PRO: Transesophageal Echocardiography (TEE) should be used routinely in all high risk noncardiac surgery
Feroze Mahmood, MD
Beth Israel Deaconess Medical Center,
Harvard Medical School, Boston, MA.
Use of TEE as a perioperative monitor during noncardiac surgical procedures has not been systematically studied. The American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists (ASA/SCA) guidelines for use of TEE describe two applications of TEE in the noncardiac surgical population (life threatening hemodynamic disturbance and intensive care monitoring) as Category I indications.1 However, the guidelines are not comprehensive, but rather restrictive.
The commonest indications for using TEE perioperatively in the noncardiac surgical setting are:
- Assessment of:
- Ventricular function
- Volume status
- Valvular pathology
- Assessment of response to therapy
- Provide rapid diagnosis:
- Pericardial pathology
- Hemodynamic instability and hypoxia
For each of the aforementioned indications, TEE provides a superior alternate to any other diagnostic modality.
TEE and Preload/Volume
TEE is rapidly becoming a
modality of choice to determine the volume status of patients in the
Intensive Care Unit (ICU) and the operating room. The LV
end-diastolic area (EDA) in the transgastric short axis view has been
shown to be a reliable indicator of LV preload in cardiac surgical
patients even in the presence of wall motion
abnormalities2. Measurement of EDA has also been shown to
help identify patients in the ICU that will respond positively to a
fluid challenge with increased stroke volume and cardiac
output.3, 4 Traditionally, Doppler analysis of mitral
inflow patterns has been used to assess the LV and left atrial filling
pressures. Factors such as pattern and rate of ventricular relaxation,
mitral leaflet mobility, and left atrial filling pressure affect the
mitral inflow.5 Correlation between transmitral Doppler
variables and PCWP has been investigated by numerous authors with
conflicting results.5 However, Minoru et al6
in one of the first intraoperative use of these variables, have
demonstrated an excellent direct correlation between PCWP and
deceleration slope of the early diastolic LV filling and inverse
relationship with the deceleration time of early diastolic filling in
patients with ejection fraction <35%. A sensitivity and specificity
of 100% and 99% for a deceleration time ≤ 120 ms to predict a PCWP
of ≥ 20 mm Hg has been reported in patients with depressed systolic
function.7 A combination of transmitral color M-mode and
Doppler Tissue Imaging (DTI) of the mitral annulus has been shown to
be moderately sensitive and specific for prediction of LVEDP and seems
to overcome the dependence of transmitral Doppler velocities on
loading conditions.8 Also, DTI has been shown to be a
better predictor of LV filling pressures in patients with preserved
systolic function.5 In the era of cost containment, use of
intraoperative TEE may prove to be a very simple, noninvasive, and
reliable alternative to the pulmonary artery catheter for estimation
of LV preload.6
TEE and Ventricular Function
TEE provides rapid
assessment of the LV systolic function by providing high quality
images in multiple planes and positions. Transgastric short axis view
of the LV is easily obtained by TEE and provides assessment of
ventricular walls supplied by all the coronary arteries.9,
10 Quantitative assessment of the LV function can be performed using
mathematical formulae such as the Teicholz formula and Simpson's rule
for those with abnormally shaped ventricles and wall motion
abnormalities.9,11 However, this can be time consuming and
it has been demonstrated that visual estimation of ventricular
systolic function is as or more accurate than off-line
echocardiographic measurements using these formulae.12
Heart failure is one of the commonest diagnoses made on
inpatients. Previously, investigators have focused on the explanation
of deterioration in systolic function to account for the symptoms of
HF. However, it is being increasingly realized that abnormalities of
diastolic function are responsible for the heart failure symptoms in
almost 1/3 of these patients who have normal systolic
function.13, 14, 15 Cardiac catheterization used to be the
only modality available to clinicians to diagnose and quantify
diastolic function. With the advent of two-dimensional
echocardiography and Doppler imaging, diastolic dysfunction is being
diagnosed and treated more often than before and TEE has become a
reliable, reproducible, and practical noninvasive method of diagnosis
and treatment, as well as longitudinal follow up in patients with
diastolic dysfunction.16 Doppler echocardiography has also been used
to develop more objective and quantifiable parameters of ventricular
function which combine systolic as well as diastolic performance, such
as "myocardial performance index" (MPI), also referred to as the "Tei
Index".17 It is defined as the sum of isovolumetric contraction time
and isovolumetric relaxation time divided by the ejection time. This
index is easily obtained, reproducible, and has shown excellent
correlation with invasively measured parameters of systolic and
diastolic function. MPI also does not seem to depend upon ventricular
geometry and heart rate, and has demonstrated prognostic value in
patients with cardiac amyloidosis and cardiomypopathy and after
myocardial infarction.18 Another very important function of TEE is an
accurate assessment of the function of right ventricle, because of its
implications on prognosis.19 A combination of two dimensional and
Doppler techniques can be used to calculate the stroke volume as well
as the cardiac output.20 Cardiac output measured via TEE has shown
good correlation with measurements made with the pulmonary artery
catheter; however, the accuracy depends upon a good alignment of the
Doppler beam with the flow profile and there is potential for
Absence of perioperative ischemia
diagnosed by any means is a predictor of a favorable postoperative
outcome.21, 22 The response of myocardium to ischemia is manifested as
diastolic dysfunction initially, followed by wall motion abnormalities
(WMA), and then ECG changes, followed by clinical symptoms.23 The
transgastric short axis view at the midpapillary level has been shown
to be most reliable in diagnosing ischemia-related WMA, but
visualizing the left ventricle in multiple planes increases the
detection of WMA.24 It has been shown that WMA can be detected on
echocardiography within a few seconds of coronary occlusion.25, 26 On
the other hand, TEE and ST segment analysis have shown poor
correlation in many studies,21, 22 with ST segments lagging behind in
the timeline. Despite their association with ischemia, WMA detected on
TEE have shown a low predictive value for association with
postoperative myocardial infarction.27, 28 This shows that TEE is
highly sensitive for detection of ischemia, and detects occurrence of
myocardial damage even before the markers for cellular damage can be
detected. However, these false positives may also be due to many
nonischemic causes of WMA, such as sudden changes in loading
conditions, conduction abnormalities, and translational motion of the
heart.29 Although the present data does not clearly demonstrate that
intraoperative ischemia detected by TEE relates to postoperative
outcome, it does not refute.
Assessment of hemodynamic instability is
one of the most important indications for TEE. Especially in cases of
trauma, a rapid diagnosis is essential prior to institution of
therapy. Use of TEE in cases of penetrating chest injuries has shown
to expedite the diagnosis (e.g., cardiac injuries) and institution of
therapy when compared with patients who do not have TEE for
diagnosis.30 In critically ill patients in the ICU, use of TEE helps
in reaching a quick diagnosis and improving management and outcome.31
Similarly, there is a growing body of evidence of beneficial use of
TEE during lung and liver transplantation as well.32, 33
Therapeutic Impact of TEE
There are very few studies in
the literature that assess the impact of TEE during noncardiac
surgery. Largely, it has been because of the ambiguous definition of
"impact" of TEE. Suriani et al34 defined impact as a change of therapy
or change in eventual management during the course of noncardiac
surgery and stated that TEE had major impact in 15% and minor impact
in 45% cases. Hofer et al35 utilized TEE in a prospective study to
assess its impact and reported that it was especially beneficial in
patients with pulmonary hypertension and right ventricular
failure. Confirmation of clinical suspicion and no change in therapy
in a situation with equivocal data from other monitors, such as the
pulmonary artery catheter, should also be defined as having
therapeutic impact during the course of noncardiac surgery. Inclusion
of no change in therapy due to TEE in estimation of therapeutic impact
would have definitely increased the percentage of impact in the
TEE is the modality of choice for Category I
indications,36 but its use for Category II indications in
perioperative settings has been shown to depend upon the preference
and training of the anesthesiologist.37 In high risk noncardiac
surgery, the cardiovascular morbidity and mortality is of the utmost
concern. Perioperative management has been shown to make an impact on
the postoperative morbidity and mortality. TEE provides an
expeditious, safe, and reliable modality of a comprehensive
qualitative and quantitative assessment of the cardiovascular system
as well monitoring the response to therapy in real-time. Newer
applications of TEE, such as visualization of aortic branches,
assessment of tissue blood flow to kidneys and intestines,38 and use
of TEE guided deployment of endovascular stents during thoracic aortic
repair39 offer exciting new uses of TEE during noncardiac
surgery. Another area of potential utilization of intraoperative TEE
during noncardiac surgery is the assessment of thoracic aortic
atherosclerotic plaques. Association of thoracic aortic plaques and
other risk factors for coronary artery disease, such as age, diabetes,
and hypertension has been reported.40 In addition, a very strong
association between severity of the thoracic aortic plaque and the
extent of coronary artery disease has been reported.41, 42
indications of TEE are being developed and it is time to incorporate
TEE training as part of accredited anesthesia residency programs and
reexamine the guidelines for the indications for TEE to make them more
comprehensive and inclusive. As more and more evidence is gathered
about the usefulness of TEE as a comprehensive monitor, it is expected
that in the near future, anesthesiologists will use it more routinely
in preference over other invasive monitors.
- Practice Guidelines for Perioperative Transesophageal Echocardiography. A Report by the American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 1996; 84: 986-1006.
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- Ommen SR, Nishimura RA, Appleton CP et al. Clinical Utility of Echocardiography and Tissue Doppler Imaging in the Estimation of Left Ventricular Filling Pressures. A comparative simultaneous Doppler- Catheterization Study. Circulation. 2000;102:1788-1794.
- Minoru M, Hillel Z, Shih H et al. The Association Between Doppler Transmitral Flow Variables Measured By Transesophageal Echocardiography and Pulmonary Capillary Wedge Pressure. Anesth Analg 1997; 84:491-6.
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- Tei C, Nishimura RA, Seward JB et al. Noninvasive Doppler-derived myocardial performance index: Correlation with simultaneous measurements of cardiac catheterization measurements. J Am Soc Echocardiogr. 1997;10: 169-178.
- Poulsen SH, Jensen SE, Nielsen JE et al. Serial Changes and Prognostic Implications of a Doppler-Derived Index of Combined Left Ventricular Systolic and Diastolic Myocardial Performance in Acute Myocardial Infarction. Am J Cardiol 2000;85:19-25.
- Sung JP, James KB, Yang XS, et al. Comparisons of mortality rate and progression of left ventricular dysfunction in patients with idiopathic dilated cardiomyopathy and dilated versus non dilated right ventricular cavities. Am J Cardiol 1997;80: 1583-1587.
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