1. 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 should be considered in coronary artery bypass graft (CABG) surgeries as well to (1) confirm and refine the preoperative diagnosis, (2) detect new or unsuspected pathology, (3) adjust the anesthetic and surgical plan accordingly, and (4) assess results of the surgical intervention. In small children, use of TEE should be considered on a case-by-case basis because of risks unique to these patients (e.g., bronchial obstruction).

2. Catheter-based intracardiac procedures: For patients undergoing transcatheter intracardiac procedures, TEE may be used.

3. 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.

4. 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 (TTE) or other modalities in a timely manner.

Valvular Surgery

During valvular surgery, TEE provides specific views of the valvular lesions (aortic and mitral) as well as heart function. TEE examination prior to CPB evaluates the mechanism and severity of valvular dysfunction; immediately after CPB, TEE assesses the repair (residual regurgitation, presence of systolic anterior motion, or restriction of leaflet motion). TEE also provides an ongoing picture of the heart function pre- and post-correction of the valvular defect. ³ In 205 patients undergoing posterior mitral leaflet quadrangular resection as treatment for mitral regurgitation, TEE revealed immediate failures in 24 patients (11%) and in 20 of those patients, identified the mechanism of failure and guided immediate correction. ⁴ Another study on 437 patients who underwent various techniques of mitral valve repair showed that successful initial repair as evidenced by intraoperative TEE was the most important predictor of repair durability. ⁵ In a study of 2076 patients undergoing mitral valve repair, TEE identified systolic anterior motion (SAM), a known complication of this type of surgery, in 174 patients (8.4%), and 4 of these patients required immediate reoperation for severe SAM; the others were managed medically. ⁶ Although mitral valve repair is a well-established procedure, it is imperative that a correct assessment of the repair be accomplished to reduce future need for reoperation. Kawano et al. reported great accuracy in evaluation of mitral valve repair, in which only 5 of 34 patients showed grade 1+ mitral regurgitation (MR) on postoperative ventriculogram, and only 1 patient had recurrent MR on follow-up TTE. ⁷ In a 5-year prospective review of the impact of intraoperative TEE on surgical management, new information was found before CPB in 15% of patients, directly affecting surgery in 14% of them; new information after CPB was found in 6% of patients. The most common finding was valvular dysfunction, with return to CPB for further repair or replacement. ⁸

In the post-CPB period, TEE evaluation of valve repair/replacement can show perivalvular leak and possible strain on the cardiac system from the repair itself, leading to volume or pressure changes that cannot be handled by the heart. In another large series by Stewart et al. studying 6340 patients undergoing cardiac surgery, return to CPB was required in 7% of the 2226 mitral valve procedures, based on the intraoperative TEE assessment. ⁹

Intraoperative TEE is recommended for valve replacement (with a stentless xenograft, homograft, or autograft) as well as repair. TEE is considered reasonable for all cardiac valve surgery to detect valvular malfunction (abnormal leaflet motion) and paravalvular regurgitation. For mitral valve surgery (repair or replacement), TEE can assess the risk to left ventricular function due to possible injury/occlusion of circumflex artery during replacement. ¹⁰ Shapira et al. retrospectively studied 417 patients who underwent valve replacement (mitral valve, 237; aortic valve, 221; tricuspid valve, 43) during a 5-year period in a single institution. Intraoperative TEE was performed in 352 patients, and unexpected pathologic findings were noted on post-bypass TEE. Immediate surgical correction was required in 15 patients (3.6%), and perivalvular leak, immobilized leaflets, coronary obstruction by an aortic bioprosthesis, and an incompetent xenograft were found in 47 patients (11.3%). Post-bypass TEE contributed to evaluation of difficulty weaning from CPB and guided management in these patients. ¹¹

TEE provides a very reliable assessment of the cause of aortic regurgitation (AR) and predicts the reparability of the valve and postoperative outcome. In a study by Waroux et al., 163 patients undergoing AR surgery underwent TEE assessment to categorize the mechanism of AR. Compared with surgical inspection, TEE correctly predicted the final surgical approach in 93% of patients undergoing replacement and 86% of patients undergoing repair. The TEE classification of AR lesions was the determinant of valve reparability and postoperative outcome (4-year freedom from > grade 2 AR, reoperation, or death; P = 0.04). ¹²

Although the acquisition cost of TEE is high, the value of the information results in a favorable cost/benefits ratio. Ionescu et al. studied the clinical impact and cost-saving implications of routine use of intraoperative TEE for elective valve replacement in a prospective study of 300 patients. In two patients undergoing aortic valve replacement, significant mitral regurgitation led to additional mitral valve replacement, and one patient scheduled for mitral valve replacement was found to have significant AR and required aortic valve replacement as well. The calculated savings by routine intraoperative TEE use were $109 per patient per year. ¹³ Based on this figure, the potential costs for reoperative exploration or need for additional surgical correction after the initial surgery would far outpace the nominal cost of TEE performed on a routine basis.

CABG Surgery

Coronary artery bypass operations can be performed on and off CPB. TEE use in the intraoperative setting can guide the operative process. Practice guidelines for perioperative TEE by the ASA and the SCA Task Force recommend that in adults without contraindications, TEE should be considered in CABG surgeries. ¹⁴ TEE has become the mainstay of cardiac operations, with actual proven beneficial use for determining other potential pathologies that may be present, such as valve lesions, abnormal loading conditions, or regional wall motion abnormalities. TEE has been shown to be the single most important factor in guiding therapies such as fluid administration, antiischemic therapy, antiarrhythmic therapy, and vasodilator or inotropic therapy in 98 instances out of 584 intraoperative interventions (17%). ¹⁵ Savage et al. observed that intraoperative TEE led to at least one major surgical management change in 33% of patients, and in 51%, at least one anesthetic/hemodynamic alteration took place based on TEE findings. These findings show just how integrated TEE is in operative management. ¹⁶ Similar numbers have been shown in off-pump CABG (OPCAB), where 16% of 744 patients studied by Gurbuz et al. required a major modification of operative strategy. ¹⁷

Masses

An intracardiac mass is a relatively infrequent operative lesion with a reported incidence between 0.0017% and 0.19%. ¹⁸ A very unique and practical use for intraoperative TEE is the ability to visualize a mass prior to surgical excision, as well as determine its pathologic implications, such as hindering valve function. TEE can also be used to determine if the mass has embolized before its surgical excision.

Congenital Lesions

The use of TEE for intraoperative repair of congenital lesions is performed for evaluation of flow pattern(s), stenosis, and regurgitation of the lesions. TEE probes are used in infants as small as 3 kg. Given the nature and intricacy of these lesions, TEE helps develop a clearer picture of the lesion and a view of the corrective process that helps alleviate the pathology. More children survive to adulthood when they may present for cardiac or other types of surgeries. Russell et al. offer an updated review of TEE use in the adult patient with congenital heart disease (congenitally corrected heart disease). ¹⁹

Hypertropic Cardiomyopathy

Hypertrophic cardiomyopathy exists as a progressive disorder that is best followed by TTE and TEE. In the perioperative setting, TEE allows for determination of the gradient across the hypertrophied outflow tract and the morphology of the myocardium. Afonso et al. posit that with evolution of newer technologies (tissue Doppler, strain imaging, 3D echo), assessment has moved from ejection fraction evaluation to mechanisms of appraising cardiac performance. ²⁰

Great Vessels

Disease involving the great vessels, specifically pathology of the aorta, is often diagnosed by TEE, a highly sensitive and specific method of detecting injury to the thoracic aorta. It is a quick and safe test in critically injured patients with suspected traumatic rupture of the aorta and compares favorably with arch aortography. ²¹

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