The impact of intraoperative transoesophageal echocardiography on an unselected cardiac surgical population: a review of 2343 cases

Initial clinical experience with a miniaturized transesophageal echocardiography probe in a cardiac intensive care unit

OBJECTIVE

To investigate the safety of a novel, miniaturized, monoplane transesophageal echocardiography probe (mTEE) and its potential as a hemodynamic monitoring tool.

DESIGN

This was a retrospective analysis of the clinical evaluation of a disposable mTEE in ventilated patients with severe cardiogenic shock requiring hemodynamic support. mTEE assessment was performed by operators with mixed levels of TEE training. Information on hemodynamic interventions based on mTEE findings was recorded.

SETTING

A tertiary university cardiac critical care unit.

PARTICIPANTS

Male and female critical care patients admitted to the unit with severe hemodynamic instability.

INTERVENTIONS

Insertion of miniaturized disposable TEE probe and hemodynamic and other critical care interventions based on this and conventional monitoring.

MEASUREMENTS AND MAIN RESULTS

In 41 patients (51.2% female, 73.2% after cardiac surgery), hemodynamic support probe insertion was accomplished without major complications. A total of 195 mTEE studies were performed, resulting in changes in therapy in 37 (90.2%) patients based on mTEE findings, leading to an improvement in hemodynamic parameters in 33 (80.5%) patients. Right ventricular (RV) failure was diagnosed in 25 patients (67.6%) and mTEE had a direct therapeutic impact on management of RV failure in 17 patients (68 %).

CONCLUSIONS

Insertion and operation of a novel, miniaturized transoesophageal echocardiography probe can be performed for up to 72 hours without major complications. Repeated assessment using this device provides complementary information to invasive monitoring in the majority of patients and has an impact on hemodynamic management.

Core review: physician-performed ultrasound: the time has come for routine use in acute care medicine

The use of ultrasound in the acute care specialties of anesthesiology, intensive care, emergency medicine, and surgery has evolved from discrete, office-based echocardiographic examinations to the real-time or point-of-care clinical assessment and interventions. "Goal-focused" transthoracic echocardiography is a limited scope (as compared with comprehensive examination) echocardiographic examination, performed by the treating clinician in acute care medical practice, and is aimed at addressing specific clinical concerns. In the future, the practice of surface ultrasound will be integrated into the everyday clinical practice as ultrasound-assisted examination and ultrasound-guided procedures. This evolution should start at the medical student level and be reinforced throughout specialist training. The key to making ultrasound available to every physician is through education programs designed to facilitate uptake, rather than to prevent access to this technology and education by specialist craft groups. There is evidence that diagnosis is improved with ultrasound examination, yet data showing change in management and improvement in patient outcome are few and an important area for future research.

Intraoperative echocardiography in valvular heart disease: an evidence-based appraisal

Intraoperative (IO) transesophageal echocardiography (TEE) is widely used for assessing the results of valvular heart disease (VHD) surgery. Epiaortic ultrasonography (EAU) has been recommended for prevention of perioperative strokes. To what extent does high-quality evidence justify the widespread use of these imaging modalities? In March 2009, we searched MEDLINE (PubMed and OVID interfaces) and EMBASE for studies published in English using database-specific controlled vocabulary describing the concepts of IOTEE, cardiac surgery, VHD, and EAU. We found no randomized trials or studies with control groups assessing the impact of IOTEE in VHD surgery. Pooled analysis of 8 observational studies including 15,540 patients showed an average incidence of 11% for prebypass surgical changes and 4% for second pump runs, suggesting that patients undergoing VHD surgery may benefit significantly from IOTEE, particularly from postcardiopulmonary bypass IOTEE in aortic repair and mitral repair and replacement, but less so in isolated aortic replacement. Further available indirect evidence was satisfactory in the test accuracy and surgical quality control aspects, with low complication rates for IOTEE. The data supporting EAU included 12,687 patients in 2 prospective randomized studies and 4 nonrandomized, controlled studies, producing inconsistent outcome-related results. Despite low-quality scientific evidence supporting IOTEE in VHD surgery, we conclude that indirect evidence supporting its use is satisfactory and suggests that IOTEE may offer considerable benefit in valvular repairs and mitral replacements. The value of IOTEE in isolated aortic valve replacement remains less clear. Evidence supporting EAU is scientifically more robust but conflicting. These findings have important clinical policy and research implications.