Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room
Publication Date: June 1, 2020
Last Updated: March 14, 2022
Key Points
Key points for the pre- and postprocedure assessment for intracorporeal LVAD placement
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| PREPROCEDURE |
| A complete pre-implantation examination should be performed in order to rule out hemodynamically significant valvular lesions, intracardiac shunts and thrombus, and evaluate baseline RV function. |
| Evaluation of TR should include assessment of the tricuspid annulus, tricuspid leaflet tethering, RA and RV size, and position and motion of IAS and IVS during the cardiac cycle. |
| Aortic regurgitation is likely to progress after LVAD implantation and to impair adequate systemic forward flow. It can be easily underestimated in patients with advanced heart failure. Re-evaluation of AR should be performed after institution of CPB, which may mimic the hemodynamic conditions during LVAD support. |
| RV function should be evaluated by integrating several echocardiographic parameters. |
| POSTPROCEDURE |
| The same elements of the pre-implantation examination should be re-evaluated in the post-implantation period: intracardiac shunts, degree of TR, degree of AR, and RV function. |
| The position of the IAS and IVS and the relative size of the LV and RV provide information regarding causes of decreased LVAD flow. |
| Leftward shift of the IAS and IVS, decreased LV size, RV dilation and dysfunction indicate decreased preload to the LVAD due to RV failure. |
| Decreased LV and RV size indicate decreased LVAD preload in the setting of hypovolemia or extrinsic compression. |
| Position and flow by CFD and spectral Doppler should be evaluated and documented for both the inflow cannula and the outflow graft as outlined in the text. |
Abbreviations: AR, Aortic regurgitation; CFD, color flow Doppler; CPB, cardiopulmonary bypass; IAS, interatrial septum; IVS, interventricular septum; LVAD, left ventricular assist device; RA, right atrium; RV, right ventricle; TR, tricuspid regurgitation.
Key points for imaging in patients undergoing total artificial heart placement
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| PREPROCEDURE |
| Examine left and right atria as well as the LAA and exclude the presence of thrombus. |
| Examine left and right pulmonary veins and document size and pulmonary vein flow (flow profile and velocities by PW Doppler). |
| Inspect RA-SVC and RA-IVC junctions for the presence of medical devices, thrombus, stenosis. |
| POSTPROCEDURE |
| Monitor for the presence of air in the native atria, and in the main PA and ascending aorta. |
| Re-evaluate size of the atria and pulmonary vein flow (flow profile and velocities) to rule out torsion or extrinsic compression. |
| Obstruction of PV flow should be suspected if there is loss of phasic systolic and diastolic flow patterns, CFD flow acceleration is detected, and peak velocities are increased above normal or baseline values. |
| Mean gradients and the corresponding ventricular rate should be recorded for the tricuspid and mitral prostheses in order to serve as a reference for subsequent examinations. |
Abbreviations: CFD, Color flow Doppler; IVC, inferior vena cava, LAA, left atrial appendage; PA, pulmonary artery; PV, pulmonary vein; RA, right atrium.
Key points for imaging during intra-aortic balloon pump placement
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| PREPROCEDURE |
| Exclude the presence of moderate or severe aortic regurgitation |
| Examine the presence of mobile atheromatous disease |
| POSTPROCEDURE |
| Note the presence of the tip of the intra-aortic balloon pump 1-2 cm below the distal aortic arch (left subclavian artery) |
| Balloon inflation during diastole will generate characteristic acoustic shadowing and reverberation artifacts |
Key points for intraoperative imaging in patients undergoing resection of intracardiac masses
| PREPROCEDURE |
| Evaluate location, size, type of attachment |
| Evaluate effect on neighboring structures and associated findings (e.g., pericardial effusion) |
| Evaluate malignant vs. benign features as outlined in the text |
| POSTPROCEDURE |
| Evaluate extent of resection |
| Exclude iatrogenic damage that may have occurred to neighboring structures during resection |
| Perform a complete examination following resection in order to uncover pathologies that may have been obscured by the presence of the tumor/mass |
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Recommendation Grading
Overview
Title
Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room
Authoring Organizations
American Society of Echocardiography
Society of Cardiovascular Anesthesiologists
Society of Thoracic Surgeons
Publication Month/Year
June 1, 2020
Last Updated Month/Year
August 29, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room
Intended Users
Physician, nurse, nurse practitioner, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D017548 - Echocardiography, Transesophageal
Keywords
cardiac surgery, Transesophageal echocardiography, intraoperative, Transesophageal
Source Citation
Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, Mankad S, Nyman CB, Pagani F, Porter TR, Rehfeldt K, Stone M, Taylor B, Vegas A, Zimmerman KG, Zoghbi WA, Swaminathan M. Guidelines for the Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room: A Surgery-Based Approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr. 2020 Jun;33(6):692-734. doi: 10.1016/j.echo.2020.03.002. Erratum in: J Am Soc Echocardiogr. 2020 Nov;33(11):1426. PMID: 32503709.