Chapter 34: Indications, Training, and Simulation

Cardiac and Thoracic Aortic Procedures

• Cardiac and thoracic aortic surgery

• For adult patients without contraindications, TEE should be used in all open heart (e.g., valvular procedures) and thoracic aortic surgical procedures and consider 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 the 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 (e.g., bronchial obstruction)

• Catheter-based intracardiac procedures

• For patients undergoing transcatheter intracardiac procedures, TEE may be used

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.

Critical Care

• For critical care patients, TEE should be used when diagnostic information that is expected to alter management cannot be obtained by transthoracic echocardiography or other modalities promptly.

Abbreviations: ASA, American Society of Echocardiography; CABG, coronary artery bypass graft; SCVA, Society of Cardiovascular Anesthesia; TEE, transesophageal echocardiography. Adapted from ⁷

Basic Training

Cognitive Skills (Knowledge of)

1. Physical principles of echocardiographic image formation and blood velocity measurement
2. Operation of ultrasonography, including all controls that affect quality of data displayed
3. Equipment handling, infection control, and electrical safety associated with the techniques of perioperative echocardiography
4. Indications, contraindications, potential complications of perioperative echocardiography
5. Appropriate alternative diagnostic techniques
6. Normal tomographic anatomy as revealed by perioperative echocardiographic techniques
7. Common blood flow velocity profiles as measured by Doppler echocardiography
8. Echocardiographic manifestations of native valvular lesions and dysfunction
9. Echocardiographic manifestations of cardiac masses, thrombi, cardiomyopathies, pericardial effusions, and lesions of the great vessels
10. Echocardiographic presentations of myocardial ischemia and infarction
11. Echocardiographic presentations of normal and abnormal ventricular function
12. Echocardiographic presentations of air embolization

Technical Skills (Ability to)

1. Operate ultrasonography, including the primary controls affecting quality of displayed data
2. Insert a TEE probe safely in the anesthetized, mechanically ventilated patient
3. Perform a comprehensive TEE examination and differentiate normal from markedly abnormal cardiac structures and function
4. Recognize marked changes in segmental ventricular contraction indicative of myocardial ischemia or infarction
5. Recognize marked changes in global ventricular filling and ejection
6. Recognize air embolization
7. Identify native and prosthetic valvular lesions or dysfunctions that would require consultation with a physician having an advanced level of training. (Ability to recognize gross valvular lesions and dysfunctions)
8. Detect intracardiac masses and thrombus (Ability to recognize large intracardiac masses and thrombi)
9. Detect pericardial effusions (Ability to detect large pericardial effusions)
10. Recognize common echocardiographic artifacts
11. Communicate echocardiographic results effectively to healthcare professionals, the medical record, and patients
12. Recognize complications of perioperative echocardiography

Advanced Training

Cognitive Skills (Knowledge of)

1. All the cognitive skills defined under basic training
2. Principles and methodologies of qualitative and quantitative echocardiography
3. Native and prosthetic valvular function, including valvular lesions and dysfunction
4. Congenital heart disease (if congenital practice, then this knowledge must be detailed)
5. All other diseases of the heart and great vessels that is relevant in the perioperative period (if pediatric practice, then this knowledge may be more general than detailed)
6. Techniques, advantages, disadvantages, and potential complications of commonly used cardiac surgical procedures for treatment of acquired and congenital heart disease
7. Other diagnostic methods appropriate for correlation with perioperative echocardiography

Cognitive Skills

Technical Skills (Ability to)

1. All the technical skills defined under basic training
2. Acquire or direct the acquisition of all necessary echocardiographic data, including epicardial and epiaortic imaging
3. Recognize subtle changes in segmental ventricular contraction indicative of myocardial ischemia or infarction
4. Quantify systolic and diastolic ventricular function and to estimate other relevant hemodynamic parameters
5. Quantify normal and abnormal native and prosthetic valvular function
6. Assess the appropriateness of cardiac surgical plans
7. Identify inadequacies in cardiac surgical interventions and the underlying reasons for the inadequacies
8. Aid in clinical decision -making in the operating room

Modified from the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists Task Force Guidelines for Training in Perioperative Echocardiography 2002. ¹²
Abbreviation: TEE, transesophageal echocardiography.

Basic components of an intra-operative transesophageal echo report should include the following basic demographics. The content of the report should address the indications for the study and may include some or all of the following components.

• Patient identification
• Study indication
• Surgical procedure

• General study information includes:
• Study date
• Referring physician identification
• Interpreting physician(s) identification
• Location of media storage (e.g. disk or tape number, server)
• Location of study (e.g. OR, PACU, ER, ICU)
• Study technical quality (e.g. teaching quality, good, fair, poor, incomplete)

Reporting the following structures as normal implies a complete examination.

• Evaluation of the structure and function of the following anatomic components of the examination: (The minimum evaluation for each, and the implied meaning of a “normal” report is detailed in the next section). In patients undergoing CABG, the focus may be on the evaluation of ventricular systolic and diastolic function. In patients who are undergoing cardiac surgery other than CABG, perform quantitative and Doppler measurements of the surgical pathology when appropriate. However, a qualitative assessment of the other cardiac components may be sufficient in a patient with a complete pre-operative TTE assessment. A more comprehensive evaluation may be required in patients without a preoperative TTE assessment or when clinically indicated

• Left Ventricle
• Right Ventricle
• Left atrium
• Left atrial appendage
• Pulmonary veins
• Right atrium

• Inferior vena cava
• Superior vena cava
• Coronary sinus
• Aortic Valve
• Mitral Valve
• Tricuspid Valve

• Pulmonic Valve
• Aorta
• Pulmonary Artery
• Interventricular septum
• Interatrial septum
• Pericardium

• Specific evaluation directed at the presenting problem and detected significant pathology

The study should incorporate a final assessment of the patient based on the intra-operative findings and include the following.

• Conclusions and summary 
• Overall interpretation/summary of findings
• Assessment of the presenting issue
• Relevant comparisons to prior studies or reports as available
• Study limitations
• Recommendations regarding alternative or additional investigations and consultation where appropriate

The above constitutes a basic examination. Specific indications or pathology require further targeted imaging and/or hemodynamic assessment. Abbreviations: CABG, coronary artery bypass grafting; ER, emergency room; ICU, intensive care unit; OR, operating room; PACU, postoperative anesthesia care unit; TTE, transthoracic echocardiography. Reproduced from the Canadian guidelines for training in adult perioperative transesophageal echocardiography.¹⁹