CON: Transesophageal Echocardiography (TEE) should be used routinely in all high risk noncardiac surgery
John E. Ellis, MD
Professor, Department of Anesthesia and Critical Care
The University of Chicago
Transesophageal echocardiography (TEE) provides useful information
on cardiac structure and function. It can diagnose ischemia, aortic
pathology, and valvular disturbances. However, just because it can do
these things does not mean that patients benefit from routine use.
Limitations include difficulty in using TEE continuously outside of
the operating room; the cost; diversion from vigilance and common
tasks; and false positive results resulting in unnecessary therapies.
Most importantly, the benefits provided by routine TEE may well not be
cost-effective. Even though years ago we showed that persistent TEE
myocardial ischemia was associated with poor outcome after major
vascular surgery,1 the San Francisco group has shown that such
ischemia is not an independent predictor of adverse
events,2 if more common clinical indicators such ischemic ECG changes
and preoperative cardiac risk factors are considered. Indeed, in my
practice, a large number of patients present with recent
echocardiography, stress echo, or thallium scanning, with estimation
of LV function. In patients with normal LV function to begin with,
intraoperative TEE may be relatively uninformative. Indeed, even
preoperative echocardiography may be limited in its ability to predict
Unlike cardiac surgery, where TEE may actually guide surgical
management4,5 (aortic cannula placement, mitral
regurgitation, coronary sinus cannulation, etc.), rarely does the same
hold true in major vascular procedures. While TEE is an excellent
tool for diagnosis of thoracic dissection,6 most patients will have
been imaged and diagnosed before coming to the operating room. In
some cases, though, TEE may help surgeons to choose a deployment site
during endovascular thoracic aneurysm (TAA) repair.7 Other specialized
but rare uses may include detection of caval and atrial thrombi.8
In my practice, I reserve TEE for evaluation of cardiac structure
and function in patients who are doing poorly. I would estimate that
after several years of routine use in abdominal aortic aneurysm (AAA)
patients, I now use TEE in approximately 10-20% of routine AAA
patients. Situations in which I use TEE today include rupture, where
rapid assessment of contractility and volume status may be helpful
before invasive monitoring can be instituted. Additionally, in those
with supraceliac clamps or those with severe cardiac, pulmonary,
and/or renal dysfunction, I may consider its use.
Indeed, the group at Mt. Sinai in New York showed that TEE resulted
in changes in management in only 15% of patients undergoing noncardiac
surgery.9 Of course, this number will depend on the severity of
illness of the patients studied. A Swiss group found a similar number
(20% of patients had changes in therapy); only in lung and liver
transplant patients was care routinely changed by TEE.10
The majority of AAA repair done at our institution today is of the
endovascular variety; in these cases we generally provide sedation
while surgeons use local anesthesia. This anesthetic technique makes
TEE nearly impossible. As endovascular techniques improve, we can
expect more and more major vascular surgery to be performed without
the need for general anesthesia. Recent series and registries suggest
that endovascular repair of aortic aneurysms (both abdominal and
thoracic) is associated with lower mortality than traditional open
repair.11 Therefore endovascular techniques make TEE both less needed
and less practical. Of course, when the rare endovascular catastrophe
occurs, TEE may be used to guide initial resuscitation,12 since it can
be rapidly placed. As mentioned previously, however, TEE may provide
useful anatomic information during thoracic stent placement.
In our patients undergoing AAA repair, we place a large-bore
central line, and occasionally float a pulmonary artery catheter.
Therefore, in major vascular surgery, we rarely make the choice of
central monitoring vs. TEE; rather TEE is an adjuvant.
Measurement of contractility and valvular function with TEE is more
straightforward than assessment of filling and diastolic function.
Unless one has a dedicated ultrasonographer to measure filling
velocities,13 one will still need invasive monitoring to avoid
overfilling the heart. This is particularly true in the elderly and
those with LVH, where compliance is low and TEE may not help the
clinician appreciate excessive fluid administration. Ischemia
monitoring is limited by the difficulty of quantitative analysis,
particularly when baseline abnormalities, conduction defects, and or
paced rhythms exist.
TEE is not benign. Complications include esophageal tear, bleeding
from esophageal varices,14 infection, and swallowing difficulties.
Admittedly, these complications are rare, but they still may occur.15
In short, I do not believe the evidence supports the utility of
routine use of TEE in major vascular surgery. However, I do use it my
practice to help guide the resuscitation of unstable patients.
Additionally, it may be useful in the management of patients with
thoracic aortic pathology.16
- Gewertz BL, Kremser PC, Zarins CK, Smith JS, Ellis JE, Feinstein SB, Roizen MF. Transesophageal echocardiographic monitoring of myocardial ischemia during vascular surgery. J Vasc Surg. 1987 Apr;5(4):607-13.
- Eisenberg MJ, London MJ, Leung JM, Browner WS, Hollenberg M, Tubau JF, Tateo IM, Schiller NB, Mangano DT. Monitoring for myocardial ischemia during noncardiac surgery. A technology assessment of transesophageal echocardiography and 12-lead electrocardiography. The Study of Perioperative Ischemia Research Group. JAMA. 1992 Jul 8;268(2):210-6.
- Halm EA, Browner WS, Tubau JF, Tateo IM, Mangano DT. Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Study of Perioperative Ischemia Research Group. Ann Intern Med. 1996 Sep 15;125(6):433-41.
- Click RL, Abel MD, Schaff HV. Intraoperative transesophageal echocardiography: 5-year prospective review of impact on surgical management. Mayo Clin Proc. 2000 Mar;75(3):241-7.
- Fanshawe M, Ellis C, Habib S, Konstadt SN, Reich DL. A retrospective analysis of the costs and benefits related to alterations in cardiac surgery from routine intraoperative transesophageal echocardiography. Anesth Analg. 2002 Oct;95(4):824-7.
- Penco M, Paparoni S, Dagianti A, Fusilli C, Vitarelli A, De Remigis F, Mazzola A, Di Luzio V, Gregorini R, D'Eusanio G. Usefulness of transesophageal echocardiography in the assessment of aortic dissection.Am J Cardiol. 2000 Aug 17;86(4A):53G-56G.
- Rapezzi C, Rocchi G, Fattori R, Caldarera I, Ferlito M, Napoli G, Pierangeli A, Branzi A. Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysms. Am J Cardiol. 2001 Feb 1;87(3):315-9.
- igman DB, Hasnain JU, Del Pizzo JJ, Sklar GN. Real-time transesophageal echocardiography for intraoperative surveillance of patients with renal cell carcinoma and vena caval extension undergoing radical nephrectomy. J Urol. 1999 Jan;161(1):36-8.
- Suriani RJ, Neustein S, Shore-Lesserson L, Konstadt S. Intraoperative transesophageal echocardiography during noncardiac surgery. J Cardiothorac Vasc Anesth. 1998 Jun;12(3):274-80.
- Hofer CK, Zollinger A, Rak M, Matter-Ensner S, Klaghofer R, Pasch T, Zalunardo MP. Therapeutic impact of intra-operative transoesophageal echocardiography during noncardiac surgery. Anaesthesia. 2004 Jan;59(1):3-9.
- Akkersdijk GJ, Prinssen M, Blankensteijn JD. The impact of endovascular treatment on in-hospital mortality following non-ruptured AAA repair over a decade: a population based study of 16,446 patients.
Eur J Vasc Endovasc Surg. 2004 Jul;28(1):41-6.
- Moskowitz DM, Kahn RA, Marin ML, Hollier LH. Intraoperative rupture of an abdominal aortic aneurysm during an endovascular stent-graft procedure. Can J Anaesth. 1999 Sep;46(9):887-90.
- Kuecherer HF, Muhiudeen IA, Kusumoto FM, Lee E, Moulinier LE, Cahalan MK, Schiller NB. Estimation of mean left atrial pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow. Circulation. 1990 Oct;82(4):1127-39.
- Ellis JE, Lichtor JL, Feinstein SB, Chung MR, Polk SL, Broelsch C, Emond J, Thistlethwaite JR, Roizen MF. Right heart dysfunction, pulmonary embolism, and paradoxical embolization during liver transplantation. A transesophageal two-dimensional echocardiographic study. Anesth Analg. 1989 Jun;68(6):777-82.
- Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg. 2001 May;92(5):1126-30.
- Gonzalez-Fajardo JA, Gutierrez V, San Roman JA, Serrador A, Arreba E, Del Rio L, Martin M, Carrera S, Vaquero C.Utility of intraoperative transesophageal echocardiography during endovascular stent-graft repair of acute thoracic aortic dissection.Ann Vasc Surg. 2002 May;16(3):297-303.