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Seminars in Cardiothoracic
and Vascular Anesthesia
Volume 12 Number 4
December 2008 265-289
2008 SAGE Publications
10.1177/1089253208328668
http://scv.sagepub.com
hosted at
http://online.sagepub.com
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
Comprehensive Ventricular
Function Assessment
Systolic function. A combination of 2-dimensional and
Doppler interrogation of both left ventricle (LV) and
right ventricle (RV) provides a comprehensive (systolic and diastolic) ventricular functional assessment.
Blood supply territory of all the major coronary vessels can be seen in the transgastric midpapillary shortaxis view of the LV, and an instantaneous assessment
of LV systolic function and WMAs can be made.29,49
Quantitative assessment of LV function can be made
with geometric modeling of the LV with either the
Teicholz formula or Simpsons method of discs.49,50
Due to multiple assumptions made about the geometry of the LV and the time-consuming nature of the
mathematical calculations, these formulae are not
routinely used, and visual estimation of systolic function by an experienced observer has been shown to
correlate well with these objective measures.51
269
morbidity and mortality.70-72 The prevalence of diastolic dysfunction increases with age, and almost 50%
of patients with CHF have been shown to have normal systolic function.46 Although Doppler assessment
of diastolic filling abnormalities has been used to
assess survival and prognosis, its specific application
to evaluate preoperative risk has thus far been limited.73-76 The lack of appreciation for diastolic dysfunction as a risk factor for postoperative outcome
may be due to the absence of a universal method of
classification and diagnosis of diastolic function and
dysfunction.46 Most studies evaluating the use of
echocardiography in noncardiac surgery have limited
the assessment to ventricular systolic function or
WMAs.77-80 Also, due to the unique history of disease
progression, most patients scheduled for elective
high-risk noncardiac surgery have coronary artery disease and an equivocal pseudo-normal Doppler filling pattern.46,81 Furthermore, general anesthesia is
associated with rapid alterations of loading conditions, which makes the traditional Doppler assessment of diastolic function more challenging and
frequently inconclusive.82 Traditionally, anesthesiologists have used PCWP as a marker of LVEDP, which
has been shown to be an unreliable indicator of the
diastolic properties of LV.83 Left ventricular filling
during diastole is a complex sequence of events, and
the application of Doppler has greatly increased the
understanding of diastole.66,84 With the use of Vp and
Doppler tissue imaging, it is possible to assess the
events of diastole and their abnormalities (relaxation
and compliance, respectively).46,66,84,85
A history of CHF has also been demonstrated to
be an independent predictor of 30-day postoperative
mortality and hospital readmission after major noncardiac surgery.86 Similarly, perioperative interventions (eg, -adrenergic antagonists and pulmonary
artery catheters) have not been associated with any
improvement of postoperative outcome in these
patients,67 but may have actually caused more complications.87 This may be because we have so far been
unable to identify the patients truly at risk and
attributed the presence of CHF to systolic dysfunction only. Xu-Cai et al88 found that patients with a
history of CHF and normal systolic function (ie, presumed diastolic dysfunction) had longer length of
stay and higher readmission rate after vascular surgery than patients with CHF and abnormal systolic
function and controls. Recently, investigators have
demonstrated changes in diastolic function of LV
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
with abdominal aortic cross-clamp application independent of systolic function.82,89 Similarly, Phillip
et al90 have reported that more than 50% of geriatric
patients undergoing cardiac and noncardiac surgery
had preoperative diastolic dysfunction with normal
systolic function. They concluded that a comprehensive LV functional assessment should include evaluation of both systolic and diastolic properties. If risk
stratification is limited to systolic function alone, a
significant proportion of patients with diastolic dysfunction who are at risk for postoperative adverse
events would not be identified. TEE provides us with
the ability to diagnose the presence of diastolic dysfunction and assess its severity. This information can
be especially useful in fluid titration for patients with
moderate to severe diastolic dysfunction.
Myocardial performance index. Systole and diastole are
both energy-dependent processes. A truly comprehensive myocardial functional assessment would include
an assessment of systolic and diastolic performance.
Traditionally, an ejection fraction of >55% has been
considered to be an evidence of a normal, global ventricular function and excludes diastolic function as a
determinant of myocardial function. Myocardial performance index (MPI), also referred to as the Tei
index, is a Doppler-derived index of global myocardial
function.91,92 It was originally described by Tei et al91 as
an echocardiographic measure of global (systolic and
diastolic) LV function. The correlation of this index
with invasively derived constants of relaxation and
contraction has been validated with simultaneous cardiac catheterization and Doppler echo studies.92
Because both isovolumetric relaxation and contraction time (IVRT and IVCT) are energy dependent,
they are directly related to dP/dt and +dP/dt, respectively.91,93 The sum of IVCT and IVRT would be an
estimate of the global myocardial function (systolic
and diastolic). A ratio of IVCT and IVRT with heart
rate or the ejection time (ET) eliminates their dependence on heart rate. The result is the sum of IVCT and
IVRT, divided by the ET. A prolonged MPI signifies
that either the IVCT or IVRT are prolonged or ET is
shortened (ie, the forward cardiac output is too low).
The Tei index has been shown to be prognostic of poor
outcomes in patients presenting with acute myocardial
infarction, dilated cardiomyopathy, and cardiac amyloidosis and has been used for risk stratification in this
patient population.91,93,94 Although MPI was initially
measured with TTE, TEE has also been validated to
measure MPI.95,96 The main advantages of the use of
Trauma (Table 3)
Early diagnosis and treatment of traumatic injury is
crucial in enhancing survival and limiting the associated morbidity. The concept of the golden hour
was demonstrated during World War I and has been
the cornerstone of trauma medicine since that time.
Patients presenting with both penetrating and blunt
chest trauma are at the highest risk for morbidity
and mortality.135 Rapid, accurate diagnosis, triage,
and definitive management have fueled improving
mortality, and TEE provides the ideal platform.
Blunt chest trauma has a high incidence of traumatic aortic injury and cardiac contusion. Aortic
injury can range from intramural hematoma to complete transection and exsanguination. Although the
specific criteria for diagnosis of contusion are vague
and changing, TEE in conjunction with TTE, serial
myocardial enzymes, and serial ECGs is a valuable
diagnostic tool.111,136-142a TTE has been shown to be
valuable in the immediate diagnosis of cardiac rupture.143 Although it has not been investigated, TEE
271
with its better image quality and enhanced diagnostic capabilities should be of equal or more benefit in
managing these patients.
Like all clinical scenarios, the use of TEE has
limitations in trauma. The possibility or presence of
cervical spine injuries can increase the risk of further
destabilizing the cervical spine with probe placement. Additionally, maxillofacial injuries and stabilizing equipment around the skull and face can make
probe placement and image acquisition very difficult.
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
Table 1.
Author
Year
Population
(n)
Gillespie 1994
et al101
22
Harpole
et al99
1989
23
Goarin
2000
et al108
209
Godet
1994
et al102
17
Iafrati
1993
et al100
17
Konstadt 1995
et al134
81
London
et al31
1990
156
Smith
et al39
1985
60
Voci
1999
et al104
Surgical
Procedure
Infrarenal AAA
repair
Observations
Carotid
endarterectomy
Type B aortic
dissection
TEE Conclusions
TEE valuable
adjunct to guide
fluid resuscitation.
Not focus of
investigation.
TEE is an accurate
diagnostic tool for
traumatic aortic
injury.
Possible to visualize
thoracic epidural
catheter.
TEE significantly
affected management
in 9 patients.
(continued)
273
Table 1. (continued)
Author
Year
Population
(n)
Taams
1988
et al120
30
Smith
1995
et al105
Surgical
Procedure
Observations
Aortic dissection
(15)/aortic
aneurysm (15)
101
Blunt chest
trauma
Nienaber 1993
et al118
110
Suspected aortic
dissection
Orihashi 1998
et al103
12
Eisenberg 1992
et al37
332
Sommer 1996
et al119
49
Aorta
Noncardiac
vascular
Suspected aortic
dissection
TEE Conclusions
TEE is a rapid and
accurate diagnostic
tool to evaluate
thoracic aortic
pathology. Rapidity
essential in
dissection, which has
associated 2% mortal
ity per hour.
TEE is a highly sensitive
and specific diagnostic
tool for detection of
thoracic aortic injury.
TEE suggested for
hemodynamically
unstable patients.
MRI to be used in
hemodynamically
stable patients.
Transgastric
echoangiography
potential method to
evaluate blood flow
following procedures
on abdominal aorta.
TEE and 12-lead added
little incremental
value in identifying
patients at high risk
for perioperative
ischemic outcomes.
Multiplanar TEE is as
valuable as CT and
MRI in detection of
thoracic aortic
dissection. Spiral CT
is superior to both
multiplanar TEE and
MRI for evaluation of
aortic arch vessel
involvement.
NOTES: TEE = transesophageal echocardiography; PAC = pulmonary artery catheter; AAA = abdominal aortic aneurysm; MRI =
magnetic resonance imaging; TTE = transthoracic echocardiography; CAD = coronary artery disease; ECG = electrocardiogram;
CXR = chest x-ray.
Obstetrics
Obstetrical anesthesia is generally performed under
regional anesthesia. However, emergent cesarean section and nonobstetrical surgery in pregnant patients
require general anesthesia. These patients may benefit
by intraoperative TEE in certain situations. A review of
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
Table 2.
Authors
Year
Population
(n)
Orihashi
et al121
2000
16
Swaminathan 2003
et al122
Swaminathan 2007
et al123
Fattori
et al124
2000
25
Rocchi
et al125
2004
42
Rapezzi
et al126
2001
22
GonzalezFajardo
et al127
2002
12
Koschyk
et al128
2005
42
van der
Starre
et al129
2004
Observations
TEE Conclusions
Aorta examined for atheromatous disease. TEE assists placement of endovascular graft and
TEE useful in measuring aortic diameter
provides immediate evaluation of deployed
for sizing graft. There were no
prosthesis. TEE assessment of endoleak and
complications related to TEE.
thromboexclusion the same as CT and
angiography (sensitivity 100%, specificity 100%).
Thoracic aorta was well visualized. Primary TEE valuable for (1) identifying aortic pathology, (2)
aortic disease identified in all patients.
confirming guidewire in true lumen, (3) aiding in
After deployment of endograft, both distal stent graft positioning, and (4) complementing
and proximal ends identified. No TEE
angiography for the determination of endoleaks.
complications; 1 hemorrhagic
Furthermore, TEE useful in evaluation of
complication from arterial access.
cardiac function and volume status.
TEE imaging of proximal aortic arch is
TEE should not be used as the sole imaging
limited. Difficulty placing the probe.
modality in endovascular repair; it complements
Change in character of spontaneous
angiography in determination of endoleaks and
echocontrast may signal occlusion of
thromboexclusion of the aneurysm.
aneurysm and endoleak.
TEE essential in determining graft landing TEE suitable for use throughout procedure. TEE
zone in 16 (62%) patients. TEE
complemented angiography in providing optimal
measurements prevented graft sizeaortic
procedural results. After deployment, TEE
mismatch in 4 patients. Distal landing
appears more sensitive than angiography in
zone change in 12 patients due to
determining endoleaks.
presence of atheromatous disease.
TEE used to confirm wire in true lumen
TEE algorithm is an easy tool to facilitate
and position graft. After deployment,
endovascular treatment of Stanford type B
appearance of spontaneous echocontrast dissection. TEE provided additional information
is suggestive of closure of the primary
from angiography in 16 (%) patients that was
intimal tear. If unsuccessful, color
critical in successful operation. The 5 endoleaks
Doppler imaging used to further guide
determined by CT at discharge were previously
stenting.
identified by TEE.
TEE identified the guidewire in the false TEE provided information that resulted in a
lumen in 2 of 7 dissections. In one third
procedural change in 13 (59%) patients.
of patients with aneurismal disease, the
Procedure was successful in all patients;
proximal landing site was changed after
complications avoided due images provided by
TEE detected atheromatous disease.
TEE.
Color Doppler echocardiography
demonstrated 7 endoleaks compared
with angiography (P = .02).
No complications due to the use of TEE
TEE is an essential adjunct to fluoscopy in the
were observed. TEE clearly identified
placement of endovascular grafts. TEE identifies
dissection in flap in all patients.
the intimal tear, establishes closure of tear with
Endoleaks were identified in 6 patients
graft, and detects endoleaks.
by TEE; angiography only demonstrated
3 leaks.
TEE and intravascular ultrasound (IVUS) TEE in conjunction with angiography provides
are superior to angiography in
useful information in the endovascular treatment
determining multiple entry sites and
of Stanford type B dissection.
demonstrating decreased flow in the
false lumen after stent deployment. TEE
superior to IVUS and angiography in the
detection of endoleaks.
An 87-year-old with Stanford type A
Endovascular graft placed successfully in the
dissection refused open surgical
ascending aorta. After deployment, TEE
treatment; opted for endovascular repair. demonstrated flow to both coronary arteries in
TEE demonstrated moderate AI,
addition to the arch vessels. TEE essential in
pericardial and pleural effusions, and
placement of prosthesis in ascending aorta.
normal contractility.
(continued)
275
Table 2. (continued)
Authors
Year
Population
(n)
Napoli
et al130
2004
30
Dobson
et al131
2004
Dobson
et al132
2006
Moskowitz
et al133
1999
Observations
TEE Conclusions
Orthopedics (Table 6)
As the demographics continue to change, older and
sicker patients are presenting for an increasing number of total joint procedures. A significant body of literature demonstrates the utility of intraoperative
TEE in the setting of orthopedic procedures.196-214
Furthermore, patients will continue to present emergently for femoral and pelvic fractures requiring
hemiarthroplasty or total arthroplasty. We believe that
intraoperative TEE will be of benefit in providing necessary functional cardiac assessment as well as guiding therapy during the actual surgical procedure.
Additionally, patients undergoing spinal instrumentation211,213 also provided medically challenging
cases as a result of their disease processes. Intraoperative TEE has provided complementary information to invasive hemodynamic monitors.
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
Table 3.
Authors
Year
Population
(n)
Ahrar
et al110
1997
89
Saletta
et al113
1995
114
Shapiro
et al114
1991
19
Frazee
et al137
1986
291
Helling
et al139
1989
68
Mattox
et al135
1985
204
Ellis and
Bender117
1991
Beggs
et al136
1987
40
Plummer
et al
1992
49
Schiavone
1991
et al143
Garcia1998
Fernandez
et al138
Mollod and
Felner141
1996
134
16
TEE Conclusions
If TEE is the primary imaging modality
in blunt chest trauma, approximately
20% of injuries will be missed or
improperly evaluated. Furthermore,
facial and cervical injuries may limit
the use of TEE in trauma patients.
TEE had a sensitivity of 63% and a
specificity of 84% for aortic rupture.
Caution on using TEE as sole
diagnostic modality in blunt chest
trauma.
TEE provides a rapid assessment of
cardiac structure and function as
well as evaluation of aorta and
mediastinum.
None
None
None
None
None
None
None
TEE can be routinely and safely used
to evaluate cardiac injuries after
blunt chest trauma.
TEE is a safe, efficient, and accurate
method to evaluate cardiac and aortic
pathology following blunt chest
trauma.
(continued)
277
Table 3.(continued)
Authors
Year
Population
(n)
Goarin
et al107
1997
28
Sparks
et al115
1991
11
Vignon
et al116
1995
32
Minard
et al112
1996
34
Weiss
et al142
1996
22
Karalis
et al111
1996
105
Goarin
et al108
2000
209
Hiatt
et al140
1988
73
Observations
TEE Conclusions
TEE can diagnosis traumatic aortic
injury with some limitations.
Additionally, TEE allows diagnosis
of additional conditions associated
with trauma: myocardial contusion,
hemopericardium, hypovolemia, and
valvular insufficiency.
TEE is a useful technique in the
diagnosis of descending aortic
rupture.
Sensitivity and specificity of TEE for
the diagnosis of TDA were 91% and
100%, respectively. TEE should be
considered the first-line imaging
modality for the evaluation of
patients with suspected pathology of
the thoracic aorta.
Compared with aortography, sensitivity
89% and specificity 100%, TEE is
less accurate. TEE should not
replace aortography as the gold
standard for diagnosis of traumatic
disruption of the aorta.
TEE examinations are safe with
excellent quality images. TTE
examinations are often inadequate
in blunt chest trauma patients.
None
NOTES: TEE = transesophageal echocardiography; TTE = transthoracic echocardiography; ECG = electrocardiogram; CPK =
creatinine phosphokinase; CK-MB = creatinine phosophokinase (MB fraction); TDA = traumatic disruption of the aorta.
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
Table 4.
Authors
Year
Population
(n)
Stoddard
et al162
1992
24
De Wolf
et al147
1993
20
Gorcsan
et al155
1995
48
Prah
et al151
1994
Ellis
et al148
1989
16
Suriani
et al154
1996
100
Harley
et al149
1996
OConnor 2000
et al150
Observations
TEE Conclusions
(continued)
Table 4.
Authors
Year
Population
(n)
Krenn
et al152
2004
10
Michel1997
Cherqui
et al153
Suriani
1996
et al154
18
(continued)
Observations
TEE Conclusions
279
NOTES: TEE = transesophageal echocardiography; LV = left ventricle; RV = right ventricle; RA = right atrium; PA = pulmonary
artery; RPA = right pulmonary artery; LPA = left pulmonary artery; PCWP = pulmonary capillary wedge pressure; MAP = mean
arterial pressure; OLT = orthotopic liver transplantation.
Table 5.
Author
Year
TEE (N)
ICU Description
Hutteman et al186
Bruch et al181
2004
2003
216
117
Colreavy et al183
Schmidlin et al191
Vignon et al194
Wake et al195
Harris et al184
McLean188
Alam180
Slama et al192
Heidenreich185
Poelaert189
Sohn et al193
2002
2001
2001
2001
1999
1998
1996
1996
1995
1995
1995
308
298
?
130
206
53
121
61
61
103
127
Chenzbraun et al182
Khoury et al187
1994
1994
113
77
Hwang et al174
Puybasset et al190
Foster and Schiller173
Oh et al177
1993
1993
1992
1990
78
32
69
51
Pearson et al178
1990
62
SICU
SICU (14%), Trauma-ICU
(9%), CTICU (48%),
ANES-ICU (29%)
MICU, CTICU
CTICU
MICU, CTICU
CTICU
CICU
ICU
CICU, MICU, SICU
MICU
CICU
ICU
CICU (18%), MICU (38%),
SICU (26%), CTICU (18%)
CTICU, MICU, CCU
SICU (48%), CICU (24%),
MICU (19%), NICU (7%)
ICU, ED
MICU
ICU
CICU (49%), MICU (22%),
SICU (29%)
CICU (48%), MICU (19%),
CTICU (21%), SICU (11%)
Diagnostic
Impact (%)
Therapeutic
Impact (%)
Complications (%)
88
59
69
43
6
2
45
45
97
41.5
47
45
65
66
97
74
52
33
73
41
58.5
32
10
18
45
48
43
21
2
NR
0
NR
NR
NR
0
1
5
1
2
45
60
26
48
7
3
50
56
17
59
NR
NR
43
24
44
NR
0
NR
0
4
4.8
NOTES: TEE = transesophageal echocardiography; ICU = intensive care unit; SICU = surgical intensive care unit; CTICU = cardiothoracic intensive care unit; ANES-ICU = anesthesia ICU; MICU = medical intensive care unit; CICU = cardiac intensive care unit;
NICU = neurointensive care unit; ED = emergency department; NR = not reported.
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Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008
Table 6.
Authors
Year
Population
(n)
Surgical
Procedure
Bisignani et al197
2008
40
Berman et al196
1998
55
Parmet et al206
1998
13
THA (55%
cemented)
TKA
(cemented)
TKA
(cemented)
Parmet et al207
1994
35
Kato et al200
2003
46
120
Propst et al212
1993
20
Moriyama et al204
2005
62
Lafont et al203
1997
48
Pitto et al209
2002
130
Pitto et al208
2000
40
Pitto et al210
1999
60
Primiano et al211
1983
36
Soliman et al213
1998
12
Ulrich et al214
1986
26
Murphy et al205
1997
16
Observations
TEE Conclusions
Not recommended
routinely
None
None
None
None
None
None
Not recommended
routinely
Not recommended
routinely
None
None
None
None
None
None
None
(continued)
281
Table 6. (continued)
Authors
Year
Population
(n)
Hirota et al199
2002
40
Christie et al198
1994
20
Surgical
Procedure
Observations
TEE Conclusions
None
None
NOTES: TEE = tranesophageal echocardiography; TKA = total knee arthroplasty; THA = total hip arthroplasty; ACL = anterior
cruciate ligament.
Conclusion
TEE is very useful monitoring modality that provides
valuable information during cardiac as well as noncardiac surgical procedures. We need to train more
anesthesiologists to perform perioperative TEE to
increase awareness of the indications and contraindications. Until relatively inexpensive TEE
equipment is available, the initial cost of equipment
acquisition remains a significant prohibitive factor
in its widespread use.
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