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Utility of Perioperative Transesophageal Echocardiography in

Non-Cardiac Surgery
Stanton Shernan, M.D Boston/Massachusetts
Since the introduction of intraoperative echocardiography into clinical practice in the 1980s, its popularity
has steadily increased. Although not as well established as for cardiac surgery, the benefit of perioperative
echocardiography for non-cardiac surgery is becoming increasingly more appreciated 1-3. Selective or emergent
intraoperative transesophageal echocardiography (TEE) has been reported as beneficial in 40% to 80% of patients
4,5
respectively . In over one-third of patients, intraoperative TEE may be associated with a change in medical
therapy, including treatment of myocardial ischemia, valvular pathology, and/or right ventricular (RV) and left
ventricular (LV) failure 4,5. Furthermore, in approximately 25% of patients, intraoperative TEE has been associated
with a change in surgical procedure 4. Based upon these findings, intraoperative echocardiography is rapidly
becoming recognized for its impact on perioperative decision-making during non-cardiac surgery.

Indications for Intraoperative Echocardiography

Indications for emergent TEE during non-cardiac surgery have included hemodynamic instability,
evaluation for chest trauma, hypoxemia, and pre-incision cardiac evaluation prior to emergent surgery 6.
In 1996 practice guidelines were published from the American Society of Anesthesiologists (ASA) and the
Society of Cardiovascular Anesthesiologists (SCA) Task Force on TEE 7. Recommendations are divided
into three categories based on the strength of supporting evidence and/or expert opinion that TEE
improves clinical outcomes. Category I indications are supported by the strongest evidence or expert
opinion that TEE is frequently useful in improving clinical outcomes in these settings, and is often
indicated. Category II indications are supported by weaker evidence and expert consensus that TEE may
be useful in improving clinical outcomes in these settings but absolute indications are less certain.
Category III indications have little scientific or expert support, and appropriate indications are uncertain.
An updated revision of this document authored by members of the ASA and SCA is currently underway.
Although the ASA/SCA practice guidelines are perhaps most applicable for cardiac surgery, they also have
relevance for non-cardiac surgery. One of the most common Category I indications for the use of intraoperative TEE
during non-cardiac surgery, is the role of rescue TEE for the evaluation of acute persistent and life-threatening
hemodynamic disturbances in which ventricular function and its determinants are uncertain or have not responded to
treatment. In a study investigating the usefulness of TEE during intraoperative cardiac arrest in non-cardiac surgery, a
primary suspected diagnosis of the underlying pathological process was established in 19 of 22 patients with TEE,
including 9 with thromboembolic events, 6 with acute myocardial ischemia, 2 with hypovolemia, and 2 patients with
pericardial tamponade 8. A definitive diagnosis could not be made in 3 patients with TEE. In 18 patients, TEE guided
specific management beyond implementation of Advanced Cardiac Life Support protocols, including the addition of
surgical procedures in 12 patients. A related Category II indication includes the perioperative use of TEE in patients
with increased risk of hemodynamic disturbances. In several single center and multicenter studies, intraoperative
TEE for non-cardiac surgery has been to shown to influence surgical and anesthetic management in
30-40% of patients, including those who already had invasive hemodynamic monitors (i.e., radial arterial lines and
pulmonary artery catheters) 4,5,9,10. Changes in management have been based upon confirming or invalidating a
prior diagnosis, detection of new diagnoses, and acquisition of pertinent information acquired during periods of
hemodynamic instability leading to changes in drug or goal-directed fluid therapy, unplanned surgical re-interventions and
further evaluation in the postoperative period. While many of the cases in the literature would be considered Category I
indications for the utility of intraoperative TEE, others have reported a consistent impact of intraoperative TEE on
perioperative clinical decision-making even for Category II indications among non-cardiac

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surgical patients. Thus, in addition to earlier reports suggesting a primary benefit for intraoperative TEE as a
diagnostic tool for evaluating myocardial ischemia during non-cardiac surgery 11, more recent reports also
confirm its utility as a monitor of hemodynamic status and overall cardiovascular performance.

Perioperative Ischemia Monitoring

Ischemic changes detected by two-dimensional echocardiography include new systolic wall motion
abnormalities (SWMA) and decreased systolic wall thickening. Echocardiography is also useful for evaluating
complications of myocardial ischemia including myocardial infarction (MI), congestive heart failure (CHF),
valvular regurgitation, septal defects, thrombi, pericardial effusions, and ventricular free wall rupture.
Controlled studies have demonstrated a clear association between SWMA, coronary ischemia and cardiac
events 12. Data from perioperative TEE studies have reported specificities and negative predictive values
>90%. However, sensitivity and positive predictive values for MI are less than 40%, possibly because not all
ischemia results in MI 12. In addition, SWMA often overestimate the area of injury, and may result from
etiologies other than ischemia including myocardial stunning, hibernation and tethering as well as changes in
loading conditions. While monitoring, diagnosing and treating myocardial ischemia is important, it is not clear
that routine TEE is either cost-effective or more beneficial than ECG monitoring with ST segment analysis 13.
However, TEE may be a worthwhile monitor and a diagnostic tool of choice for the initial assessment of
myocardial ischemia or MI-related complications for high-risk patients undergoing non-cardiac surgery.

Vascular Surgery
SWMA occur frequently during vascular surgery, but are less frequently associated with
perioperative MI, CHF, and cardiac death. In one study, 55% of patients undergoing aortic reconstruction
experienced new SWMA at the time of aortic clamping, with a greater incidence seen following supraceliac clamping (92%) compared to suprarenal (33%), and infra-renal (0%) 14. In this particular series,
only 1 patient (in the supra-celiac group) suffered a perioperative MI.
As previously stated, SWMA may result from a variety of etiologies other than ischemia.
Furthermore, even if all SWMA were indicative of ischemia or ventricular dysfunction, ischemia does not
always result in a significant cardiac event. Anesthetic agents, metabolic changes, blood loss, and
placement of the aortic cross clamp are known causes of SWMA. Since these are transient processes,
the occurrence of an adverse cardiac event is reduced. The low positive predictive value of SWMA may
also be associated with rapid detection and subsequent prompt treatment. Nonetheless, the utilization of
TEE during major vascular procedures may influence perioperative management and outcome.
Liver and Lung Transplantation
Despite the presence of a coagulopathy and gastroesophageal varices, TEE has been used safely in
patients undergoing liver transplantation, with a reported bleeding complication rate of 1-2% 15. During liver
transplantation, TEE monitoring has demonstrated new findings in > 50% of patients, improved hemodynamic
management, and has been shown to impact overall perioperative care in 11% of patients 15. During lung
transplantation, TEE has been used to assess severity and etiology of pulmonary hypertension, intraoperative
ventricular function, and surgical anastomotic integrity. Diagnoses such as pulmonary artery (PA) thrombi,
patent foramen ovale, atrial septal and ventricular septal defects in 25% of patients, resulted in the requirement
for additional surgery in one study 16. Furthermore, echocardiographic visualization of pulmonary vascular
anastomoses suggests that up to 30% may be abnormal, thus prompting additional surgical procedures 16.
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Orthopedics
Patients undergoing total hip replacement (THR) are vulnerable to perioperative cardiac complications
due to comorbidity and hemodynamic instability occurring during certain aspects of the surgical procedure.
Emboli released during preparation of the femur are readily diagnosed with TEE and have been associated
with decreases in blood pressure, increases in PA pressure, RV and LV SWMA, and occasionally
cardiovascular collapse 17. Emboli have also been diagnosed in patients undergoing total knee replacement
following thigh tourniquet release 18. However, in comparison to THR, the hemodynamic consequences of
these embolic events may not be as severe 18. Although TEE may not be indicated for all patients undergoing
orthopedic procedures, elderly patients and those with significant cardiovascular and pulmonary comorbidity
may benefit from its utility as a monitor and diagnostic tool for evaluating perioperative hemodynamics.

Neurosurgery
Hemodynamic instability during major neurological surgery is affected by a number of variables
including patient demographics, anesthetic agents and surgical techniques. Venous air embolism (VAE),
which may cause hemodynamic and pulmonary instability, occurs in 25 -50% of neurosurgical
procedures, and has been reported in as many as 76% of craniotomies performed in the sitting position
19
. Although precordial Doppler echocardiography or TEE is believed to be the most sensitive monitor for
VAE, actual utilization varies from 25-87% 19. Patients scheduled to undergo craniotomy in the sitting
position should have a pre-surgical echocardiographic evaluation either preoperatively or immediately
after induction of anesthesia to determine the presence of any intracardiac shunts.
Obstetrics
It is becoming increasingly more common for high-risk obstetrical patients with cardiac disease including
congenital heart diseases, CAD, cardiomyopathies, and heart transplantation to present for peripartum care. In
addition, a number of pregnancy-related conditions, including pregnancy-induced-hypertension, pulmonary emboli,
hemorrhage, and peripartum cardiomyopathy have a significant influence on tolerance for the normal hemodynamic
changes associated with pregnancy. Although echocardiographic analysis during normal deliveries is not costeffective, use in assessing high-risk obstetric patients may be warranted 20.

Trauma and Critical Care

Prompt and accurate diagnoses of traumatic cardiac injuries are crucial to improving survival. In one study
of penetrating chest injury, echocardiographic evaluation and diagnosis was achieved within 15 minutes, compared
to 42 minutes in the non-echo group. The survival was 100% in the former and 57% in the latter. Compared to
transthoracic echocardiography (TTE), TEE also significantly contributes to the diagnostic and hemodynamic
evaluation of cardiac and vascular injury, and can be performed in as quickly as 9-15 minutes 21,22.

There is strong support for the use of echocardiography in critically ill patients 2,3. Common
indications for postoperative echocardiography include evaluation of hypotension, LV and RV function,
MR, prosthetic valves, aortic injury, pericardial pathology, myocardial ischemia, complications following
MI, cardiac masses and sources of emboli or infection 23-27. Echocardiographic evaluation of
hemodynamic instability, trauma, and hypoxemia are particularly common 23-27.

When compared to clinical impression, echocardiography has been shown to provide new information in 80% of
critically ill patients, changed medical management in 60%, and led to a surgical procedure in as many as

30% of patients 6,23. Comparative analyses have shown that TEE improved cardiac evaluation
compared to TTE in as many as 50-70% of patients 19-27.

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Conclusions
Perioperative echocardiography for non-cardiac surgical patients is useful for diagnosing
cardiovascular pathology and assessing hemodynamics. Echocardiographic evaluation of cardiac performance
compares favorably to other gold standards, and expands on the ability to obtain a comprehensive
cardiovascular exam. In recognition of the utility of intraoperative TEE for non- cardiac surgery, the ASA, SCA
and National Board of Echocardiography have collaborated to develop a pathway for certification in basic
perioperative TEE (www.echoboards.org). In addition, the ECHO-in-ICU group and the American College of
Emergency Physicians have each proposed limited scope training guidelines for the focused use of
echocardiography in the initial management of critically ill patients 28 in the ICU and emergency room
respectively 29-31. As the popularity of echocardiography increases and the indications for its perioperative
utility evolves, appreciation for its value in the non-cardiac surgical population will continue to develop.

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Copyright 2011 American Society of

Anesthesiologists. All rights reserved.

Disclosure
Boston Scientific, Funded research