The role of intraoperative TEE in complex cardiothoracic procedures

Shvetank Agarwal, MD, FASE Associate Professor and Section Chief of Cardiothoracic Anesthesia

Case #1: A 54-year-old male with rheumatic mitral valve disease and considerable mitral annularcalcification underwent a mechanical mitral valve replacement. On coming off bypass, a moderate to severe paravalvular leak was noted, which seemed to swirl around in the left atrium to the extent that determining its origin was almost impossible. Sequential 2D and 3D color Doppler views helped to identify the exact spot, which was around 9 o’clock position, just next to the left atrial appendage, which was successfully repaired by the surgeon in the second bypass run. (See figure 1)

Case #2: A 21-year-old female came for a percutaneous repair of a perimembraneous ventricular septal defect (pmVSD). These defects are usually not amenable to percutaneous repairs because of their close proximity to the tricuspid and aortic valves and also because the occluder device specifically designed for this defect has not yet been approved by the U.S. Food and Drug Administration (FDA). In this patient, the defect was aneurysmal, which made it suitable for this approach, and a decision was made by the interventional cardiologist to use the PDA duct occluder, which is FDA approved in the U.S. A close communication was required throughout the procedure, including proper sizing of the defect, as too large an occluder would interfere with the functioning of the aortic valve leaflets and a too-small device would leave a residual leak or could dislodge and embolize. 2D and 3D TEE was used to guide the placement of the Judkins right catheter and the retrograde glidewire across the pmVSD and then finally an 10X8 Amplatzer Duct Occluder as it was deployed. A thorough post-deployment TEE showed a well-placed device without any residual shunt and no impingement of the aortic or tricuspid valvular apparatus. (See figure 2)

Use of TEE in the OR did not become commonplace until the late 1980s, when high-frequency transducers became available. Since then, its use has grown considerably in the modern cardiac ORs. Our perioperative TEE-trained cardiac anesthesiologists regularly use TEE in the OR for a multitude of reasons, including to provide diagnostic information that could not be obtained preoperatively, prompt diagnosis of myocardial ischemia, confirmation of the adequacy of valve reconstruction and other surgical repairs, determination of intraoperative complications and other hemodynamic pertubations to name a few.

A relatively safe, although invasive, monitor called “TEE” trumps other monitoring devices such as electrocardiography (ECG) and pulmonary artery catheters by rapidly providing important qualitative and quantitative information on valvular and ventricular functions not possible otherwise. In 1993, the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists established a Task Force on Practice Parameters for Transesophageal Echocardiography to develop evidence-based guidelines on the proper indications for performing TEE in the operative setting labeling it as a class I indication for all valve repairs, repair of HOCM, congenital heart surgery, pericardial widows and endocarditis, among others. At Augusta University Heart and Cardiovascular Services, we use TEE in every cardiac procedure as well as some thoracic and major vascular procedures.

Introduction of real-time 3D imaging has been another important milestone in the evolution of TEE in the operating rooms. 3D TEE offers much better spatial and temporal resolutions enabling more intelligent intraoperative surgical valve repair and replacement decisions. With the help of our 3D-enabled state-of-the art TEE machines, we were also able to do the following:

  • Play a vital role in minimally invasive and percutaneous interventions helping in last-minute evaluation of suitability for an intervention.
  • Provide guidance during the intervention to detect complications.
  • Comment on the success of the procedure.

The Section of Cardiac Anesthesia has recently expanded with the addition of four cardiac anesthesiologists. Our highly skilled and dedicated group of anesthesiologists continue to provide anesthesia, sedation ICU care and perioperative TEE services for all cardiac, thoracic, major vascular surgeries and out-of-OR procedures in the electrophysiology, cardiac catheterization and echocardiography labs.