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:

  1. Assessment of:
    • Ventricular function
    • Volume status
    • Valvular pathology
  2. Monitoring:
    • Ischemia
    • Assessment of response to therapy
  3. Provide rapid diagnosis:
    • Trauma
    • 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 significant error.20

Ischemia Monitoring
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.

Emergency TEE
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 aforementioned studies.

Conclusion
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

Newer 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.

References

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