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Chapter 86. Intraoperative TEE

Sanford M. Littwin, MD

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Uses of Intraoperative Transesophageal Echocardiography (TEE)
Noncardiac surgeryCardiac surgery
  • Assessment of regional wall motion abnormalities (RWMA)
  • Assessment of volume status
  • Same as noncardiac
  • Basic TEE exam
  • Assessment of valve function, evaluation of repair/replacement
  • Assessment of tolerance of proximal aortic cross-clamping
  • Diagnosis and evaluation of therapy for difficulty weaning off cardiopulmonary bypass

Relative contraindications: esophageal lesions (e.g., diverticulum, varices) or recent surgery, or unstable cervical spine lesion.

Lubricated probe inserted after stomach contents emptied with OG suction

Initially placed into mid-esophageal position approximately 25–30 cm.

  • Probe manipulation (Figure 86-1)
    • Rotation of probe
    • Knobs
      • Anteflexion/retroflexion
      • Left/right flexion of probe tip
    • Probe button(s)
      • Scan angle: imaging array rotation from 0° to 180°
  • Position of probe and views
    • Position
      • Upper esophageal
      • Mid-esophageal
      • Transgastric
    • Views
  • Views performed systematically to gain information about cardiac pathology and performance
  • Subset of views most often used for noncardiac cases
    • Mid-esophageal 4 chamber view
      • Allows for assessment of overall chamber size (right and left atria, right and left ventricles)
      • Cardiac function (RWMA)
      • Valve pathology
        • Tricuspid regurgitation
        • Mitral regurgitation
    • Transgastric mid-papillary view
      • Assessment of RWMA
      • Volume status

Figure 86-1. Probe Manipulation Nomenclature
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Reproduced with permission from Shanewise JS, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplanetransesophageal echocardiography examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg. 1999;89:870.

Figure 86-2. Standard Views
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The 20 standard views grouped together based upon the location in the esophagus where they are obtained, upper esophageal (UE), middle esophageal (ME), transgastric (TG), and descending aortic (DA). Major cardiac structures are labeled including: right atrium (RA); left atrium (LA); mitral valve (MV); tricuspid valve (TV); right ventricle (RV); left ventricle (LV); left atrial appendage (LAA); aorta (AO); anterior leaflet of the mitral valve (ALMV); posterior leaflet of the mitral valve (PLMV); ascending aorta (Asc AO); right pulmonary artery (RPA); superior vena cava (SVC); main pulmonary artery (MPA); intra atrial septum (IAS); pulmonic valve (PV); right ventricular outflow tract (RVOT); noncoronary cusp of the aortic valve (NCC); right coronary cusp of the aortic valve (RCC); left coronary cusp of the aortic valve (LCC); posterior scallops of the mitral valve P1, P2, P3; anterior scallops of the mitral valve A1, A2, A3; posterior medial papillary muscle (Post/Med PM); anterior scallops of the mitral valve A1, A2, A3; posterior medial papillary muscle (Post/Med PM); anterolateral papillary muscle (Ant/Lat PM); inferior vena cava (IVC); descending aorta (Desc AO); left brachiocephalic vein (BCV). Reproduced from Wasnick JD, Hillel Z, Kramer D, Littwin S, Nicoara A. Cardiac Anesthesia and Transesophageal Echocardiography. Figure Intro–6. Available at: www.accessanesthesiology.com. Copyright © ...

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