Dwelling on the Utility of Transesophageal Echocardiography (TEE) in the Operating Room: Is It Time to Integrate Training in TEE into the Anesthesia Postgraduate Curriculum?
Year: 2024
Type: article
Abstract: Echocardiography continues to remain the most widely used diagnostic modality for evaluating the anatomy and the function of the heart. While preoperative transthoracic echocardiography (TTE) remains the cornerstone of cardiovascular imaging, assessment of the left atrium (LA) is often difficult using TTE. In contrast, transesophageal echocardiography (TEE) is useful for visualizing the posterior structures of the heart. The high sensitivity and specificity of TEE for the detection of LA thrombus, a potentially life-threatening condition, is particularly noteworthy.[1] Additionally, TEE also plays a crucial role in the intraoperative assessment and diagnosis of catastrophic conditions such as myocardial ischemia, pulmonary embolism, and cardiac tamponade in patients with known cardiac comorbidities undergoing noncardiac surgeries.[2] A 58-year-old woman with a history of severe mitral stenosis (MS) and atrial fibrillation (AF) was scheduled for mitral valve replacement in our institute. Preoperative TTE revealed severe MS with a mean pressure gradient of 14 mmHg and an estimated mitral valve area of 0.9 cm2. However, no evidence of LA thrombus was noted on TTE imaging. Due to the high risk of thromboembolic events in patients with severe MS and AF, TEE was performed intraoperatively, which revealed spontaneous echo contrast and a large LA thrombus measuring 3 × 3 cm2 [Figure 1a]. This finding was confirmed intraoperatively by the operating surgeon as well [Figure 1b]. This critical finding was missed on TTE due to suboptimal visualization of the LA. Given the myriad implications of missed diagnoses and their significant impact on patient outcomes, we believe that the integration of formal basic TEE training into the anesthesia postgraduate teaching curriculum is the need of the hour.Figure 1: a) Left atrium thrombus on TEE. b) Thrombus in the left atriumThe National Board of Echocardiography (NBE) has formulated a basic TEE course in the United States, which is recommended for the use of anesthesiologists who are not trained in cardiac anesthesia, for use during noncardiac surgeries.[3] Moreover, TEE seems to be the intuitive and practical approach for intraoperative hemodynamic assessment when the use of TTE or ultrasonography would interfere with the sterility of the surgical field. It is also a relatively noninvasive method for the intraoperative assessment of fluid responsiveness and cardiac output in noncardiac surgeries.[4] A 41-week didactic training in TEE was found to improve examination scores among anesthesiology residents in a study conducted by Goldstein et al.[5] A 2-month rotation in basic TEE was also found to result in 45% of the residents achieving either NBE testamur or certification status in a report on their institutional experience in TEE training published by Subramaniam et al.[3] Integrating basic TEE training into the postgraduate curriculum offers several benefits. It ensures that all anesthesiologists receive fundamental training in basic TEE techniques, thereby helping them to care for older and sicker patients with greater precision. However, reporting the findings of a TEE examination comprehensively and accurately requires specialized and dedicated training. Postgraduate training is an ideal time to introduce the trainee to the complexities of cardiac anatomy as well as to the sector alignment of a TEE probe. These skills, when acquired early, are likely to stimulate an interest in superspecialization and they may be further honed during superspecialty training. It may also reduce their need to rely on a cardiac anesthesiologist, an intensivist, or a cardiologist to perform a rescue TEE during intraoperative hemodynamic instability. Since anesthesiologists are considered to be perioperative physicians, it seems intuitive to have a grasp on the basic concepts of TEE to bolster their confidence and, in turn, improve patient outcomes. We suggest that the basics of cardiac imaging for perioperative management should be incorporated into the postgraduate anesthesiology training. Educational institutions and regulatory bodies should recognize the importance of TEE in the practice of anesthesiology and prioritize the integration of TEE training into the postgraduate anesthesia curriculum. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Annals of Cardiac Anaesthesia
Authors: Gegal Pruthi, Ankita Dey, R Shwaetha, Rajiv Kumar
Institution: All India Institute of Medical Sciences
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4403131151