Download Transesophageal echocardiography in the OR and ICU

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MINERVA ANESTESIOL 2009;75
O R I G I N A L A RT I C L E
Transesophageal echocardiography
in the OR and ICU
F. GUARRACINO, R. BALDASSARRI
Operative Unit of Cardiothoracic Resuscitation Anaesthesia and Intensive Care Medicine
Pisa University Hospital, Pisa, Italy
ABSTRACT
The application of transesophageal echocardiography (TEE) in the perioperative setting has been expanding over the
past decades. TEE has become increasingly important in the management of critically ill patients both in the operating room and in the intensive care unit (ICU). TEE is a semi-invasive imaging technique that provides a rapid, realtime, bedside assessment of cardiac function and morphology. It provides information about the anatomy of all cardiac structures and their functional status. A comprehensive exam evaluates both ventricles’ morphology, dimensions,
and wall motion. It can also detect any anatomical abnormalities and the presence of intracardiac masses or thrombi.
Over the last few years, a large number of studies in different ICU and critical care settings and populations have
demonstrated the feasibility of TEE in the management of hemodynamic instability. Hemodynamic parameters, such
as volumes and pressures, can be obtained via TEE assessment of cardiac performance and may be helpful for diagnosis and treatment. Intraoperative TEE is actually considered an important diagnostic tool in patients scheduled for cardiac surgery as well as in high-risk patients undergoing non-cardiac surgery. All types of hemodynamic impairment can
be quickly assessed via TEE, and the management of the echo data can define both the cause and the diagnosis.
Key words: Echocardiography, transesophageal - Intensive care - Operating rooms.
T
he application of transesophageal echocardiography (TEE) in the perioperative setting has
been expanding for the past 15 years.1, 2 TEE has
become increasingly important in the management of critically ill patients in both the operating
room and in the intensive care unit (ICU). Due to
the position of the probe inside the esophagus,
the transducer is close to the heart and extracardiac
structures so the acoustic window is optimized for
TEE even when the chest is open. A comprehensive examination of the heart can thus be performed in a few minutes.3-5
TEE evaluation of the heart
TEE is a semi-invasive imaging technique that
provides a rapid, real-time, bedside assessment of
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cardiac function and morphology. It provides information about the anatomy of all cardiac structures
and their functional status.3, 6, 7
A comprehensive TEE exam evaluates both ventricles’ morphology, dimensions, and wall motion.
A comprehensive assessment of cardiac function
requires a complete evaluation of systolic and diastolic left ventricle (LV) performance.3, 4, 6, 7, 8-19
Systolic function can be assessed by measuring different systolic indexes, such as ejection
fraction (EF), shortening fraction (SF) and fractional area change (FAC) (Figures 1, 2), by sampling systolic myocardial velocities at the mitral
annulus by tissue Doppler echocardiography, or
by measuring the stroke volume (SV) with the
Doppler technique.18-21
Diastolic function can be evaluated by study-
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Figure 1.—Measurement of ejection fraction and fractional area changes of the left ventricle.
Figure 2.—Measurement of shortening fraction of the left ventricle.
ing the transmitral inflow velocities (Figure 3)
using the pulsed-wave echo Doppler technique.
Two waves are first identified: the E wave (rapid fill-
2
ing) and the A wave (atrial contraction). The E/A
ratio and the deceleration time (DT) of the E wave
are both useful parameters for the evaluation of
diastolic function. Another method for estimating the diastolic function is a Doppler evaluation
of the pulmonary venous flow pattern. Recently,
Tissue Doppler Imaging (TDI) of myocardial
velocities has been recognized as an important tool
for the detection of diastolic impairment, as has
flow propagation velocity of the left ventricle by
color M-mode analysis.19, 22-28
A proper assessment of cardiac function also
requires a complete estimation of regional myocardial contractility through the study of myocardial
movement and the thickening of any cardiac
walls.3, 15 A TEE examination can assess or exclude
the diagnosis of myocardial ischemia through the
evaluation of myocardial contractility. To evaluate myocardial contractility means to observe both
myocardial thickening and endocardial movement
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Figure 3.—Diastolic evaluation: transmitral flow; pulmonary venous flow; tissue Doppler imaging from mitral annulus; mitral
flow propagation velocity.
for each segment. Any alteration in thickening or
in movement of a specific myocardial region is
defined as a Regional Wall Motion Abnormality
(RWMA). TEE can be used to evaluate the extension of the ischemic area via examination of the
myocardial segmental kinesis using a segmental
model of the LV in which 16 or 17 segments are
recognized.18 This imaging technique can also be
used to assess cardiac function and any associated
complications. For instance, an acute valvular dysfunction due either to chordal or papillary muscle
rupture can be assessed early with TEE. A free wall
rupture, ventricular septal defect, or the presence
of mural thrombi, ventricular pseudoaneurysm,
or pericardial effusion can all also be detected with
TEE.
Although more difficult to study, the right ventricle (RV) can also be evaluated with TEE in terms
of both systolic and diastolic function. RV systolic
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function can be estimated by measuring the tricuspid annular plane systolic excursion (so-called
TAPSE) using M-mode analysis or 2D measurement. The application of TDI to the myocardial
wall just below the tricuspid plane allows evaluation of systolic myocardial velocity, which is a good
estimate of global RV systolic performance. The
TDI also offers the opportunity to detect diastolic
myocardial velocities, thus providing a prompt
evaluation of RV diastolic function. TEE evaluation of RV function is crucial in many clinical scenarios when acute RV dysfunction, either primary
(acute RV infarction) or secondary (pulmonary
embolism, RV failure secondary to pressure overload under mechanical ventilation), can influence
the clinical course. The recognition of RV failure
can guide diagnosis and treatment, leading to
appropriate hemodynamic management.
Aortic valve anatomy and function can also be
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explored. TEE can evaluate the morphology and
movement patterns of the valvular leaflets, providing information about the competency of the
valvular apparatus and revealing the presence of
stenosis and/or regurgitation.3, 4, 11, 12
The mitral valve apparatus including the leaflets,
annulus, subvalvular apparatus, and ventricular
wall can be extensively explored. Any abnormality in either morphology or function can be precisely evaluated.13-15
A high-quality assessment of prosthetic valves
can easily be performed with a standard TEE exam
because it can show the presence of prosthetic
valvular malfunction and/or vegetations.16
It can also detect any anatomical abnormalities
and the presence of intracardiac masses or thrombi,8-10 and the left and right atria can be evaluated
and measured.
TEE can also be used to investigate the pericardium for evidence of thickening, effusion, or
tamponade.2
TEE and hemodynamics
Besides providing essential information about
cardiac function, TEE has been recognized as an
efficient hemodynamic monitoring tool.
Over the last few years, a large number of studies in different ICU and critical care settings and
populations have demonstrated the feasibility of
TEE in the management of hemodynamic instability. It is now clear that this semi-invasive tool
can provide much new and useful information
about the heart. Even when invasive continuous
monitoring by a pulmonary artery catheter (PAC)
is present, TEE helps to define the diagnosis by
acquiring morphological and functional information that can be integrated with the PAC
data.1, 29, 30
Hemodynamic parameters, such as volumes
and pressures, can be obtained via TEE assessment
of cardiac performance and may be helpful for
diagnosis and treatment.
Volumetric indices are actually considered to
be more useful than pressure estimations in assessing preload.
TEE also allows for the evaluation of the adequacy of loading conditions, often the first step in the
management of critically ill patients in the acute
4
setting.1, 19 Echocardiography provides a volumetric evaluation of the cardiac chambers that can be
correlated with the cardiac cycle and the loading
condition.20, 21
Preload can also be evaluated by measuring left
ventricular end-diastolic area (LVEDA), which
correlates well with end-diastolic volume, and also
by evaluating the respiratory variation in the diameter of the inferior vena cava or the collapsibility
of the superior vena cava, and then sampling the
velocity time integral (VTI) of the aortic valve
flow during inspiration.19
A proper understanding of the relationship of
diastole to LV preload is crucial for proper management of hemodynamics.19 The majority of LV
filling occurs during the LV rapid-filling phase
following isovolumetric relaxation (IVR). A normal duration of IVR is of great importance for an
adequate subsequent filling phase. In fact, a prolonged IVR phase as observed in abnormal relaxation patterns causes a reduction in the rapid-filling time. Moreover, a lower drop in LV pressure
during a prolonged IVR phase leads to increased
subendocardial wall pressures just at the most
important coronary perfusion time. Thus, prolonged relaxation may practically impact both filling and myocardial perfusion. On the other hand,
a change in LV compliance causes an increase in LV
filling pressures and leads to a more pronounced
contribution of atrial contraction to LV chamber
filling. In this condition, the maintenance of a
sinus rhythm is crucial.
The understanding of diastole by echo as previously described has great influence on cardiovascular management in critical patients. An echoguided approach will lead to measures to avoid
tachycardia and hypotension in patients with
abnormal relaxation, and measures to prevent
rhythm abnormalities and acute unloading in
patients with reduced compliance.
Dynamic obstruction of the LV outflow tract
is a typical ultrasound diagnosis in acute settings.
TEE can quickly reveal the anatomical and functional features of this condition, consisting of anterior movement of mitral leaflets into the LV outflow tract (LVOT) with dynamic obstruction of
the LVOT and reduced stroke volume. In some
circumstances, this finding is also accompanied
by mitral regurgitation. Prompt diagnosis facili-
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tates adequate interpretation of hemodynamic
monitoring, which usually shows hypotension,
reduced stroke volume and increased filling pressures. Of course, TEE can play a crucial role in
guiding proper treatment, such as cessation of
inotrope treatment and administration of volume,
beta blockers, and sometimes vasoconstrictors.
Intraoperative TEE
Intraoperative TEE is actually considered an
important diagnostic tool in patients scheduled
for cardiac surgery as well as in high-risk patients
undergoing non-cardiac surgery.2, 6
All types of hemodynamic impairment can be
quickly assessed by TEE intraoperatively, and the
proper management of the echo data can define
both the cause and the type of impairment.
Cardiac surgery
Intraoperative echocardiography (IOE) in cardiac surgery is particularly helpful in the evaluation
of the surgical repair of valvular lesions. TEE can
influence the surgical strategy, leading to a more
conservative replacement surgery, and can evaluate the efficacy of the procedure.31-33
This utility is particularly significant in the
repair of a regurgitant mitral valve, where TEE
can evaluate the mechanism of regurgitation before
cardiopulmonary bypass (CPB), thus guiding the
surgeon to the proper surgical technique.12, 34-36
Moreover, TEE can assess the success of the surgery
by evaluating the valvular function once the patient
is separated from CPB.37, 38
TEE also provides a good assessment of the aortic valve morphology, giving the size of the aortic
root structures including the annulus, aortic valve
cusps, sinuses of Valsalva, sinotubular junction
and the ascending aorta, and measures the transvalvular flow gradient.39-41
In case of aortic pathology requiring surgery,
TEE can provide a good assessment of the aorta
because of the favorable position of the probe
inside the esophagus; with the transducer very
close to the aorta and the heart, it is possible to
have an optimal view of the vascular structures.42
Among the aortic diseases, an acute aortic dissection represents a real emergency; early detection
and assessment of rupture site and extension of
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the dissection is the gold standard in clinical management and can strongly guide surgical planning.19, 43, 44
The echo finding of an aortic dissection involves
the detection of an intimal membrane (flap) inside
the aorta (Figure 4) that divides the aortic channel into two lumen (the true and the false
lumens).43, 45 The TEE probe can be advanced and
withdrawn in the esophagus, following the aorta
along its entire length from the aortic valve to the
diaphragm. In this way, TEE provides not only the
proper diagnosis, but also the localization and the
extension of the dissection. This information is
important for prompt surgical treatment if the dissection affects the ascending aorta and or the aortic arch.
TEE can also detect the eventual associated
complications of the dissection such as aortic rupture, pericardial effusion or tamponade, myocardial ischemia, or epiaortic hematoma, all of which
have been recognized as significant prognostic
indicators.
In any cardiac surgical procedure, the evaluation of an acute, severe hemodynamic instability
whose cardiac etiology remains uncertain or unresponsive to treatment represents a strong indication for a TEE examination in the OR.
In specific complex surgical procedures such as
the repair of aortic dissection or congenital heart
lesions, or placement of intracardiac devices and
cannulas, TEE is very helpful for evaluation.2-6
Non-cardiac surgery
TEE in the non-cardiac setting is highly recommended in patients at risk for myocardial
ischemia or with an acute or chronic hemodynamic disturbance during major surgical procedures.
It can detect the first signs of myocardial dysfunction by studying the global and regional wall
motion and can guide hemodynamic management
(i.e., fluid administration and/or inotrope therapy) based on ultrasound evaluation of cardiac function and filling.46, 47
TEE in the ICU patient
Evaluation of hemodynamic instability of
uncertain or suspected cardiac etiology is the first
indication for the cardiovascular assessment in
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any acute setting, or intraoperative or ICU scenario.1, 7, 29, 48
The management of hemodynamic instability
depends on its pathophysiology. Extreme hypotension and low cardiac output symptoms can have
many different causes, including severe cardiac
functional impairment, acute real (massive bleeding) or relative hypovolemia (sepsis, excess of
vasodilators), cardiac tamponade, and even extracardiac causes.49, 50 In several clinical scenarios, an
acute hemodynamic impairment may result from
severe cardiac dysfunction, either systolic or diastolic, and echocardiography can detect the cardiac
performance, assessing both systolic and/or diastolic impairment.51
In patients with acute unexplained hypotension
and suboptimal TTE images due to mechanical ventilation, surgical wounds, medications or drainages,
TEE can provide a good assessment of cardiac function and loading conditions to detect treatable causes and thus lead to proper treatment.1, 52-54
Considering that impaired cardiac performance
is one of the most frequent and important causes
of hemodynamic instability in the ICU clinical
scenario, TEE has become an important diagnostic tool because of its capability to provide a highquality assessment of cardiac dysfunction, either
systolic or diastolic, and of the adequacy of fluid
replacement at the same time.27, 28, 55, 56
TEE can also aid in the detection of myocardial ischemia, such as in patients post-primary
PTCA or with cardiogenic shock.
Moreover, in an ICU patient with acute respiratory symptoms, it is crucial to make the correct
diagnosis, i.e., to understand whether or not the
respiratory failure is related to cardiac dysfunction.23 TEE provides a good assessment of cardiac
function and can thus detect cardiac causes, both
systolic and diastolic, of the respiratory distress.7,
57 It also allows for detection of a cardiac cause of
failure of ventilation weaning. In this setting, TEE
in an intubated patient may offer a better acoustic
window for cardiac evaluation during weaning
maneuvers, which can diagnose a cardiac cause of
failure to wean.
TEE can also be used to detect thrombi in the
pulmonary artery tree (Figure 5) in patients with
a suspected pulmonary embolism.8, 58 The main
and right pulmonary arteries can be easily identi-
6
fied. The main pulmonary artery can be followed
until its division into two branches; often the left
pulmonary artery is not visualized because of the
interposition of the left bronchus. TEE can be
used to diagnose a pulmonary embolism through
the direct detection of thrombi in the pulmonary
arteries, rather than through the evaluation of indirect criteria of right ventricular pressure overload
(such as right ventricular enlargement, paradoxical septal movement, tricuspid regurgitation, or
loss of inspiratory collapse of the inferior vena
cava).
Beyond the situations described above for which
there are recommendations and strong evidence
that TEE can be useful, there are other conditions
such as the hemodynamic profile in septic shock,
endocarditis and trauma where such an ultrasound
exam can provide interesting insight into cardiovascular function.
The hemodynamic profile of septic shock is
characterized by myocardial depression, hypovolemia (relative or absolute) and vasoplegia. In the
last decade, TEE has expanded and come to play
an important role in the diagnosis and monitoring
of sepsis.59, 60 It can promptly recognize the mechanism of sepsis-induced hemodynamic changes
through the real-time evaluation of cardiac function and measurement of hemodynamic parameters.61
The cardiac functional impairment can be either
only diastolic, as in the early phases of septic shock,
or it can evolve to severe systolic-diastolic heart
failure with both ventricles possibly involved.60, 61
Right ventricle (RV) impairment can quickly
turn into acute cor pulmonale due to an increase in
RV afterload. This danger is especially true in
mechanically-ventilated or ARDS-affected patients.
TEE provides a good evaluation of ventricular
function as well as of the hemodynamic status and
can provide some indices of fluid responsiveness
(defined as an increase of 15% in Cardiac Index
[CI] after a fluid bolus).
These indices are based on cardiopulmonary
interaction under positive-pressure mechanical
ventilation:19, 62-64
— Respiratory variation of the inferior vena
cava (IVC) diameter: an increase of >18% in the
IVC diameter after a fluid bolus is predictive of
an increase >15% in the CI;
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— Collapsibility of the superior vena cava (SVC)
during inspiration: a variation of >36% in the
SVC diameter after a fluid bolus is predictive of an
increase of more than 11% in the CI;
The aortic flow VTI respiratory variation (TG
0° or 120°): by positioning the sample on the LV
outflow tract and applying the PW Doppler, it is
possible to measure the highest and the lowest
velocities of the aortic flow (∆V peak). A variation >12% in the ∆V peak is the cut-off.
Such evaluations allow for an assessment of the
volemic status in a dynamic way, and can guide
fluid administration even in patients with systolic
dysfunction in whom the standard monitoring
based on filling pressures would be misleading.
TEE is considered an important tool to diagnose endocarditis in septic ICU patients. It is far
more sensitive (90-100%) than TTE in detecting
vegetations on native or prosthetic valves, and has
a specificity of 88-100%.
TEE can identify the presence, size, and mobility of the vegetations (Figure 6), and it can also
visualize any complications of endocarditis such
as a perivalvular abscess, perforation, ruptures,
and extension to non-valvular structures. Other
information that can be obtained with TEE is the
degree of valvular destruction and the eventual
presence of valvular regurgitation.
Several studies have investigated the relationship between the size of the vegetations and the
risk of embolism, but the argument is ongoing.
Many authors have reported that vegetations larger than 10 mm, especially if located on the mitral
valve, are at higher risk of embolization.1, 19, 29
False positive and false negative findings may
occur. The first are generally associated with the presence of valvular lesions that can be erroneously interpreted as endocarditis vegetations (Lambl’s excrescences, fibrin strands, etc.) or as artifacts associated
with prosthetic valves. Sometimes the vegetations
are not detectable in the early stage of infection, generating a false negative, resulting from either a previous embolism or an acoustic shadow.
The negative predictive value of TEE has been
reported as high as 98%, so a negative exam would
not be considered sufficient to exclude the diagnosis of endocarditis. In the case of suspected endocarditis without evidence of vegetations, TEE
should be repeated after seven to ten days.
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Due to its high sensitivity and negative predictive value, TEE must be considered an essential
tool for the diagnosis and treatment of endocarditis in septic ICU patients.
TEE in the trauma patient
Blunt or penetrating chest trauma can cause
important but often misunderstood lesions of the
mediastinic organs. These lesions are often either
severe or life-threatening, and thus require a
prompt diagnosis and immediate appropriate treatment. Aortic rupture, myocardial contusion or
rupture, disruption of the major vessels, pericardial
effusion or tamponade, tracheal or bronchial
lesions, and pleural effusion must be considered in
any patient with severe trauma and important
hemodynamic instability.29, 65
After a blunt thoracic injury, the heart and
great vessels are involved in 9% and 4% of cases,
respectively. Traumatic aortic rupture occurs in
94% of the aortic injury lesions. This injury is a
life-threatening pathology that ranges from an
intimal tear to an intramural hematoma to complete transection. The lesion is more often localized at the aortic isthmus or at the ascending aorta just proximal to the origin of the brachiocephalic vessels.
TEE has been recognized as a useful tool for
the rapid evaluation of the thoracic organs in trauma, especially when TTE cannot be used because
the chest trauma presents a technical limitation.
Several investigations have demonstrated the efficacy of TEE in making the correct diagnosis in
the most severely injured patients.
It is necessary to keep in mind that only adequate TEE views and the correct interpretation of
the echo data, which are eventually correlated with
findings from other diagnostic systems, are helpful for decision-making.
Safety
TEE is a semi-invasive technique. An expert
examiner can quickly pass the TEE probe blindly into the esophagus 1, 19 without any particular
risk, especially in sedated and intubated patients.
TEE is a semi-invasive technique that is relatively safe, but is not without risk. The TEE probe is
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introduced blindly into the esophagus, so it can
damage the hypopharynx and the esophagus itself.
The most common complications of the procedure are associated with pre-existing esophageal
pathology, which thus makes pre-existing
esophageal conditions the first contraindications
to the use of TEE.
TEE-related lesions have been reported less frequently in those patients in whom the probe was
inserted with concomitant nasal videoscope monitoring. In a retrospective evaluation of 7 200 cardiac surgery patients, there was no mortality, and
morbidity was only about 0.2% in such cases.
The most important recommendation for minimizing TEE complications is the cautious passage of the probe associated with an adequate training of the practitioner. An improper maneuver
can cause hemodynamic issues such as hypertension, hypotension, and arrhythmias.
In awake patients, especially when marked
hemodynamic instability is present, or in patients
who are at risk for severe hemodynamic changes
(aortic dissection), good sedation or adequate local
anesthesia is required to avoid circulatory disturbances.
Training and competence in TEE
Due to the rapidly expanding use of TEE in
anesthesia and the ICU, practical training in
echocardiography modalities is mandatory for all
anesthesia and ICU physicians involved in the
hemodynamic management of high-risk patients.
This training includes developing an appropriate
level of skill in performing a comprehensive TEE
exam with the ability to acquire the standard TEE
views. This competence can be achieved only via
specific training in echocardiography.2, 66
Although the technique is quite easy to learn, the
extreme variability of cardiac abnormalities, the
importance of correct understanding of the echo
data and the management of critically ill patients
make acquiring good skills in the performance of
TEE quite difficult. Despite the lack of specific
training programs, there are many recommendations for the proper use of TEE in anesthesia and
intensive care units.
The echocardiography accreditation processes
(from the ASE, EAE, EACTA and BSE) do not
8
adequately assess competencies for ICU practitioners because they focus too specifically on cardiac alterations (such as valvular diseases) while
ignoring ICU pathologies and giving little attention to hemodynamic monitoring. According to
the recommendations published by several societies and associations (the Royal College of
Radiologists and British Society of Echocardiography, European Association of Echocardiography,
and American Society of Echocardiography), the
World Interactive Network Focused on Critical
Ultrasound (WINFOCUS) has recently published
a document to outline the specific requirements of
clinical training in echocardiography for ICU practitioners.66
It is divided into three levels of knowledge and
competence. The first level is the basic level; at
this level of competency, a TEE performer should
be able to safely acquire the standard TEE views
and interpret echo data to distinguish normal cardiac structure and function from pathologic ones,
and to diagnose most common abnormalities and
to recognize when another diagnostic test is
required.
At the second level, the physicians should be
able to recognize and diagnose almost all cardiac
abnormalities and pathologies, manage the referrals from other practitioners from level 1, teach
echocardiography and, eventually, conduct some
research in echocardiography. This level of training should be achieved at the end of specialist
training or echocardiography accreditation (i.e.,
BSE/ASE/EAE).
The third level is an advanced level of competency; the physicians should have the skills to perform high-level TEE examinations and echo-guided invasive procedures, to teach TEE to physicians
of all levels, to accept referrals from level 1 and
level 2 practitioners, and to conduct research in
echocardiography. An ICU physician should
achieve a basic level of expertise in performing
baseline TEE to diagnose and detect the most
important causes of hemodynamic instability in
critically ill patients. In the field of TEE training,
we must consider the emergency echo-assessment
(Focused Assessment with Transthoracic
Echocardiography) as a target diagnostic tool in
emergency clinical scenarios. In addition to standard echocardiography skills, an ICU echocardio-
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grapher should be able to interpret findings from
transthoracic and transesophageal studies, to
answer specific questions in the context of the rapidly changing pathophysiological status of the critically ill patient, and to be accessible for continued
echocardiographic monitoring.
4.
Conclusions
TEE is a semi-invasive, safe imaging technique
that provides a continuous, real-time, high-quality assessment of the cardiac performance and
hemodynamic status of critically ill patients in the
intraoperative and ICU settings.
Intraoperative use of TEE in cardiac surgery
has a great impact on clinical outcomes, provides
a comprehensive evaluation of cardiac pathophysiology, results in good assessment of the surgical effectiveness, and yields new information
that can guide surgical or anesthetic management. Intraoperative TEE findings can influence
surgical procedures by changing planning in
many cases.
The use of TEE intraoperatively in non-cardiac
procedures provides important information in the
management of hemodynamic instability and in
the detection of myocardial ischemia.
TEE has acquired an important role in the management of critically ill patients in the ICU by
allowing assessment of the pathophysiology of
hemodynamic disturbances in many acute and
severe clinical scenarios.
Only adequate TEE views and the correct interpretation of the echo data, eventually correlated
with those from other hemodynamic monitoring
systems, can be helpful for decision-making. This
outcome requires good technical skills and the
capability to integrate the TEE information into
the clinical scenario. This ability can be acquired
with appropriate training, caution and critical
interpretation of echo data.
6.
7.
8.
9.
10.
11.
12.
13.
14.
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Corresponding author: Dr. F. Guarracino, Operative Unit of Anesthesia and Cardiothoracic Resuscitation, Pisa University Hospital, Via
Paradisa 2, 56124 Pisa, Italy. E-mail [email protected]
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