EXPERT CONSENSUS STATEMENT

Basic Perioperative Transesophageal Echocardiography

Examination: A Consensus Statement of the American
Society of Echocardiography and the Society of
Cardiovascular Anesthesiologists
Scott T. Reeves, MD, FASE, Alan C. Finley, MD, Nikolaos J. Skubas, MD, FASE,
Madhav Swaminathan, MD, FASE, William S. Whitley, MD, Kathryn E. Glas, MD, FASE,
Rebecca T. Hahn, MD, FASE, Jack S. Shanewise, MD, FASE, Mark S. Adams, BS, RDCS, FASE, and Stanton K. Shernan, MD,
FASE, for the Council on Perioperative Echocardiography of the American Society of Echocardiography and the Society of
Cardiovascular Anesthesiologists, Charleston, South Carolina; New York, New York; Durham, North Carolina; Atlanta, Georgia;
Boston, Massachusetts

(J Am Soc Echocardiogr 2013;26:443-56.)

Keywords: Transesophageal echocardiography, Basic certification

TABLE OF CONTENTS ME Long-Axis (LAX) View 447

ME Ascending Aortic LAX View 447
Introduction 443 ME Ascending Aortic SAX View 447
History 444 ME AV SAX View 447
Medical Knowledge 444 ME RV Inflow-Outflow View 447
ME Bicaval View 448
TG Midpapillary SAX View 449
From the Medical University of South Carolina (S.T.R., A.C.F.); Descending Aortic SAX and LAX Views 450
Weill-Cornell Medical College, New York, New York (N.J.S.); Duke Indications 450
University, Durham, North Carolina (M.S.); Brigham’s and Women’s Global and Regional LV Function 451
Hospital, Harvard Medical School, Boston, Massachusetts (S.K.S.); RV Function 451
Emory University, Atlanta, Georgia (W.S.W., K.E.G.); Columbia Hypovolemia 452
University College of Physicians and Surgeons, New York, New Basic Valvular Lesions 452
York (R.T.H., J.S.S.); and Massachusetts General Hospital, Boston, Pulmonary Embolism (PE) 452
Massachusetts (M.S.A.). The following authors reported Neurosurgery: Air Embolism 452
relationships with one or more commercial interests: Scott T. Pericardial Effusion and Thoracic Trauma 453
Reeves, MD, FASE, edited and receives royalties for A Practical Ap- Simple Congenital Heart Disease in Adults 453
proach to Transesophageal Echocardiography and The Practice of Maintenance of Competence and Quality Assurance 453
Perioperative Transesophageal Echocardiography: Essential Cases Conclusions 454
(Wolters Kluwer Health). Kathryn E. Glas, MD, FASE, edited and Notice and Disclaimer 454
receives royalties for The Practice of Perioperative Transesophageal Appendix 454
Echocardiography: Essential Cases (Wolters Kluwer Health). Members of the Council on Perioperative Echocardiography 454
Stanton K. Shernan, MD, FASE, has served as a lecturer for Philips References 454
Healthcare, Inc., and is an editorfore-Echocardiography.com. All
other authors reported no actual or potential conflicts of interest in
relation to this document. INTRODUCTION__________________________________
Members of the Councils on Perioperative Echocardiography are
listed in the Appendix. This consensus statement by the American Society of
Echocardiography (ASE) and the Society of Cardiovascular
Anesthesiologists (SCA) describes the significant role of a basic
Attention ASE Members:
perioperative transesophageal (PTE) cardiac examination in the
The American Society of Echocardiography (ASE) has gone green! Visit care and treatment of an unstable surgical patient.
www. aseuniversity.org to earn free continuing medical education credit
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Echocardiography. http://dx.doi.org/10.1016/j.echo.2013.02.015

Training 445
Basic Perioperative Transesophageal Examination 445
ME Four-Chamber View 446
ME Two-Chamber View 447
 The National Board of Echocardiography (NBE) was created in 1998
Abbreviations The use of a noncomprehensive as a collaborative effort between the ASE and the SCA. The mission
basic PTE examination to delineate of the NBE is ''to improve the quality of cardiovascular patient care
the cause of hemodynamic insta- by developing and administering examinations leading to certifi-
ASA = American Society of bility was originally proposed for cation of licensed physicians with special knowledge and expertise
Anesthesiologists the emergency room and neonatal in echocardiography,'' which is accomplished by
ASD = Atrial septal defect intensive care unit settings and is
ASE = American Society of meant to be complementary to 1. overseeing the development and administration of the Adult
Echocardiography comprehensive echocardiogram- Special Competency in Echocardiography Examination, the Advanced
AV = Aortic valve phy.1,2 However, the principal goal Perioperative TEE Examination (PTEeXAM), and the Basic PTEeXAM;
IAS = Interatrial septum of a basic PTE examination is 2. recognizing physicians who successfully complete the
LAD = Left anterior descending intraoperative monitoring. 3 examinations as testamurs; and
LAX = Long-axis Whereas this may encompass a 3. certifying physicians who have fulfilled training and/or experience
LCX = Left circumflex broad range of anatomic imaging, requirements in echocardiography as diplomates of the NBE.
LV = Left ventricular the intent of noninvasive monitoring
LVOT = Left ventricular outflow should focus on cardiac causes of In 2006, the ASA House of Delegates approved the development
tract hemodynamic or ventilatory and implementation of a program focused on basic
ME = Midesophageal instability, including ventricular size echocardiography education. In 2009, a memorandum of
MV = Mitral valve and function, valvular anatomy and understanding between the NBE and the ASA established a
NBE = National Board of function, volume status, pericardial strategic partnership to mutually promote an examination and
Echocardiography abnormalities and complications certification process in basic PTE echocardiography. Specifically,
PA = Pulmonary artery from invasive procedures, as well the basic PTE scope of practice was defined as the limited
PTE = Perioperative as the clinical impact or etiology of application of a basic PTE examination to ''non-diagnostic
transesophageal pulmonary dysfunction. The basic monitoring within the customary practice of anesthesiology. Because
PTEeXAM = Perioperative TEE PTE examination is not designed to the goal of, and training in, Basic PTE echocardiography is focused
Examination prepare practitioners to use the full on intraoperative monitoring rather than specific diagnosis, except in
PV = Pulmonic valve diagnostic potential of emergent situations, diagnoses requiring intraoperative cardiac
RCA = Right coronary artery transesophageal echocardiography surgical intervention or postoperative medical/surgical management
RV = Right ventricular (TEE). Therefore, a basic PTE must be confirmed by an individual with advanced skills in TEE or by
RVOT = Right ventricular outflow practitioner should be prepared to an independent diagnostic technique.'' A comprehensive and
tract request consultation with an quantitative examination is thus not in the scope of the basic PTE
SCA = Society of advanced PTE practitioner on examination, but those performing basic PTE echocardiography
Cardiovascular issues outside the scope of must be able to recognize specific diagnoses that may require
Anesthesiologists practice as defined within these advanced imaging skills and competence.
TEE = Transesophageal guidelines. Echocardiographic as-
echocardiography NBE criteria for certification in basic PTE echocardiography include
sessments that influence the surgi-
TG = Transgastric cal plan are specifically excluded 1. possession of a current medical license,
TV = Tricuspid valve from this consensus statement, be- 2. current board certification in anesthesiology,
VAE = Venous air embolism cause their acquisition requires an 3. completion of one of the perioperative TEE training pathways
advanced PTE skill set. (Table 2), and
The purposes of the current document 4. passing the Basic PTEeXAM or Advanced PTEeXAM.
are
1. to review concisely the history of
basic PTE certification,
2. to define the prerequisite medical knowledge, MEDICAL KNOWLEDGE_____________________
3. to define the necessary training requirements,
4. to recommend an abbreviated basic PTE examination sequence,
5. to summarize the appropriate indications of basic PTE PTE echocardiography is an invasive medical procedure that carries
examination, and rare but potentially life threatening complications and therefore must
6. to define maintenance of competence and quality assurance. be performed only by qualified physicians. The application of basic
PTE echocardiography can often dramatically influence a patient's
intraoperative management. A thorough understanding of anatomy,
HISTORY____________________________________ physiology, and the surgical procedure is critical to appropriate
application.
TEE was introduced to cardiac operating rooms in the early 1980s. 3 Because of the risks, technical complexity, and potential impact of
Many guidelines have been written that further expand on its utility to TEE on perioperative management, the basic PTE
facilitate surgical decision making. 4-8 The idea of distinguishing basic echocardiographer must be a licensed physician. Previous
PTE skills was incorporated into the American Society of guidelines have addressed the cognitive knowledge and technical
Anesthesiologists (ASA) and SCA practice guidelines for skills necessary for the successful use of PTE and are summarized
perioperative TEE, published in 1996. 4 In 2002, training guidelines in in Table 3.4-7 The NBE's Basic PTEeXAM knowledge base content
perioperative echocardiography that include specific case number outline is described in Table 4.
recommendations for training in basic and advanced PTE
echocardiography were endorsed by the ASE and the SCA. 5 The
evolution of the perioperative echocardiographic guidelines is
summarized in Table 1.

Table 1 Evolution of perioperative echocardiography guidelines

Year Citation Society Title Porpuse Comments
199 Anesthesiology ASA/SCA Practice guidelines for Distinguish basic from Cognitive and technical skills
6 1996;84:986-1006 perioperative advanced PTE skills for basic and advanced PTE
transesophageal echocardiography are
 echocardiography described; monitoring aspect
of basic TEE is described;
full diagnostic potential of
advanced PTE
echocardiography

199 Anesth Analg ASE/SCA ASE/SCA Guidelines for Describes 20 views making up
9 1999;89:870-884; performing a a comprehensive
J Am Soc comprehensive transesophageal
Echocardiogr intraoperative echocardiographic
1999;12:884-900 transesophageal examination
echocardiography
examination
200 Anesth Analg ASE/SCA American Society of Training objectives and
2 2002;94: 1384- Echocardiography and number of required
1388 Society of Cardiovascular transesophageal
Anesthesiologists task echocardiographic
force guidelines for examinations are set
training in perioperative
echocardiography

200 J Am Soc ASE/SCA American Society of Establish recommendations

6 Echocardiogr Echocardiography/Society and guidelines for a continuos
2006;19:1303- of Cardiovascular quality improvenment program
1313 Anesthesiologists specific to the preioperative
recommendations and environment
gidelines for continuos
quality improvement in
perioperative
echocardiography
201 Anesthesiology ASE/SCA Practice guidelines for Update of 1996 document
0 2010;112:1084- perioperative
1096 transesophageal
echocardiography

TRAINING__________________________________ If complex pathology is anticipated or suspected (e.g., valvular

abnormality or aortic dissection), appropriate consultation with an
Cahalan et al.5 provided guidelines for components of basic and ad- advanced echocardiographer is indicated. Figure 1 demonstrates
vanced training in 2002. The NBE relied on this document as a the ASE and SCA comprehensive 11-viewba- sic PTE examination.
guideline for basic PTE certification. The components of basic PTE The basic PTE examination starts in the midesophageal (ME) four-
training include independent clinical experience, supervision, and chamber view. It is the expectation of this writing group that a basic
continuing education requirements (Table 2). PTE examination can be performed using three primary positions
within the gastrointestinal tract (Figure 2): the ME level, the
transgastric (TG) level, and the upper esophageal level. This writing
group also recognizes that current advances in technology allow
BASIC PERIOPERATIVE TRANSESOPHAGEAL simultaneous multiplane imaging of real-time images, which may
EXAMINATION________________________________ reduce the acquisition time for the basic PTE examination views.16 It
is the expectation of the writing group that a complete basic PTE
PTE is relatively safe and has been associated with mortality of <1 examination be performed on each patient as a standard
per 10,000 patients and morbidity of 2 to 5 per 1,000 patients. 9-15 examination. Once completed and stored, a more focused
Probe manipulation, including positioning, turning, rotation, and examination can be used for monitoring and to track changes in
imaging planes, has previously been extensively described in the therapy. As noted in prior guidelines, this writing group also
ASE comprehensive document.6 recognizes that individual patient characteristics, anatomic
Prior guidelines developed by the ASE and the SCA have described variations, pathologic features, or time constraints imposed on
the technical skills for acquiring 20 views in the performance of a performing the basic PTE examination may limit the ability to
comprehensive intraoperative multiplane transesophageal perform every aspect of the examination and, furthermore, that there
echocardiographic examination.6 The current writing committee may be other entirely acceptable approaches and views of an
believes that although a basic PTE echocardiographer should be intraoperative examination, provided they obtain similar information
familiar with the technical skills needed to acquire these 20 views, it in a safe manner.
is nonetheless a realistic expectation that a basic PTE examination
focus on encompassing the 11 most relevant views, which can
provide anesthesiologists with the necessary information to use
basic PTE echocardiography as a tool for diagnosing the general
etiology of hemodynamic instability in surgical patients.

Table 2 The NBE’s Basic PTE training pathways

Clinical experience in basic Supervision training Continuing medical

PTE echocardiography education
Supervised training pathway >150 basic PTE >50 of the 150 basic No requirement
echocardiographic intraoperative transesophageal
examinations studied under echocardiographic
supervision examinations must be
performed and interpreted
under supervision throughout
the procedure
Practice experience >150 basic intraoperative Supervision not required >40 American Medical
pathway* transesophageal Association Physician
echocardiographic Recognition Award Category 1
 examinations performed and Credits focused perioperative
interpreted within 4y of TEE and completed within the
application, with <25 same period as the clinical
examinations in any 1y experience

Adapted with permission from Anesthesiology.4

*The practice experience pathway will not be available to those completing their anesthesiology residency training after June 30, 2016.

Table 3 Recommended training objectives for basic PTE training

Cognitive skills
1. Knowledge of the physical principles of echocardiographic image formation and blood velocity measurement
2. Knowledge of the operation of ultrasonographs, including all controls that affect the quality of data displayed
3. Knowledge of the equipment handling, infection control, and electrical safety associated with the techniques of perioperative
echocardiography
4. Knowledge of the indications, contraindications, and potential complications of perioperative echocardiography
5. Knowledge of the appropriate alternative diagnostic techniques
6. Knowledge of the normal tomographic anatomy as revealed by perioperative echocardiographic techniques
7. Knowledge of commonly encountered blood flow velocity profiles as measured by Doppler echocardiography
8. Knowledge of the echocardiographic manifestations of native valvular lesions and dysfunction
9. Knowledge of the echocardiographic manifestations of cardiac masses, thrombi, cardiomyopathies, pericardial effusions, and lesions of the
great vessels
10. Knowledge of the echocardiographic presentations of myocardial ischemia and infarction
11. Knowledge of the echocardiographic presentations of normal and abnormal ventricular function
12. Knowledge of the echocardiographic presentations of air embolization Technical skills

Technical Skills
1. Ability to operate ultrasonographs, including the primary controls affecting the quality of the displayed data
2. Ability to insert a transesophageal echocardiographic probe safely in an anesthetized, tracheally intubated patient
3. Ability to perform a basic PTE echocardiographic examination and differentiate normal from markedly abnormal cardiac structures and
function
4. Ability to recognize marked changes in segmental ventricular contraction indicative of myocardial ischemia or infarction
5. Ability to recognize marked changes in global ventricular filling and ejection
6. Ability to recognize air embolization
7. Ability to recognize gross valvular lesions and dysfunction
8. Ability to recognize large intracardiac masses and thombi
9. Ability to detect large pericardial effusions
10. Ability to recognize common echocardiographic artifacts
11. Ability to communicate echocardiographic results effectively to health care professionals, the medical record, and patients
12. Ability to recognize complications of perioperative echocardiography

Adapted with permission from Anesth Analg 2002;94:1384-1388.

Table 4 Basic PTE examination content outline

ME Four-Chamber View
1.Patient safety considerations
2.Echocardiographic imaging: acquisition and optimization
The ME four-chamber view is obtained by advancing the probe to a
3.Normal cardiac anatomy and imaging plane correlation
depth of approximately 30 to 35 cm until it is immediately posterior to
4.Global ventricular function
the left atrium (Figure 3, Video 1 [available at www.onlinejase.
5.Regional ventricular systolic function and recognition of
com]). Turning the probe to the left (counterclockwise rotation of the
pathology
probe) or to the right (clockwise rotation of the probe) is performed
6.Basic recognition of cardiac valve abnormalities
to center the mitral valve (MV) and left ventricle in the sector display.
7. Identification of intracardiac masses in noncardiac surgery
The image depth is then adjusted to ensure viewing of the left
8.Basic perioperative hemodynamic assessment
ventricular (LV) apex. The multiplane angle should be rotated to ap-
9.Related diagnostic modalities
proximately 10° to 20° until the aortic valve (AV) or LV outflow tract
10.Basic recognition of congenital heart disease in adults
(LVOT) is no longer in the display and the tricuspid annular
11Surface ultrasound for vascular access
dimension is maximized.
Source: National Board of Echocardiography.80

Diagnostic information regarding chamber volume and function, MV

and TV function, and assessment of global LV and right ventricular
(RV) systolic function and of regional LV inferoseptal and
anterolateral walls can be determined. In the ME four-chamber view
(Figure 4), the basal anterolateral, mid anterolateral, and apical
lateral wall segments are perfused by the left anterior descending
(LAD) or left circumflex (LCX) coronary artery, the apical septum and
Because the apex is at a slightly inferior plane to the left atrium,
the apical cap by the LAD coronary artery, the mid inferoseptum by
slight retroflexion may be required to align the MV and LV apex.
the right coronary artery (RCA) or LAD coronary artery, and the
Required structures seen include the right atrium, interatrial septum
basal inferoseptum by the RCA.17 A color flow Doppler sector with
(IAS), left atrium, MV, tricuspid valve (TV), left ventricle, right
the Nyquist limit set to 50 to 60 cm/sec should be placed over both
ventricle, and interventricular septum. This view will allow the identi-
the MV and TV to aid in the identification of valvular pathology
fication of both the anterior and posterior leaflets of the MV, the TV
(regurgitation and/or stenosis), as well as to the IAS to identify shunt
septal leaflet adjacent to the interventricular septum, to the right of
flow.
the sector display, and the TV posterior leaflet adjacent to the RV
free wall, to the left of the display.
ME Two-Chamber View

From the ME four-chamber view, rotating the multiplane angle

forward to between 80° and 100° until the right ventricle disappears
from the image will develop the ME two-chamber view (Figure 5,
Video 2 [available at www.onlinejase.com]). Structures seen in the
image include the left atrium, MV, left ventricle, and left atrial proximal ascending aorta, superior vena cava, PV, and proximal
appendage. Diagnostic information obtained from this view includes (main) PA. Proximal pulmonary emboli can sometimes be seen from
global and regional LV function, MV function, and regional this view.
assessment of the LV anterior and inferior walls. The basal inferior
and mid inferior wall segments are perfused by the RCA, whereas
the apical inferior, apical cap, apical anterior, mid anterior, and basal ME AV SAX View
anterior wall segments are perfused by the LAD coronary artery
(Figure 4). A color flow Doppler sector with the Nyquist limit at 50 to Advancing the probe from the ME ascending aortic SAX view results
60 cm/sec should be applied over the MV to aid in the identification in SAX imaging of the AV (ME AV SAX; Figure 9, Video 6 [available
of valvular pathology (regurgitation and/or stenosis). The coronary at www.onlinejase.com]). The AV cusps should be clearly identified.
sinus is seen in short axis (SAX), as a round structure immediately For a trileaflet valve, the left coronary cusp should be posterior and
superior to the basal inferior LV segment. on the right side of the image. The noncoronary cusp is adjacent to
the IAS. The right coronary cusp is anterior and adjacent to the
RVOT. Color flow Doppler can be applied over the AV to aid in
ME Long-Axis (LAX) View identifying aortic regurgitation.

From the ME two-chamber view, rotating the multiplane angle for -

ward to between 120 ° and 160° until the LVOT and AV come into the ME RV Inflow-Outflow View
display develops the ME LAX view (Figure 6, Video 3 [available at
www.onlinejase.com]). Visualized structures include the left atrium, From the ME ascending aortic SAX view, the probe is advanced and
MV, left ventricle, LVOT, AV, and proximal ascending aorta. This turned clockwise to center the TV in the view, while the multiplane
view offers diagnostic information regarding chamber volume and angle is rotated forward to between 60 ° and 90° until the RVOT and
function, MV and AV function, LVOT pathology, and regional the PV appear in the display, indicating the ME RV inflow- outflow
assessment of the left ventricle. The basal inferolateral and mid view (Figure 10, Video 7 [available at www.onlinejase. com]).
inferolateral wall segments are perfused by the RCA or LCX Structures seen in this view include the left atrium, right atrium, TV,
coronary artery, whereas the apical lateral, apical cap, apical right ventricle, PV, and proximal (main) PA. The RV free wall is
anterior, mid anteroseptum, and basal anteroseptum wall segments visualized on the left of the display, while the RVOT is on the right.
are perfused by the LAD coronary artery (Figure 4). Color flow This view offers diagnostic information regarding RV volume and
Doppler can be applied to the MV, LVOT, and AV to aid in the function and TV and PV function. Color flow Doppler can be applied
identification of valvular pathology (regurgitation and/or stenosis). to the TV and PV to aid in the identification of valvular pathology (in-
sufficiency or stenosis). If a parallel Doppler beam alignment with
the tricuspid regurgitation color jet is possible, the RV systolic
pressure can be estimated using the modified Bernoulli equation:

ME Ascending Aortic LAX View

RV systolic pressure = 4 x (tricuspid regurgitation peak velocity jet) 2
Withdrawing the probe from the ME LAX view allows imaging of the + central venous pressure,
LAX of the ascending aorta (Figure 7, Video 4 [available at www.
onlinejase.com]). The right pulmonary artery (PA) is adjacent to the
esophagus and posterior to the ascending aorta. When the image is where central venous pressure is measured using a central venous
centered on this structure, counterclockwise rotation results in LAX line or is estimated. RV systolic pressure equals PA systolic
imaging of the main PA and the pulmonic valve (PV). Because the pressure if there is no pulmonary stenosis, which is easily excluded
LAX of the PA is parallel to the insonation beam, this is an optimal by TEE. If a parallel Doppler beam alignment is not possible,
view for pulsed-wave or continuous-wave Doppler of the RV outflow significant underestimation of the jet velocity will occur, resulting in
tract (RVOT) or PV. Proximal pulmonary emboli can sometimes be underestimation of RV systolic pressure.
seen from this view.

ME Ascending Aortic SAX View

From the image of the main PA, rotating the multiplane angle back
to 20° to 40° images the bifurcation of the PA, the SAX view of the
ascending aorta, and the SAX view of the superior vena cava (ME
ascending aortic SAX; Figure 8, Video 5 [available at
www.onlinejase. com]). Structures seen in this view include the
Figure 1 Cross-sectional views of the 11 views of the ASE and SCA basic PTE examination. The approximate multiplane angle is indicated by the
icon adjacent to each view. Asc, Ascending; Desc, descending; UE, upper esophageal.

Figure 2 Lateral chest x-ray depicting relative positions of the heart (black outline), aorta (white line), and esophagus (yellow line). Arrows indicate
the upper esophageal (UE), ME, and TG positions of the transesophageal echocardiographic probe.

Figure 3 ME four-chamber view. AL, Anterior leaflet of the MV; LA, left atrium; LV, left ventricle; PL, posterior leaflet of the MV; RA, right atrium; RV,
right ventricle.

Figure 4 Typical distributions of the RCA, the LAD coronary artery, and the circumflex (CX) coronary artery from transesophageal views of the left
ventricle. The arterial distribution varies among patients. Some segments have variable coronary perfusion. Modified with permission from Lang
etal1

Figure 5 ME two-chamber view. CS, Coronary sinus; LA, left atrium; LAA, left atrial appendage; LV, left ventricle.

Figure 6 ME LAX view. AL, Anterior leaflet of the MV; LA, left atrium; LV, left ventricle; PL, posterior leaflet of the MV; RV, right ventricle.
aneurysms are associated with interatrial shunts. Color Doppler of
ME Bicaval View the IAS, including the use of a lower Nyquist limit setting, may be
used to assess the presence of a low-velocity interatrial shunt.
From the ME RV inflow-outflow view, the multiplane angle is rotated Agitated saline may also be injected after the administration of a
forward to 90° to 110° and the probe is turned clockwise to the ME Valsalva maneuver for further documentation of a right-to-left
bicaval view (Figure 11, Video 8 [available at www.onlinejase.com]). component.
From this view, catheters or pacing wires entering the right atrium
from the superior vena cava are well imaged. Structures seen in the TG Midpapillary SAX View
view include the left atrium, right atrium, right atrial appendage, and
IAS. Motion of the IAS should be observed because atrial septal
From the ME four-chamber view (at 0°), the probe is advanced into
the stomach and anteflexed to come in contact with the gastric wall.
The multiplane angle should remain at 0°. Proper positioning re -
quires a two-step process. First, probe depth is manipulated until the
posteromedial papillary muscle comes into view at the top of the
image display. Visualization of the MV leaflet chords indicates that
the probe should be advanced, whereas not visualizing any papillary
muscles indicates that the probe is too deep and should be
withdrawn. Once the posteromedial papillary muscle is in view,
visualization of the anterolateral papillary muscle is optimized by Figure 7 ME ascending aortic LAX view. Ao, Aorta.
varying the degree of anteflexion. If MV leaflet chords are seen,
anteflexion should be decreased, whereas not visualizing any Figure 8 ME ascending aortic SAX view. Ao, Aorta; SVC, superior
papillary muscles indicates that anteflexion should be increased. vena cava.
The TG midpapillary SAX view provides significant diagnostic infor-
mation and can be extremely helpful in hemodynamically unstable The inferoseptum is perfused by either the RCA or the LAD coronary
patients (Figure 12, Video 9 [available at www.onlinejase.com]). LV artery. The anteroseptum and anterior wall segments are perfused
volume status, systolic function, and regional wall motion can be by the LAD coronary artery. The anterolateral wall segment is
obtained in this view. This is the only view in which the myocardium perfused by either the LAD coronary artery or the LCX coronary
supplied by the LAD coronary artery, LCX coronary artery, and RCA artery. Finally, the inferolateral wall segment is perfused by either
can be seen simultaneously (Figure 4). The inferior wall segment is the RCA or the LCX coronary artery. 17 The development of a new
perfused by the RCA. wall motion abnormality in one of these regions could indicate
myocardial ischemia. A pericardial effusion can be seen as a
distinctive echo-free space separating the epicardium from the
pericardium. The ability to simultaneously monitor and acquire all of
this information makes the TG midpapillary SAX view very popular
for intraoperative monitoring.

Descending Aortic SAX and LAX Views

Imaging of the descending thoracic aorta during a basic PTE

examination is easily performed, because the aorta is immediately
adjacent to the esophagus in the mediastinum. The descending
aorta is visualized by turning the probe to the left from the ME four-
chamber view until the descending thoracic aorta comes into the
display. The SAX view of the aorta is obtained at a multiplane angle
of 0° (Figure 13, Video 10 [available at www.onlinejase.com]), while
the LAX view is obtained at a multiplane angle of approximately 90°
(Figure 14, Video 11 [available at www.onlinejase.com]). Image
depth should be decreased to enlarge the size of the aorta and the
focus set to be in the near field.

Finally, gain should be increased in the near field to optimize

imaging. While keeping the aorta in the center of the image, the
probe can be advanced and withdrawn to image the entire descend-
ing aorta. Because there are no internal anatomic landmarks in the
descending aorta, describing the location of pathology may be
difficult. One approach to this problem is to identify the location in
terms of distance from the left subclavian artery and the location in
the vessel wall relative to the esophagus. For follow-up
examinations, the distance of the probe from the incisors should be
reported. This view offers diagnostic information about aortic
pathology, including aortic diameter, aortic atherosclerosis, and
aortic dissection. Additionally, if left pleural fluid is present, this view
offers visualization of the fluid in the far field. A right pleural effusion
may be imaged by turning the probe further clockwise to image the
right chest.

Figure 9 ME AV SAX view. LA, Left atrium; LCC, left coronary cusp;
NCC, noncoronary cusp; RA, right atrium; RCC, right coronary cusp.

Figure 10 ME RV inflow-outflow view. LA, Left atrium.

 publications support the use of TEE in patients with severe
hemodynamic disturbances and unknown ventricular function. 26,27,30
INDICATIONS_______________________________________ Regional wall motion analysis using a 17-segment wall motion score
described in the ASE guidelines 17 can be performed using the ME
The ASA practice guidelines recommend ''appropriateness'' criteria four- chamber, ME two-chamber, and ME LAX views. However,
for performing basic and advanced PTE echocardiography in the visualization of 6 midpapillary segments from the TG midpapillary
context of the condition of the patient, the risks of the procedure, and
SAX view may suffice and has been shown to have prognostic
the specific circumstances. These same ASA practice guidelines
importance.36
recommend basic PTE echocardiography when the nature of the
planned surgery or the patient's known or suspected cardiovascular
The TG midpapillary SAX view provides significant diagnostic in-
pathology might result in severe hemodynamic, pulmonary, or
formation pertaining to regional and global ventricular function in the
neurologic compromise. In addition, when available, basic PTE
hemodynamically unstable patient. However, it is the recommenda-
echocardiography should be used when unexplained life-threatening
tion of the writing committee that a physician trained in basic PTE
circulatory instability persists despite corrective therapy. 7,18-21 The
echocardiography also use the ME four-chamber, ME two-chamber,
goals of a basic PTE examination in a patient with hemodynamic
and ME LAX views for a more comprehensive evaluation and for
instability include early diagnosis of the etiology of hypotension
monitoring of global and regional LV function.
despite the use of inotropic and vasoactive support and guidance of
therapeutic interventions to treat the underlying cause. Failure to
take early corrective action may lead to end-organ damage and peri-
operative mortality. Multiple reports in the literature support the use
and delineate the impact of transesophageal echocardiographic
guidance and intraoperative decision making. Incidental findings
play a large role in this impact and can significantly influence the
surgical procedure and outcome.9,22-35

Figure 13 Descending aortic SAX view.

Figure 14 Descending aortic LAX view.

RV Function

Several techniques for acquiring quantitative measures of global RV

systolic function have been well described. 17 Nonetheless, most
basic echocardiographers rely on a qualitative, visual estimation of
Figure 11 ME bicaval view. IVC, Inferior vena cava; LA, left atrium;
systolic function. Evaluation of RV function should be routinely
SVC, superior vena cava; RA, right atrium.
performed when assessing hypotensive patients. For example,
patients undergoing liver transplantation are at increased risk for
Figure 12 TG midpapillary SAX view. ALP, Anterior lateral papillary
hypotension secondary to RV failure.37 Patients presenting for liver
muscle; PMP, posterior medial papillary muscle.
transplantation with pulmonary hypertension have additional risk for
RV dysfunction secondary to acute changes in pulmonary pressures
Global and Regional LV Function
associated with volume shifts and acid base disturbances during
transplantation.38 Use of basic PTE echocardiography in this
Determination of global LV systolic function is one of the most com-
population allows rapid determination of cardiac status and
mon indications of a basic PTE examination. Several techniques for therapeutic advantages over invasive monitoring alone. Wax et al39
acquiring quantitative measures of global LV systolic function have showed TEE to be safe and effective in the liver transplantation
been well described and are beyond the scope of this document. 17 population despite the presence of esophageal disease and
Nonetheless, most basic echocardiographers rely on qualitative, coagulopathies.
visual estimation of systolic function. This method of determination is It is the recommendation of the writing committee that a physician
far from precise but allows a basic echocardiographer to identify trained in basic PTE echocardiography evaluate the right ventricle in
those patients who might benefit from inotropic therapies. Multiple cases of refractory hypotension and that basic PTE monitoring be
considered for patients at high risk for RV dysfunction, in particular
those patients undergoing nonthoracic procedures in whom direct Basic Valvular Lesions
inspection of the right ventricle is not possible.
Practitioners of basic PTE echocardiography need familiarity with
basic valvular lesions. This includes knowledge of color flow Doppler
assessment of valvular regurgitation for the AV, MV, TV, and PV.
Although specific semiquantitative assessments do not have to be
obtained, differentiation of mild from moderate versus severe
degrees of insufficiency should be possible with visual inspection of
regurgitant jet area within the receiving chamber and vena contracta
width. Caution should be used when assessing the severity of
eccentric jets. The mechanism of any regurgitant jet may require
consultation with a physician with advanced PTE capabilities. Rapid
assessment of possible stenotic valvular lesions can be made by
visualizing leaflet motion and using continuous-wave Doppler
through the valve in any imaging plane in which blood flow is parallel
to the interrogating continuous-wave Doppler beam.
Complete assessment of valvular regurgitant and stenotic lesions is
outlined in multiple ASE guideline documents. 46,47 The assessment
of prosthetic value function should be performed by a physician with
advanced PTE knowledge. It is the recommendation of the writing
committee that a physician trained in basic PTE echocardiography
use the complete basic PTE examination to qualitatively delineate
valvular regurgitation and/or stenosis. However, if the valve lesion is
considered severe, or if comprehensive quantification is required to
ultimately determine the need for intervention, a consultation with an
advanced PTE echocardiographer is necessary to confirm the
severity and etiology of the valve pathology.

Pulmonary Embolism (PE)

Both surgery and trauma pose an increased risk for PE. Thus,
anesthesiologists may be responsible for both PE diagnosis and
treatment. Although TEE is not the gold standard for PE diagnosis, it
compares well with computed tomography when the PE is acute and
cen- tral.48,49 Moreover, TEE is often readily available to anesthesio-
logists, and its use does not interfere with ongoing surgery. The
sensitivity of two-dimensional TEE to diagnose a PE by direct
visualization of a thrombus in the PA is actually quite low, 50 but
studies using TEE to diagnose hemodynamically significant PEs
have shown far better diagnostic sensitivity.48,49,51 Echocardiographic
Hypovolemia findings consistent with acute PE include signs of RV dysfunction
(e.g., RV dilation, RV hypokinesis) 52 and atypical regional wall
Hypovolemia is a common cause of hemodynamic instability in the motion abnormalities of the RV free wall.53
perioperative period. The most common echocardiographic parame- In the opinion of the writing committee, the echocardiographic
ters used to diagnose hypovolemia are LV end-diastolic diameter diagnosis of a PE using direct evidence often requires advanced
and LV end-diastolic area obtained in the TG midpapillary SAX view. PTE skills. In addition, previously recommended cognitive and
In an emergent setting, a transesophageal echocardiographic probe technical objectives for basic PTE training have not included PE. 4
can be placed quickly and provides real-time assessment of LV However, it is the recommendation of the writing committee that a
cavity size. Acute blood loss causes changes in LVend-diastolic physician trained in basic PTE echocardiography at least be able to
area, PA occlusion pressure, and LVend-diastolic wall stress, even use the ME four-chamber, ME ascending aortic SAX, and ME RV
in patients with LV wall motion abnormalities. 40 Compared with inflow-outflow views to identify indirect echocardiographic findings
baseline imaging, measurements of LV end-diastolic area can be consistent with a PE, such as the presence of thrombus and/or signs
used as an indirect measurement of LV preload 40,41 and can be used of RV dysfunction, before the initiation of treatment.
to monitor response to fluid therapy. 42 Compared with the more
invasive PA catheterization, TEE has been shown to provide a better
index of LV preload in patients with normal LV function. 43-45 More Neurosurgery: Air Embolism
advanced Doppler-derived data can also be obtained, but this is
time-consuming, requires advanced training, and may have limited Venous air embolism (VAE) is a common occurrence during craniot-
accuracy in anesthetized patients.42 Relative changes between omies in the sitting position and has an incidence as high as 76%. 54
baseline status and the critical event, however, remain useful in Although the vast majority of VAEs are small with little clinical signif-
detecting acute changes in LV preload. icance, the sequelae of massive VAE and paradoxical embolism
The use of basic PTE echocardiography as a monitor includes both across a patent foramen ovale can be catastrophic. Thus, early
intermittent acquisition of images and ongoing live imaging, particu- detection and treatment are necessary. Basic PTE
larly related to the TG midpapillary SAX view. A certified
echocardiography offers the advantage of providing both real-time
echocardiographer (basic or advanced) must be involved in the
data and a visual quantification of a VAE. TEE is a more sensitive
evaluation of images and its use to effect changes in management,
whether it be used to direct volume resuscitation or pressor method for the detection of VAE than precordial Doppler. In fact, it is
administration. It is outside the scope of practice for other individuals potentially too sensitive, in that TEE can detect hemodynamically
participating in patient management to interpret the basic PTE insignificant microbubbles.55 Nevertheless, detection of these
images and direct therapy, but it is reasonable for these individuals microbubbles may alert the clinician to an insignificant problem that
to request interpretation and management guidance from can easily be addressed before it becomes significant. Last, basic
anesthesiologist echocardiographers. PTE echocardiography allows the detection of right-to-left shunts.
It is the recommendation of the writing committee that a physician Diagnosis of a shunt may influence the operative team to avoid the
trained in basic PTE echocardiography use the TG midpapillary SAX sitting position in this patient population, because these patients are
view to monitor and guide a hypovolemic patient's response to fluid prone to paradoxical embolisms.54,56-58
and blood component therapy.
Previously recommended training objectives for basic PTE training to identify basic adult congenital heart disease as a potential
included the requirement for knowledge of the echocardiographic mechanism for right-to-left or left-to-right shunts in a patient with
presentations of air embolization. 4 It is the recommendation of the unexplained hypoxia or hemodynamic instability. However, the
writing committee that a physician trained in basic PTE echocardiographic diagnosis and directed intervention for more
echocardiography use a complete basic PTE examination to identify complex adult congenital heart disease, including ventricular septal
patients at risk for right-to-left shunts and be able to detect the early defects and less commonly encountered ASDs, require consultation
with an advanced PTE echocardiographer.77,78
entrainment of intracardiac air.
MAINTENANCE OF COMPETENCE AND QUALITY ASSURANCE
After an anesthesiologist echocardiographer has obtained basic PTE
Pericardial Effusion and Thoracic Trauma certification, he or she should continue to perform a minimum of 25
examinations per year to maintain his or her skills and competence
Echocardiography plays an integral part in the evaluation of trauma level.4,5,79,80 Maintenance of competence by regularly participating in
involving the thoracic cavity. In trauma, rapid diagnosis and local or national echocardiographic continuing medical education
intervention are crucial to optimizing patient outcomes. The value of approved conferences or training courses is strongly recommended.
ultrasonography has long been recognized in the trauma Each basic PTE examination should be organized according to cur-
literature,26,59-61 as it is rent professional standards regarding image acquisition, image stor-
now part of the Focused Assessment With Sonography in Trauma age, and reporting.8 All hospital-based ultrasound systems should
examination.62 Similarly, TEE offers a mobile diagnostic tool that pro- allow for recording data onto a media format that allows offline re-
vides a rapid, accurate diagnosis of pericardial effusions, traumatic view and archiving. At a minimum, the initial basic PTE examination
aortic injuries, and cardiac contusions. 26 Both physical trauma (blunt should be stored, and any changes resulting in therapeutic interven-
or penetrating thoracic trauma) and iatrogenic trauma (during tions should be documented. The basic PTE examination should be
invasive procedures) can result in the accumulation of a pericardial documented as a paper or computer-generated report. The written
effusion. or computer-generated report of the findings should be placed in the
If the effusion accumulates rapidly, hemodynamic instability may patient's medical record as soon as possible, and no later than be-
ensue, and TEE can facilitate treatment with pericardiocentesis. fore leaving the operating room. If the patient's medical condition re-
Many publications support the use of TEE for traumatic aortic injury quires emergent transfer to the intensive care unit or another
given the safety, portability, and high diagnostic accuracy of this location, an initial verbal reporting of the findings may be acceptable,
modality.62-69 Nonetheless, it is important to keep in mind that followed by the written or electronic report as soon as the patient's
visualization of the distal ascending aorta and aortic arch are quite medical condition permits.
limited via TEE. Diagnosis of cardiac contusions may also be difficult The report should contain the following information2:
and limited in that there is no one diagnostic test for this condition.
1. The date and time of the study;
When used in conjunction with transthoracic echocardiography, 2. The name and hospital identification number of the patient;
serial electrocardiography, and serial myocardial enzyme 3. The patient's date of birth, age and gender;
assessment, TEE provides valuable diagnostic information. 60,70-76 4. The indication for the study;
However, caution should be used with TEE probe placement and 5. Documentation of informed consent;
manipulation because of a potential coexisting esophageal or 6. The names of the performing and interpreting physicians;
cervical spine injury. 7. Findings;
Previously recommended training objectives for basic PTE training 8. Impression;
9. Any known complications of the examination;
included the requirement for knowledge of the echocardiographic 10. The date and time the report was signed; and
manifestations of pericardial effusions and lesions of the great 11. The mode of archiving of the study.
vessels as appropriate cognitive skills 4 Thus, it is the
recommendation of the writing committee that a physician trained in
basic PTE echocardiography use a complete basic PTE examination CONCLUSIONS
to demonstrate signs consistent with a pericardial effusion, aortic
dissection, or cardiac contusion. However, once obtained, except in To date, a definitive document describing a basic PTE examination
emergency situations, a consult with an advanced PTE sequence that can be used by anesthesiologists for the evaluation of
echocardiographer is necessary to confirm the diagnosis and initiate perioperative hemodynamic instability in surgical patients has not
appropriate surgical or medical therapy. been available. Guidelines recommending a methodology for
performing a basic PTE examination on the basis of a series of 11
anatomically referenced cross-sectional images are described, along
Simple Congenital Heart Disease in Adults with applicable clinical indications, to promote training in basic PTE
echocardiography and consistency across patient populations and
Transesophageal echocardiographic assessment of adult patients institutions.
with complex congenital heart disease usually requires a meticulous
sequential evaluation that requires the knowledge and experience of
an advanced PTE echocardiographer. Although adult congenital NOTICE AND DISCLAIMER
heart lesions have not previously been included within the scope of
basic cognitive echocardiographic skills,4 several basic congenital This report is made available by the ASE and the SCA as a courtesy
lesions may have an impact on intraoperative care (as discussed reference source for members. This report contains recommenda-
under ''Neurosurgery: Air Embolism'') and should be recognized by a tions only and should not be used as the sole basis to make medical
practitioner with basic PTE training. A patent foramen ovale and/or practice decisions or for disciplinary action against any employee.
secundum atrial septal defect (ASD) is generally easily recognized The statements and recommendations contained in this report are
via two-dimensional and color flow Doppler imaging in the ME bi- based primarily on the opinions of experts, rather than on scientifi-
caval view as a defect in the central portion of the IAS and should be cally verified data. The ASE and the SCA make no express or
considered in patients in whom there is high clinical suspicion of an implied warranties regarding the completeness or accuracy of the
otherwise unexplainable right-to-left shunt (hypoxia) or left-to- information in this report, including the warranty of merchantability or
right shunt.77,78 However, an advanced PTE echocardiographer fitness for a particular purpose. In no event shall the ASE or the SCA
should be consulted if further echocardiographic interrogation of the be liable to you, your patients, or any other third parties for any
entire IAS is warranted to exclude more complex congenital lesion of decision made or action taken by you or such other parties in
the IAS, including smaller secundum ASDs, primum ASDs, or more reliance on this information. Nor does your use of this information
difficult to visualize sinus venous ASDs.77,78 constitute the offering of medical advice by the ASE or the SCA or
create any physician-patient relationship between the ASE or the
Ventricular septal defects are classified on the basis of their location SCA and your patients or anyone else.
(perimembranous, muscular, double committed outlet, inlet) or their
pathophysiology (postinfarction) and can be associated with signifi-
cant hemodynamic instability. Although a basic echocardiographer
may perform a basic PTE examination with two-dimensional and
color flow Doppler using the ME four-chamber, ME two-chamber, APPENDIX
and ME AV LAX views to evaluate a patient for a ventricular septal
defect, this writing committee believes that this type of diagnostic in- Members of the Council on Perioperative Echocardiography
terrogation usually requires advanced PTE skills. Thus, it is the Scott T. Reeves, MD, MBA, FASE, Chairman
recommendation of the writing committee that a physician trained in Madhav Swaminathan, MD, FASE, Vice Chairman
basic PTE echocardiography use a complete basic PTE examination Kathryn E. Glas, MD, MBA, FASE, Immediate Past Chair
Mark S. Adams, BS, RDCS, FASE
Mary Beth Brady, MD, FASE
Alan C. Finley, MD
Rebecca T. Hahn, MD, FASE
Marsha Roberts, RCS, RDCS, FASE
David Rubenson, MD, FASE
Stanton K. Shernan, MD, FASE
Doug Shook, MD, FASE
Roman Sniecinski, MD, FASE
Nikolaos J. Skubas, MD, FASE
Christopher A. Troianos, MD
Jennifer D. Walker, MD
Will S. Whitley, MD