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Over the past 25 years, transesophageal echocardiography (TEE) has become an integral part of the care received by patients undergoing heart surgery. The interest in the perioperative application of TEE (PTE) continues to broaden and now includes, to name just a few, liver transplantation, lung transplantation, major vascular surgery, and persistent hemodynamic instability in the operating room. Anesthesiologists have been actively involved with PTE from its inception, and some degree of training in PTE has become an integral, accepted component of all anesthesiology residencies. The program requirements for anesthesiology training state that residents should have “significant experience with … the use of TEE.”1 This chapter reviews the issue of training for anesthesiologists in PTE and discusses the development of certification in this area.


One of the first publications addressing training in PTE came from the Cleveland Clinic Foundation, the largest center for heart surgery in the United States.2 The authors described an extensive training program developed for the cardiac anesthesiologists using TEE during heart surgery at their institution. The training took place over a year and started off with 6 months devoted to full-time training, initially in the echocardiography laboratory and then divided between the lab and the cardiac operating room (OR). The second 6 months consisted of closely supervised intraoperative echocardiography experience integrated with anesthesiology responsibilities. The program included extensive training and experience with transthoracic echocardiography (TTE) as well as TEE. The editorial accompanying this publication thoughtfully supported the importance of training in PTE, but pointed out the impracticality of extended, full-time training for many anesthesiologists, and advocated in favor of an “on the job” approach to training through a mentoring program with an experienced expert in PTE to be available at critical times during the procedure.3 The editorial also put forth the view that training in TTE was not the most efficient way for practitioners exclusively using TEE to be trained. Both approaches have been successfully applied in different ways at various institutions, and many TEE education programs provide a combination of intensive full-time echo lab experience with mentoring in the OR.


Perhaps the most important early document to address training and the use of TEE in the perioperative setting was the seminal Practice Guidelines for Perioperative Transesophageal Echocardiography,4 jointly developed by the American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA) and published in 1996. It was written by a task force formed in 1993 that was led by Daniel Thys, MD, and consisted of nine anesthesiologists, two cardiologists, and one methodologist who reviewed over 500 publications relevant to PTE. While this document focused primarily on the various indications for TEE in the perioperative setting, it did discuss training and fairly specifically defined the cognitive and technical skills needed for training in PTE at two levels, basic and advanced (Tables 26–1 and 26–2). Basic training was defined as the use of TEE in the customary practice of anesthesiology ...

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