The role of peri-operative transoesophageal echocardiography

Abstract

The role of peri-operative transoesophageal echocardiography cardiovascular surgery. (5,6,7,8,9,10) More recent retrospective analyses of prospectively collected data suggest that around 5.6% of surgical procedures are altered on the basis of intra-operative echocardiographic findings and that there are cost-benefit savings particularly during combined valve and graft operations. (11,12,13) Recently, the roles for peri-operative echocardiography have also extended to include intensive care (14,15) and non-cardiac surgery. (16,17,18) Although it is complex to scientifically prove the benefits of a diagnostic monitor, TOE has been shown to strongly influence intra-operative anaesthetic decisions, particularly in patients with increased risk factors for haemodynamic instability or myocardial ischaemia. In a prospective observational case series of 98 patients undergoing abdominal surgery, the judgement of the anaesthetists was that TOE led to useful alterations in intraoperative care such as administration of fluids, vasoactive drugs and β blockers. In some patients, use of the pulmonary artery catheter was obviated. (19) Similarly, in another case series comprising 90 patients undergoing vascular, visceral and chest surgery, TOE directed changes in drug (47%) and fluid therapy (24%). PERI-OPERATIVE TOE IntroductIonIn 1976 transoesophageal echocardiography (TOE) was introduced into clinical practice.(1) Within a decade, its use extended from cardiology departments into the cardiac surgical arena. However,at that time few probes were available for the operating theatre.Indeed in a report from the United States in 1988, only about 50 TOE probes were accessible for intra-operative use.(2) Furthermore, despite its utility for cardiac surgery, it became evident that few cardiologists were able to spend long periods in the operating theatre. Over time much enthusiasm and expertise for TOE has developed amongst cardiac anaesthesiologists, and by 2001, 94%of respondents in a survey of the Society of CardiovascularAnaesthesiologists utilised intra-operative echocardiography in their routine practice.Over the past 30 years technology has improved tremendously and intra-operative TOE has become an established imaging modality and the gold standard intra-operative cardiac monitor and diagnostic tool in certain cardiac procedures, e.g. mitral valve repair, congenital heart surgery, etc. IndIcAtIons And PrActIcE guIdElInEsEarly experience with the use of peri-operative echocardiography was obtained from its application in cardiac anaesthetic practice; recently however, its role has extended to include non-cardiac surgery and intensive care. Category I indications are supported by strong evidence and expert opinion that TOE is indicated, very useful and will improve patient outcome. These category I indications encompass the everyday practice of the intra-operative anaesthetist-echocardiographer and will be discussed in more detail in this review.Category II indications are supported by weaker evidence and less expert opinion ...