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
Chicago, IL

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 preoperative risk.3

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

References

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.

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