I Made Adi Parmana
The utility of intraoperative TEE has become increasingly more evident as anesthesiologists, cardiologists, and surgeons continue to appreciate its potential application as an invaluable diagnostic tool and monitor of cardiac performance for the management of cardiac surgical patients (Ann Thorac Surg 2008;85:845 53)
Class I 1. Evaluation of acute, persistent, and life-threatening hemodynamic disturbances in which ventricular function and its determinants are uncertain and have not responded to treatment 2. Surgical repair of valvular lesions, hypertrophic obstructive cardiomyopathy, and aortic dissection with possible aortic valve involvement 3. Evaluation of complex valve replacements requiring homografts or coronary reimplantation, such as the Ross procedure 4. Surgical repair of most congenital heart lesions that require cardiopulmonary bypass 5. Surgical intervention for endocarditis when preoperative testing was inadequate or extension to perivalvular tissue is suspected 6. Placement of intracardiac devices and monitoring of their position during portaccess and other cardiac surgical interventions 7. Evaluation of pericardial window procedures in patients with posterior or loculated pericardial effusions J Am Soc Cardiol 2003;(5):954-970
C. Kihara et al.journal of Cardiology (2009) 54, 282 288
C. Kihara et al.journal of Cardiology (2009) 54, 282 288
C. Kinara et al.journal of Cardiology (2009) 54, 282 288
Conclusions : Intraoperative TEE influences cardiac surgical decisions in more than 9% of all patients in the presented study population, with the greatest observed impact in patients undergoing combined CABG and valve procedures. A revision of the MV procedure was again the most frequent post-cpb change in the surgical management of this group, as in the other combined procedure groups. (Ann Thorac Surg 2008;85:845 53)
Conclusions : Pre-cardiopulmonary bypass imaging yielded unsuspected findings in 26 patients (12.8%) and changed the planned surgery in 22 patients (10.8%). Journal of Cardiothoracic and Vascular Anesthesia, Vol 14, No 1 (February), 2000: pp 45-50
Individual cases in which post-cardiopulmonary bypass transesophageal echocardiography modified the operative procedur Immediate repeat bypass and further surgery were necessary because of significant residual mitral regurgitation in one case, a large air bubble trapped in the left atrium was removed with a needle 30 minutes after weaning of CPB in the other case Journal of Cardiothoracic and Vascular Anesthesia, Vol 14, No 1 (February), 2000: pp 45-50
Hemodynamic parameters Preload and fluid responsiveness Ventricular function (LV systolic and diastolic function, RV function) The presence of tamponade Valvular function LVOT obstruction Decision to reoperate
TEE is very sensitive in detecting post-cpb myocardial ischemia and new regional wall motion abnormalities associated with possible graft kinking or occlusion
Contractility (EF) End Diastolic Area (EDA) Diagnosis Hypovolemia N Low SVR RWMA N to Ischemia LV Failure
Hypovolemiaa LV Failure Ischemia Low SVR
Perioperative transesophageal echocardiography. A companion to Kaplan s Cardiac Anesthesia; 2014
EF : 55-75% LVEDV : 80-180 ml LVESV : 30-90ml
Partial or total collapse of the SVC during inspiration accurately predicts fluid responsiveness. A collapsibility index of more than 36% identifies fluid responders, with a sensitivity of 90% and a specificity of 100%. Intensive Care Med. 2004;30:1734 1739
Annals of cardiothoracic surgery, Vol 2, No 6 November 2013
The incidence of SAM and LVOTO were reported to range from 2-16% Displacement of the anterior leaflet of the mitral valve into the LVOT during systole The consequences of SAM : Coaptation defect of the mitral valve LVOT obstruction
Paravalvular leak of prosthetic valve occurs between 5 17%
A comprehensive pre-cpb TEE examination allows the cardiac surgeon and anesthesiologist to validate the preoperative indication for surgery, and therefore to avoid an unnecessary intervention with its associated morbidity. The post-cpb TEE examination can provide a direct and immediate assessment of the surgical procedure, and therefore can expedite the decision to return to CPB when necessary.