV = right ventricle; RA = right atrium; PA = pulmonary
artery; RPA = right pulmonary artery; LPA = left pulmonary artery; PCWP = pulmonary capillary wedge pressure; MAP = mean
arterial pressure; OLT = orthotopic liver transplantation.
Table 5.
Transesophageal Echocardiography and Critical Care
Author
Year
TEE (N)
ICU Description
Hutteman et al186
Bruch et al181
2004
2003
216
117
Colreavy et al183
Schmidlin et al191
Vignon et al194
Wake et al195
Harris et al184
McLean188
Alam180
Slama et al192
Heidenreich185
Poelaert189
Sohn et al193
2002
2001
2001
2001
1999
1998
1996
1996
1995
1995
1995
308
298
?
130
206
53
121
61
61
103
127
Chenzbraun et al182
Khoury et al187
1994
1994
113
77
Hwang et al174
Puybasset et al190
Foster and Schiller173
Oh et al177
1993
1993
1992
1990
78
32
69
51
Pearson et al178
1990
62
SICU
SICU (14%), Trauma-ICU
(9%), CTICU (48%),
ANES-ICU (29%)
MICU, CTICU
CTICU
MICU, CTICU
CTICU
CICU
ICU
CICU, MICU, SICU
MICU
CICU
ICU
CICU (18%), MICU (38%),
SICU (26%), CTICU (18%)
CTICU, MICU, CCU
SICU (48%), CICU (24%),
MICU (19%), NICU (7%)
ICU, ED
MICU
ICU
CICU (49%), MICU (22%),
SICU (29%)
CICU (48%), MICU (19%),
CTICU (21%), SICU (11%)
Diagnostic
Impact (%)
Therapeutic
Impact (%)
Complications (%)
88
59
69
43
6
2
45
45
97
41.5
47
45
65
66
97
74
52
33
73
41
58.5
32
10
18
45
48
43
21
2
NR
0
NR
NR
NR
0
1
5
1
2
45
60
26
48
7
3
50
56
17
59
NR
NR
43
24
44
NR
0
NR
0
4
4.8
NOTES: TEE = transesophageal echocardiography; ICU = intensive care unit; SICU = surgical intensive care unit; CTICU = cardiothoracic intensive care unit; ANES-ICU = anesthesia ICU; MICU = medical intensive care unit; CICU = cardiac intensive care unit;
NICU = neurointensive care unit; ED = emergency department; NR = not reported.
280
Table 6.
The Use of Transesophageal Echocardiography in Orthopedics
Authors
Year
Population
(n)
Surgical
Procedure
Bisignani et al197
2008
40
Berman et al196
1998
55
Parmet et al206
1998
13
THA (55%
cemented)
TKA
(cemented)
TKA
(cemented)
Parmet et al207
1994
35
Kato et al200
2003
46
Koessler and Pitto202 2001
120
Propst et al212
1993
20
Moriyama et al204
2005
62
Lafont et al203
1997
48
Pitto et al209
2002
130
Pitto et al208
2000
40
Pitto et al210
1999
60
Primiano et al211
1983
36
Soliman et al213
1998
12
Ulrich et al214
1986
26
Murphy et al205
1997
16
Observations
Flurry of echogenic emboli without adverse

sequelae.
Increased pulmonary vascular resistance in
patients with emboli >0.5 cm.
Patients undergoing knee replacement with
tourniquet had 5.33-fold greater risk of large
venous emboli compared with patients without
tourniquet.
TKA
Echogenic emboli occurred in all patients on
(cemented)
release. Increased pulmonary vascular
resistance only in patients with large emboli.
TKA
Randomized to tourniquet or no tourniquet.
(cemented
??Patients with severe echogenic emboli
tourniquet)
experienced cardiopulmonary impairment.
THA
Embolic events during THA can cause increased
(cemented)
pulmonary shunt, particularly in patients with
systemic disease.
THA
Methylmethacrylate cement is associated with
(cemented)
increased amount of intraoperative pulmonary
embolism and segmental or global wall motion
abnormalities.
THA (32%
Intraoperative TEE did not predict the
cemented)
occurrence of pulmonary embolism on
postoperative day 1.
THA
TEE revealed showers of emboli in all but 1
(cemented)
patient. No correlation between size or
frequency of emboli and clinical events.
THA (cemented Vacuum-cemented technique associated with
vs vacuum
decreased embolic load and incidence of
cemented)
postoperative deep vein thrombosis.
Hemiarthroplasty Comparison of conventional versus
(cemented vs
vacuum-cemented techniques in patients with
vacuum
femoral neck fractures. Bone vacuum group
cemented)
experience less severe embolic load, both in
size and frequency.
THA (cemented Purpose of the study focused on prevention of
vs vacuum
pulmonary emboli as a function of cementing
cemented)
technique. Conventional cementing technique
associated with severe pulmonary embolic load
and cardiopulmonary impairment.
No surgery
Transthoracic evaluation of right ventricular and
pulmonary function in adolescents and young
adults in early idiopathic scoliosis.
Scoliosis repair
Central venous pressure monitoring inaccurate in
kyphosis/scoliosis repair in prone position.
TEE may provide better evaluation of volume
status and function.
THA (cemented) Primary goal to evaluate venting borehole in
femoral shaft prior to cementing. Significantly
decreased embolic load in patients with
venting borehole.
THA (mongrel
Pressurization of medullary cavity was associated
dogs)
with increased embolic load and right
ventricular dimensions.
TEE Conclusions
Not recommended
routinely
None
None
None
None
None
None
Not recommended
routinely
Not recommended
routinely
None
None
None
None
None
None
None
(continued)
281
Authors
Year
Population
(n)
Hirota et al199
2002
40
Christie et al198
1994
20
Surgical
Procedure
Observations
TKA versus ACL

repair
Embolic phenomenon in both groups within 1

minute of tourniquet release. Embolic load
significantly increased in patients undergoing
intramedullary procedure.
Hemiarthroplasty Hemiarthroplasty with cement was associated
(cement)
with more frequent and severe embolic
phenomenon. Increased embolic load may be
caused by pulmonary hypertension and
impaired gas exchange.
TEE Conclusions
None
None
NOTES: TEE = tranesophageal echocardiography; TKA = total knee arthroplasty; THA = total hip arthroplasty; ACL = anterior
cruciate ligament.
change in anesthetic or surgical plan, additional

surgical procedures, or follow-up. Others have
defined initiation of inotropic, vasodilator or pressors,
and TEE-based fluid management as therapeutic
impact of TEE.18,154,177,189,215-218 Due to the varying
designs of these studies, it is difficult to compare
them and definitively calculate the degree of therapeutic impact. TEE has higher impact on intraoperative decision making for category I indications than
category II indications.154,216,218 TEE has been definitely shown to be beneficial during periods of hemodynamic instability, right ventricular dysfunction, in
elderly patients, and for initiation of anti-ischemic
therapy. Despite the higher impact for category I indications, TEE is used more often for category II indications.218 It has been suggested that due to the
supportive nature of the information provided, the
exact degree of the impact of TEE is difficult to measure.18,177 Confirmation of clinical suspicion with TEE
leading to no change in therapy should also be considered an impact, which would significantly increase
the value of TEE during noncardiac surgery. During
routine coronary artery bypass graft surgery, intraoperative TEE is considered almost a standard of care
without having direct evidence of its usefulness (ie, it
is a category II indication). Hence, when it comes to
TEE for noncardiac surgery, anesthesiologists may be
skeptical, requiring this monitoring modality to prove
what very few other invasive and noninvasive monitors have showna difference in outcome. Other
than the initial cost and training, lack of familiarity of
the practicing anesthesiologists, and lack of realization of its true potential may be keeping this very useful monitor out of the noncardiac ORs.
Conclusion
TEE is very useful monitoring modality that provides
valuable information during cardiac as well as noncardiac surgical procedures. We need to train more
anesthesiologists to perform perioperative TEE to
increase awareness of the indications and contraindications. Until relatively inexpensive TEE
equipment is available, the initial cost of equipment
acquisition remains a significant prohibitive factor
in its widespread use.
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Transesophageal Echocardiography

and Noncardiac Surgery

Feroze Mahmood, MD, Angus Christie, MD, and Robina Matyal, MD

regard is presented. Landmark trials evaluating the use

esophageal stethoscope for intraoperative use was

he use of transesophageal echocardiography

Keywords: transesophageal echocardiography; transthoracic echocardiography; noncardiac surgery

also be diagnosed, and the response to therapy

Safety Profile of Transesophageal

The other available intraoperative monitors (eg,

Indications During Noncardiac Surgery

TEE and Noncardiac Surgery / Mahmood et al

sophisticated techniques can be employed by

intraoperative WMAs as detected by TEE have

therapy and more vigilant care) to improve outcome.

TEE Preload Assessment

predict a range of LVEDP.45,46 The Doppler estimation

TEE and Noncardiac Surgery / Mahmood et al

Determination of ventricular stroke volume and

MPI to assess myocardial function are the simplicity

Application of TEE for

Vascular Surgery (Table 1)

TEE and Noncardiac Surgery / Mahmood et al

mobile diagnostic tool with which to image the aorta.

Endovascular Surgery (Table 2)

Transplant Surgery (Table 4)

Use of Transesophageal Echocardiography in Vascular Surgery

Observational study investigating the correlation

TEE is very sensitive but

30% incidence of new or worsened segmental wall

TEE and Noncardiac Surgery / Mahmood et al

In dissection subpopulation, TEE was more likely

Study successfully completed in 93 of 101 patients.

Celiac, superior mesenteric, left and right renal

332 men at high risk for CAD; 111 (39%)

Sensitivity in detection of thoracic aortic dissection

the literature shows that TEE in obstetrical patients is

The Use of Transesophageal Echocardiography in Endovascular Surgery

TEE and Noncardiac Surgery / Mahmood et al

Study goal to investigate the use of

NOTES: TEE = transesophageal echocardiography; CT = computed tomography.

Critical Care (Table 5)

Therapeutic Impact of TEE

An Overview of Transesophageal Echocardiography Use in Trauma

TEE abnormal in 12 patients. Abnormalities

TEE and Noncardiac Surgery / Mahmood et al

Patients with severe blunt chest trauma, confirmed

Eleven underwent aortography with 6 positive

Examination unsuccessful in 5 patients. In the

Retrospectively, reviewed charts of patients with

TEE is valuable when TTE images are

TEE is an accurate diagnostic tool for

A Limited Review of Transesophageal Echocardiography in Transplant Surgery

TTE technically difficulty in 7 (29%) patients.

TEE is a valuable adjunct to TTE when TTE

TEE indicated for monitoring in 62 patients, 41

Used TEE to evaluate RV function;

TEE is a useful adjunct in the preoperative

TEE clearly identified patients with RV wall

TEE essential in providing accurate diagnosis

TEE and Noncardiac Surgery / Mahmood et al

TEE-measured left ventricular shortening

TEE useful monitor of contractility in