Impact of routine use of intraoperative transesophageal echocardiography during cardiac surgery

Abstract

Purpose: To determine the relative impact of each category-based TEE indication according to the ASA guidelines. Methods: In 851 patients undergoing cardiac surgery, TEE clinical indications were classified as category I or II according to the ASA guidelines. Category I indications are patients in which TEE is considered useful and category II are those where TEE is potentially useful but indications are less clear. All TEE examinations were reviewed by two anesthesiologists with advanced training in TEE. For each patient, the clinical impact of TEE in the clinical management was assessed using five criteria: 1) change of medical therapy; 2) change in the surgical procedure; 3) confirmation of a suspected diagnosis; 4) positioning of an intravascular device, and 5) substitute to a pulmonary artery catheter (PAC).Results: TEE had greater utility in category I than in category II indications (15/53 (28%) vs 110/798 (14%) respectively) (P < 0.01). The nature of the clinical impact was as follows: modification of medical therapy in 67/125 (53%), modification of planned surgical intervention in 38/125 (30%), confirmation of a diagnosis in 34/125 (27%). The impact on therapy was higher in complex surgical procedures (39%) than in valvular replacement (19%) (P < 0.01) and coronary artery bypass surgery (10%) (P < 0.001).Conclusions: Our findings validate the usefulness of the ASA practice guidelines demonstrating a greater impact of TEE on clinical management for category I indications than for category II. TEE also had a greater clinical impact in complex surgical procedures and in valvular replacement.Objectif : Déterminer l'effet relatif de l'indication de l'ETO basée sur chacune des catégories relevant des recommandations ASA.Méthode : Chez 851 patients devant subir une intervention chirurgicale cardiaque, les indications cliniques de l'ETO ont été classées en catégorie I ou II selon les recommandations de l'ASA. Dans la catégorie I, ce sont les patients pour qui l'ETO est considérée utile et dans la catégorie II, ceux pour qui l'ETO est probablement utile, les indications n'étant pas aussi claires. Tous les examens d'ETO ont été révisés par deux anesthésiologistes de formation poussée en ETO. Les répercussions cliniques de l'ETO sur le traitement clinique de chaque patient ont été évaluées selon cinq critères: 1) la modification du traitement médical 2) un changement de technique chirurgicale 3) la confirmation d'un diagnostic présumé 4) la mise en place d'un appareil intravasculaire 5) un substitut au cathéter de l'artère pulmonaire (CAP).Résultats : L'ETO a présenté une plus grande utilité avec les indications de catégorie I qu'avec celles de caté-gorie II (15/53 (28 %) vs 110/798 (14 %) respectivement) (P < 0,01). La nature de l'effet clinique a été : une modification de traitement médical chez 67/125 (53 %), un changement d'intervention chirurgicale chez 38/125 (30 %), la confirmation d'un diagnostic chez 34/125 (27 %). Les conséquences sur le traitement ont été plus grandes pour des interventions chirurgicale...

Perioperative use of transesophageal echocardiography by anesthesiologists: Impact in noncardiac surgery and in the intensive care unit

“…The impact of TEE in the noncardiac setting was even more important than that we had observed in cardiac surgery. 5 These findings extend the role of TEE outside the cardiac surgical arena. This study represents a large anesthesiologists' experience in the use of TEE in the noncardiac surgical and in the ICU setting using the ASA guidelines.…”

“…Since the introduction of TEE in our practice in 1990 at Notre-Dame Hospital, we previously reported our experience in cardiac surgery 5 but the role and impact of TEE performed solely by anesthesiologists outside of the cardiac operating theater is still poorly explored. We now are reporting our experience in the use of perioperative TEE in the noncardiac operating room (OR), the recovery room and in the ICU to determine the relative impact of category-based TEE indications.…”

Transesophageal echocardiography-related complications

“…Examinations using TEE are considered safe when conducted in a controlled environment by trained operators. 2 Information obtained from TEE can have a significant impact in cardiac [3][4][5][6][7][8][9] and non-cardiac surgery, [10][11][12] as well as in making decisions in the ICU. 11,13,14 Considering the widespread application of this technique, it is important to address the issue of safety.…”

Transesophageal Echocardiography

“…TEE alters therapy more often in patients with category I indications (28%) (Table 3) than in those with category II indications (14%). 16 One of the strongest indications for intraoperative TEE is evaluation of the mitral valve during repair. When a systematic approach is used to assess mitral valve morphology, there is excellent agreement between TEE and surgical findings, with a 92% agreement on mechanism and precise location of pathology compared with a 60% agreement in patients not systematically studied.…”