DK2985_C000 1..28 - AlSharqia Echo Club

Indications for Perioperative TEE 565intraoperatively. The need to return for further surgery andthe risk of complications might thereby be reduced byintraoperative TEE, but this hypothesis needs to be confirmedthrough further research. Suspected cardiactrauma is a category II indication for perioperative TEE.L. Detection of Aortic AtheromatousDisease or Other Sources ofAortic EmboliApproximately 1–5% of patients suffer strokes duringCPB, and the presence of atheromatous aortic ulcers isconsidered a major risk factor. Palpation of the Ao is notknown to be sensitive, but TEE has been shown to allowdetection of aortic atheromas. The detection of aorticatheromatous disease or other sources of aortic emboli isa category II indication for intraoperative TEE.Intraoperative TEE and epivascular echocardiographyare capable of detecting aortic atheromatous disease, butit is unclear whether its detection improves clinical outcomes.Atheromatous disease of the ascending Ao isnoted in 9% of elderly patients and results in a change intherapy in 8–17% of patients (12).The relationship between the severity of aortic atheromatousdisease and postoperative dysfunction has been establishedpreviously. Choudary et al. (32) documented severeatheromatous disease in 12 of 126 patients undergoingCABG. Protruding atheromas were significantly morecommon in patients over 60 years of age. Out of fourpatients with grade V atheromas, two developed right hemiplegiapostoperatively. To determine the optimal method todetect ascending aortic atheromas intraoperatively, manualpalpation, TEE, and epiaortic scanning were compared in100 patients (33). Age older than 70 years and hypertensionwere significant risk factors for severe ascending atheromas.Epiaortic scanning was found to be superior to both manualpalpation and TEE.M. Evaluation of Pericardial SurgeryTransesophageal echocardiography may be helpful inevaluating constrictive pericarditis and pericardiectomyprocedures (see Chapter 11, Fig. 11.17). Evaluating theeffectiveness of pericardiectomy constitutes a category IIindication, but uncomplicated pericarditis is a category IIIindication.N. Evaluation of Anastomotic Sites DuringHeart and/or Lung TransplantationSome studies suggest that TEE is more sensitive than TTEin screening heart donor patients and more accurate thanpulmonary capillary wedge pressure measurements indetecting hemodynamic disturbances during transplantsurgery. Postoperative studies have demonstrated itsability to evaluate cardiac allograft function and detectthrombotic obstruction and stenoses in patients with lungtransplants (see Chapter 21, Fig. 21.7).Anastomotic integrity can be accurately assessed byTEE using two-dimensional (2D) or Doppler modalities(see Chapter 21, Fig. 21.6). Hemodynamic benefits ofTEE during major organ transplant surgery are especiallyimportant. Evaluating anastomotic sites during heart and/or lung transplantation is a category II indication forintraoperative TEE.O. Assessment of Residual Duct Flow AfterInterruption of Patent Ductus ArteriosusThe efficacy of intraoperative TEE in reducing the incidenceof residual ductal flow after video-assisted thoracoscopyinterruption of a patent ductus arteriosus (PDA) wasstudied by Lavoie et al. (34). In two of 30 consecutivepatients (mean age 2.4 years; mean weight 11.2 kg),intraoperative TEE detected residual flow after placementof the vascular clip, requiring placement of a second clip.At one-month follow-up, three patients presented residualduct flow.P. Evaluation of Myocardial Perfusion,Coronary Artery Anatomy, Graft PatencyUse of perioperative TEE to evaluate myocardial perfusion,coronary anatomy, or graft patency are categoryIII indications. The argument for using TEE is strengthenedwhen ECG monitoring cannot provide accurate information,such as patients with conduction disorders or inprocedures that interfere with ECG lead placement. Theargument for using TEE is weakened when clinicalfactors (e.g. pre-existing regional ventricular dysfunction)limit the accuracy of wall motion interpretation.IV.CATEGORY III: LITTLE CURRENTSCIENTIFIC OR EXPERT SUPPORTConditions for which there is evidence and/or generalagreement that the procedure/treatment is not useful/effective and in some cases may be harmful (11).A. Repair of Cardiomyopathies(Other than HypertrophicObstructive Cardiomyopathy)Hypertrophic obstructive cardiomyopathy repair is acategory I indication for either EE or TEE assessment.Use of intraoperative TEE for other cardiomyopathies ishowever a category III indication.