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Chapter 21. TEE for Noncardiac Surgery

Angus Christie; Frederick W. Lombard

Transesophageal echocardiography (TEE) is remarkably efficient and effective in revealing a wide spectrum of new findings and information during periods of hemodynamic instability. Since TEE technology is now readily accessible in most settings, TEE is increasingly used during noncardiac surgical procedures. However, in contrast to the cardiac surgery setting, little evidence supports the routine use of TEE in noncardiac surgery. This is largely due to the fact that the validated indications for intraoperative TEE are for use as a diagnostic tool, and not a monitor (Table 21–1). The majority of established indications in cardiac surgery directly pertain to the planned surgical procedure, or the assessment of relevant anatomical structures. To date, no large randomized trials have assessed the impact of intraoperative TEE on outcome in noncardiac surgery. Several reviews, however, have debated the use of TEE in noncardiac surgery.1–8

Table 21–1. Recommendations for the Use of TEE in the Perioperative Period.
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Table 21–1. 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 (eg, 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 (eg, 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 neurologic 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 patients, TEE should be used when diagnostic information that is expected to alter management cannot be obtained by TTE or other modalities in a timely manner

TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; CABG, coronary artery bypass graft.

Reproduced with permission from Practice Guidelines for Perioperative Transesophageal Echocardiography. An Updated Report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010;112:1084-1096.

Life-threatening intraoperative hemodynamic collapse is an indication for the use of TEE (ASA/SCA guidelines).9 TEE in this setting could rapidly identify abnormalities and help in establishing a diagnosis, monitor the response to treatment, and may have some prognostic value.

The etiology of precipitating events may be difficult to diagnose, since these are often only transiently manifested. Nevertheless, TEE can be useful in diagnosing the majority of specific cardiovascular abnormalities associated with cardiovascular ...

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