Echocardiography For the AnesthesiologistSc o t t R. St e w a R t , MD Fellow in cardiothoracic anesthesiology Medical University of South Carolina Charleston, South Carolinaca R o l i n e c. McKi l l o p , MDFellow in cardiothoracic anesthesiology Medical University of South Carolina Charleston, South CarolinaJa M e S H. ab e R n a t H y , MD, MpHAssociate Professor of Anesthesiology and Perioperative Medicine Medical University of South Carolina Charleston, South CarolinaThe authors have no relevant disclosures to report.Transesophageal echocardiography (TEE) plays an important role in patient management during the perioperative period. It is routinely used during cardiac surgery but also has great value for the unstable patient undergoing noncardiac surgery. This article presents the anesthesiologist with a practical review of the basic TEE examination, ultrasound physics and fundamental principles, indications for TEE, the TEE certification process, perioperative use of transthoracic echocardiography (TTE), and the increasing use of 3-dimensional (3-D) echocardiography.Basic ExaminationTransesophageal echocardiography provides an excellent diagnostic and monitoring tool for anesthesiologists in the operating room. The TEE examination can be broken down into complete/comprehensive and abbreviated forms; the user may select either depending on the urgency of the situation and other clinical responsibilities. As with any invasive procedure, the potential risks and benefits of TEE should be discussed with the patient and preoperative informed con-sent obtained. A study by researchers at Brigham and Women’s Hospital, in Boston, retrospectively reviewed more than 7,000 TEE examinations and found rates of procedure-related morbidity and mortality of 0.2% and 0%, respectively. Although rare, the most common TEE-related injuries were odynophagia, dental trauma, malpositioning of the endotracheal tube, upper gastrointestinal hemorrhage, and esophageal perforation. Few contraindications exist to insertion of the TEE probe; these include dysphagia, odynophagia, significant reflux, hematemesis, history of gas-tric and/or esophageal pathology (a hiatal her-nia is not a contraindication but may complicate imaging), and significant resistance during inser-tion or advancement of the probe (Table 1). By 1IndEpEndEntly dEvElopEd By McMahon puBlIshIng anEsthEsIology nEws • dEcEMBEr 2010prIntEr-FrIEndly vErsIon at anEsthEsIologynEws.coMcarefully selecting candidates using these guidelines, as well as minimizing probe manipulation, clinicians can make intraoperative TEE relatively safe and beneficial for assessing cardiovascular function and anatomy.1In 1999, the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists (SCA) developed recommendations on what should be included in a comprehensive TEE examination. Shane-wise and colleagues applied these recommendations to the 20 standard imaging views that allow for a com-plete examination of the ventricular, valvular, and major vascular functions and anatomy.2 Miller and colleagues subsequently condensed the comprehensive examina-tion into 12 necessary views that would enable basic TEE practitioners to quickly examine and interpret car-diovascular function and anatomy.3 The following section describes how to complete the basic TEE examination. The order can vary according to practitioner preference. In any case, the sequence should minimize probe movement.Image acquisition depends on controllable and uncontrollable factors. Uncontrollable factors, such as the patient’s anatomy, “acoustic windows,” and shad-ows from an implanted cardiac device, will affect the quality of the ultrasound images. However, an experi-enced and skilled user can manipulate both the prop-erties and the position of the probe to obtain adequate images. The probe is controlled by advancing and with-drawing the instrument to view more distal and proxi-mal structures and by rotating it counterclockwise and clockwise to image left- and right-sided structures. In combination with using the large control dial to anteflex or retroflex the probe tip, using the smaller dial to flex the probe tip right to left, and using the scan angula-tion control from 0 to 180 degrees, the practitioner can obtain and optimize the required TEE images in order to acquire accurate data for analysis.4The basic examination begins with insertion of the TEE probe. After securing the patient’s airway and evac-uating the stomach, the clinician should carefully insert a bite guard with lubricating jelly into the patient’s mouth. The probe is then passed (with the control lock in the off position) into the upper esophagus using a sustained jaw lift, constant gentle pressure, and a slight twisting motion. Beyond the cricopharyngeus muscle, a distinct loss of resistance will be noted. Particular care must be taken at this point because numerous possibil-ities exist for trauma and morbidity to both the patient and the probe.1table 1. contraindications to Intraoperative tEE DysphagiaOdynophagiaHematemesis History of gastric and/or esophageal pathology Significant reflux Significant resistance during insertion or advancement of the probetEE, transesophageal echocardiographyFigure 1. Mid-esophageal 4-chamber view. The entire heart is visualized in a single view. This view provides an excellent “overview” of ventricular and valvular function. Figure 2. Mid-esophageal 4-chamber view with colorflow doppler over the mitral valve. This image allows assessment of atrioventricular valve function and flow patterns. For meanings of abbreviations, see key on page 8.IndEpEndEntly dEvElopEd By McMahon puBlIshIng2When positioned in the esophagus, the probe should be gently advanced until a recognizable structure is reached—usually the mid-esophageal 4-chamber (ME-4C) view ( Figure 1). This view is obtained by advancing the probe at 0 degrees of scan angulation and slight retroflexion of the tip. All 4 cardiac chambers, the tri-cuspid valve (TV), and the mitral valve (MV), should be visible with the left-sided structures on the right of the TEE screen and right-sided structures on the left of the screen (as with a chest x-ray). These structures should be evaluated regarding size, shape, structure, and func-tion.4 This view is easy to obtain and commonly is used as a landmark