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Chapter 4: Transesophageal Tomographic Views

Ryan E. Lauer; Joseph P. Mathew

GUIDELINES AND CLINICAL INDICATIONS FOR A COMPREHENSIVE TRANSESOPHAGEAL EXAMINATION

Transesophageal echocardiography (TEE) training and certification have become standardized with the use of recognized nomenclature and tomographic views.1 A consistent nomenclature has the advantage of not only facilitating communication between physicians but also promoting the performance of comprehensive examinations. Familiarity with standard views enables the echocardiographer to detect abnormalities more readily and compare sequential images. However, in some patients, it may not be possible to obtain a complete set of two-dimensional views because of time constraints or because the patient's body habitus or anatomy impedes the ability to develop the appropriate imaging planes. With practice, a complete TEE examination generally can be performed in 10 minutes or less, with images recorded and archived in a digital format. A written report should then be generated as part of the patient's medical record (see Chapter 26). Recommendations presented in this chapter primarily pertain to the widely available TEE equipment, which permits multiplane two-dimensional imaging. Standardized recommendations for three-dimensional (3D) imaging are also available and are discussed in Chapter 23.1

Guidelines for a comprehensive TEE examination have been recently updated and expanded by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.1 Additionally, a new set of guidelines for a basic perioperative TEE exam has been established with the intent of defining a TEE exam limited to intraoperative monitoring and diagnosis of the cause of hemodynamic instability.2 This chapter will focus on the comprehensive exam, and images that constitute a basic exam will only be highlighted. The indications for performing a perioperative TEE examination continue to evolve on the basis of evidence attesting to its value and the weight of expert opinion and are listed in Table 4-1.3

Table 4–1.Recommendations for the use of TEE in the perioperative period.
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Table 4–1. Recommendations for the use of TEE in the perioperative period.
I. Cardiac and Thoracic Aortic Procedures

  • Cardiac and Thoracic Aortic Surgery

    • For adult patients without contraindications, TEE should be used in all open heart (e.g., valvular procedures) and thoracic aortic surgical procedures and should be considered in CABG surgeries as well to

      • Confirm and refine the preoperative diagnosis

      • Detect new or unsuspected pathology

      • Adjust the anesthetic and surgical plan accordingly

      • Assess results of the surgical intervention

    • In small children, the use of TEE should be considered on a case-by-case basis because of risks unique to these patients (e.g., bronchial obstruction)

  • Catheter-Based Intracardiac Procedures

    • For patients undergoing transcatheter intracardiac procedures, TEE may be used
II. Noncardiac Surgery

  • TEE may be used when the nature of the planned surgery or the patient's known or suspected cardiovascular pathology might result in severe hemodynamic, pulmonary, or neurological compromise

  • If equipment and expertise are available, TEE should be used when unexplained life-threatening circulatory instability persists despite corrective therapy
III. Critical Care

  • For critical care ...

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