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Introduction
This consensus statement by the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) describes the significant role of a basic perioperative transesophageal (PTE) cardiac examination in the care and treatment of an unstable surgical patient. The use of a noncomprehensive basic PTE examination to delineate the cause of hemodynamic instability was originally proposed for the emergency room and neonatal intensive care unit settings and is meant to be complementary to comprehensive echocardiography. However, the principal goal of a basic PTE examination is intraoperative monitoring. Whereas this may encompass a broad range of anatomic imaging, the intent of noninvasive monitoring should focus on cardiac causes of hemodynamic or ventilatory instability, including ventricular size and function, valvular anatomy and function, volume status, pericardial abnormalities and complications from invasive procedures, as well as the clinical impact or etiology of pulmonary dysfunction. The basic PTE examination is not designed to prepare practitioners to use the full diagnostic potential of transesophageal echocardiography (TEE). Therefore, a basic PTE practitioner should be prepared to request consultation with an advanced PTE practitioner on issues outside the scope of practice as defined within these guidelines. Echocardiographic assessments that influence the surgical plan are specifically excluded from this consensus statement, because their acquisition requires an advanced PTE skill set.
The purposes of the current document are
- 1.
to review concisely the history of basic PTE certification,
- 2.
to define the prerequisite medical knowledge,
- 3.
to define the necessary training requirements,
- 4.
to recommend an abbreviated basic PTE examination sequence,
- 5.
to summarize the appropriate indications of basic PTE examination, and
- 6.
to define maintenance of competence and quality assurance.
Introduction
This consensus statement by the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) describes the significant role of a basic perioperative transesophageal (PTE) cardiac examination in the care and treatment of an unstable surgical patient. The use of a noncomprehensive basic PTE examination to delineate the cause of hemodynamic instability was originally proposed for the emergency room and neonatal intensive care unit settings and is meant to be complementary to comprehensive echocardiography. However, the principal goal of a basic PTE examination is intraoperative monitoring. Whereas this may encompass a broad range of anatomic imaging, the intent of noninvasive monitoring should focus on cardiac causes of hemodynamic or ventilatory instability, including ventricular size and function, valvular anatomy and function, volume status, pericardial abnormalities and complications from invasive procedures, as well as the clinical impact or etiology of pulmonary dysfunction. The basic PTE examination is not designed to prepare practitioners to use the full diagnostic potential of transesophageal echocardiography (TEE). Therefore, a basic PTE practitioner should be prepared to request consultation with an advanced PTE practitioner on issues outside the scope of practice as defined within these guidelines. Echocardiographic assessments that influence the surgical plan are specifically excluded from this consensus statement, because their acquisition requires an advanced PTE skill set.
The purposes of the current document are
- 1.
to review concisely the history of basic PTE certification,
- 2.
to define the prerequisite medical knowledge,
- 3.
to define the necessary training requirements,
- 4.
to recommend an abbreviated basic PTE examination sequence,
- 5.
to summarize the appropriate indications of basic PTE examination, and
- 6.
to define maintenance of competence and quality assurance.
History
TEE was introduced to cardiac operating rooms in the early 1980s. Many guidelines have been written that further expand on its utility to facilitate surgical decision making. The idea of distinguishing basic PTE skills was incorporated into the American Society of Anesthesiologists (ASA) and SCA practice guidelines for perioperative TEE, published in 1996. In 2002, training guidelines in perioperative echocardiography that include specific case number recommendations for training in basic and advanced PTE echocardiography were endorsed by the ASE and the SCA. The evolution of the perioperative echocardiographic guidelines is summarized in Table 1 .
| Year | Citation | Society | Title | Purpose | Comments |
|---|---|---|---|---|---|
| 1996 | Anesthesiology 1996;84:986-1006 | ASA/SCA | Practice Guidelines for Perioperative Transesophageal Echocardiography | Distinguish basic from advanced PTE skills | Cognitive and technical skills for basic and advanced PTE echocardiography are described; monitoring aspect of basic TEE is described; full diagnostic potential of advanced PTE echocardiography |
| 1999 | Anesth Analg 1999;89:870-884; J Am Soc Echocardiogr 1999;12:884-900 | ASE/SCA | ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination | Describes 20 views making up a comprehensive transesophageal echocardiographic examination | |
| 2002 | Anesth Analg 2002;94:1384-1388 | ASE/SCA | American Society of Echocardiography and Society of Cardiovascular Anesthesiologists Task Force Guidelines for Training in Perioperative Echocardiography | Training objectives and number of required transesophageal echocardiographic examinations are set | |
| 2006 | J Am Soc Echocardiogr 2006;19:1303-1313 | ASE/SCA | American Society of Echocardiography/Society of Cardiovascular Anesthesiologists Recommendations and Guidelines for Continuous Quality Improvement in Perioperative Echocardiography | Establish recommendations and guidelines for a continuous quality improvement program specific to the perioperative environment | |
| 2010 | Anesthesiology 2010;112:1084 -1096 | ASA/SCA | Practice Guidelines for Perioperative Transesophageal Echocardiography | Update of 1996 document |
The National Board of Echocardiography (NBE) was created in 1998 as a collaborative effort between the ASE and the SCA. The mission of the NBE is “to improve the quality of cardiovascular patient care by developing and administering examinations leading to certification of licensed physicians with special knowledge and expertise in echocardiography,” which is accomplished by
- 1.
overseeing the development and administration of the Adult Special Competency in Echocardiography Examination, the Advanced Perioperative TEE Examination (PTEeXAM), and the Basic PTEeXAM;
- 2.
recognizing physicians who successfully complete the examinations as testamurs ; and
- 3.
certifying physicians who have fulfilled training and/or experience requirements in echocardiography as diplomates of the NBE.
In 2006, the ASA House of Delegates approved the development and implementation of a program focused on basic echocardiography education. In 2009, a memorandum of understanding between the NBE and the ASA established a strategic partnership to mutually promote an examination and certification process in basic PTE echocardiography. Specifically, the basic PTE scope of practice was defined as the limited application of a basic PTE examination to “ non-diagnostic monitoring within the customary practice of anesthesiology. Because the goal of, and training in, Basic PTE echocardiography is focused on intraoperative monitoring rather than specific diagnosis, except in emergent situations, diagnoses requiring intraoperative cardiac surgical intervention or post-operative medical/surgical management must be confirmed by an individual with advanced skills in TEE or by an independent diagnostic technique .” A comprehensive and quantitative examination is thus not in the scope of the basic PTE examination, but those performing basic PTE echocardiography must be able to recognize specific diagnoses that may require advanced imaging skills and competence.
NBE criteria for certification in basic PTE echocardiography include
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possession of a current medical license,
- 2.
current board certification in anesthesiology,
- 3.
completion of one of the perioperative TEE training pathways ( Table 2 ), and
Table 2
The NBE’s Basic PTE training pathways
Clinical experience in basic PTE echocardiography
Supervision of training
Continuing medical education
Supervised training pathway
≥150 basic PTE echocardiographic examinations studied under supervision
≥50 of the 150 basic intraoperative transesophageal echocardiographic examinations must be performed and interpreted under supervision throughout the procedure
No requirement
Practice experience pathway ∗
≥150 basic intraoperative transesophageal echocardiographic examinations performed and interpreted within 4 y of application, with ≤25 examinations in any 1 y
Supervision not required
≥40 American Medical Association Physician Recognition Award Category 1 Credits focused perioperative TEE and completed within the same period as the clinical experience
Adapted with permission from Anesthesiology .
∗ The practice experience pathway will not be available to those completing their anesthesiology residency training after June 30, 2016.
- 4.
passing the Basic PTEeXAM or Advanced PTEeXAM.
Medical Knowledge
PTE echocardiography is an invasive medical procedure that carries rare but potentially life threatening complications and therefore must be performed only by qualified physicians. The application of basic PTE echocardiography can often dramatically influence a patient’s intraoperative management. A thorough understanding of anatomy, physiology, and the surgical procedure is critical to appropriate application. Because of the risks, technical complexity, and potential impact of TEE on perioperative management, the basic PTE echocardiographer must be a licensed physician . Previous guidelines have addressed the cognitive knowledge and technical skills necessary for the successful use of PTE and are summarized in Table 3 . The NBE’s Basic PTEeXAM knowledge base content outline is described in Table 4 .
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Training
Cahalan et al. provided guidelines for components of basic and advanced training in 2002. The NBE relied on this document as a guideline for basic PTE certification. The components of basic PTE training include independent clinical experience, supervision, and continuing education requirements ( Table 2 ).
Basic Perioperative Transesophageal Examination
PTE is relatively safe and has been associated with mortality of <1 per 10,000 patients and morbidity of 2 to 5 per 1,000 patients. Probe manipulation, including positioning, turning, rotation, and imaging planes, has previously been extensively described in the ASE comprehensive document.
Prior guidelines developed by the ASE and the SCA have described the technical skills for acquiring 20 views in the performance of a comprehensive intraoperative multiplane transesophageal echocardiographic examination. The current writing committee believes that although a basic PTE echocardiographer should be familiar with the technical skills needed to acquire these 20 views, it is nonetheless a realistic expectation that a basic PTE examination focus on encompassing the 11 most relevant views, which can provide anesthesiologists with the necessary information to use basic PTE echocardiography as a tool for diagnosing the general etiology of hemodynamic instability in surgical patients. If complex pathology is anticipated or suspected (e.g., valvular abnormality or aortic dissection), appropriate consultation with an advanced echocardiographer is indicated. Figure 1 demonstrates the ASE and SCA comprehensive 11-view basic PTE examination. The basic PTE examination starts in the midesophageal (ME) four-chamber view. It is the expectation of this writing group that a basic PTE examination can be performed using three primary positions within the gastrointestinal tract ( Figure 2 ): the ME level, the transgastric (TG) level, and the upper esophageal level. This writing group also recognizes that current advances in technology allow simultaneous multiplane imaging of real-time images, which may reduce the acquisition time for the basic PTE examination views. It is the expectation of the writing group that a complete basic PTE examination be performed on each patient as a standard examination. Once completed and stored, a more focused examination can be used for monitoring and to track changes in therapy. As noted in prior guidelines, this writing group also recognizes that individual patient characteristics, anatomic variations, pathologic features, or time constraints imposed on performing the basic PTE examination may limit the ability to perform every aspect of the examination and, furthermore, that there may be other entirely acceptable approaches and views of an intraoperative examination, provided they obtain similar information in a safe manner.
ME Four-Chamber View
The ME four-chamber view is obtained by advancing the probe to a depth of approximately 30 to 35 cm until it is immediately posterior to the left atrium ( Figure 3 , Video 1 [available at www.onlinejase.com ]). Turning the probe to the left (counterclockwise rotation of the probe) or to the right (clockwise rotation of the probe) is performed to center the mitral valve (MV) and left ventricle in the sector display. The image depth is then adjusted to ensure viewing of the left ventricular (LV) apex. The multiplane angle should be rotated to approximately 10° to 20° until the aortic valve (AV) or LV outflow tract (LVOT) is no longer in the display and the tricuspid annular dimension is maximized. Because the apex is at a slightly inferior plane to the left atrium, slight retroflexion may be required to align the MV and LV apex. Required structures seen include the right atrium, interatrial septum (IAS), left atrium, MV, tricuspid valve (TV), left ventricle, right ventricle, and interventricular septum. This view will allow the identification of both the anterior and posterior leaflets of the MV, the TV septal leaflet adjacent to the interventricular septum, to the right of the sector display, and the TV posterior leaflet adjacent to the RV free wall, to the left of the display. Diagnostic information regarding chamber volume and function, MV and TV function, and assessment of global LV and right ventricular (RV) systolic function and of regional LV inferoseptal and anterolateral walls can be determined. In the ME four-chamber view ( Figure 4 ), the basal anterolateral, mid anterolateral, and apical lateral wall segments are perfused by the left anterior descending (LAD) or left circumflex (LCX) coronary artery, the apical septum and the apical cap by the LAD coronary artery, the mid inferoseptum by the right coronary artery (RCA) or LAD coronary artery, and the basal inferoseptum by the RCA. A color flow Doppler sector with the Nyquist limit set to 50 to 60 cm/sec should be placed over both the MV and TV to aid in the identification of valvular pathology (regurgitation and/or stenosis), as well as to the IAS to identify shunt flow.
ME Two-Chamber View
From the ME four-chamber view, rotating the multiplane angle forward to between 80° and 100° until the right ventricle disappears from the image will develop the ME two-chamber view ( Figure 5 , Video 2 [available at www.onlinejase.com ]). Structures seen in the image include the left atrium, MV, left ventricle, and left atrial appendage. Diagnostic information obtained from this view includes global and regional LV function, MV function, and regional assessment of the LV anterior and inferior walls. The basal inferior and mid inferior wall segments are perfused by the RCA, whereas the apical inferior, apical cap, apical anterior, mid anterior, and basal anterior wall segments are perfused by the LAD coronary artery ( Figure 4 ). A color flow Doppler sector with the Nyquist limit at 50 to 60 cm/sec should be applied over the MV to aid in the identification of valvular pathology (regurgitation and/or stenosis). The coronary sinus is seen in short axis (SAX), as a round structure immediately superior to the basal inferior LV segment.
