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  1. Transesophageal echocardiography (TEE) is an essential component of anesthesia care for modern cardiac and thoracic aortic surgery.

  2. A complete diagnostic examination should include the standard set of views (at a minimum) suggested by guidelines from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.

  3. Intraoperative evaluation of acute persistent and life-threatening hemodynamic disturbances in which ventricular function is uncertain and unresponsive to treatment is a Category I indication for TEE.

  4. Real-time 3-dimensional echocardiography represents a breakthrough technology that fundamentally transforms intraoperative imaging.


Intraoperative echocardiography now is considered an essential part of modern cardiac and thoracic aortic surgery and is routinely used during other major surgical procedures such as liver and lung transplantations. It can be performed using transesophageal, epicardial, epiaortic, intravascular, and transthoracic approaches. Available imaging modalities include 2-dimensional (2D) and 3-dimensional (3D) imaging; pulsed-wave, continuous-wave, color-flow, and tissue Doppler; M-mode; speckle tracking. The echocardiographic data are obtained in real time (RT) and interpreted by a physician in a timely manner to direct the clinical treatment of surgical patients. The clinical applications of intraoperative echocardiography are numerous, including assessment of left ventricular (LV) and right ventricular (RV) function, assessment of preload, measurement of cardiac output, detection of myocardial ischemia, assessment of valvular function and pathology, detection and assessment of various congenital heart diseases, and evaluation of aortic atheromatous disease before manipulation of the aorta. Intraoperative echocardiography serves as both an important diagnostic tool and a monitor for cardiac surgical patients. With an emphasis on 2D and 3D transesophageal echocardiography (TEE), this chapter combines practical recommendations for a comprehensive 2D TEE examination with some of the key features of the emerging 3D TEE technology.


Perioperative TEE has evolved as an important clinical tool that aids the hemodynamic management and improves outcome in patients undergoing cardiac surgery for valve repairs, coronary artery bypass grafting (CABG), thoracic aortic surgery, and repair of complex congenital lesions. Perioperative TEE involves the use of cardiac ultrasonography in surgical patients immediately before, during, or after their operations. In the perioperative setting, TEE not only facilitates diagnoses and optimizes the surgical approach during cardiac operations but also guides the institution of specific treatments and helps monitoring interventions throughout the operative course without disrupting the surgical workflow.1-5


Since 1996, when evidence-based practice guidelines for perioperative TEE initially were published (Fig. 31-1), support for the superiority of intraoperative TEE over other cardiovascular monitoring techniques (eg, electrocardiograms [ECGs] or pulmonary artery catheters) has steadily increased.6,7 Recently updated guidelines recommend the use of TEE in all adult patients without contraindications undergoing open- heart (eg, valvular procedures) and thoracic aortic surgical procedures and to consider its use in CABG surgeries to confirm and refine the preoperative diagnosis, detect new or unsuspected pathology, amend the anesthetic and surgical plan accordingly, and evaluate the results of the surgical procedure. In younger patients, the use of TEE should be considered on a case-by-case basis because of risks ...

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