Perioperative Transoesophageal Echocardiography in ... - MedIND

Review 108 BilottaArticle et al. TOE in Noncardiac Surgery

Annals of Cardiac Anaesthesia 2006; 9: 108–113

Perioperative Transoesophageal Echocardiography in Noncardiac Surgery Federico Bilotta, MD, PhD, Deepak K. Tempe, MD, Federico Giovannini, MD, Giovanni Rosa, MD Department of Anesthesiology, Intensive Care, and Pain Medicine, University of Rome “La Sapienza”, Rome, Italy; Department of Anaesthesiology and Intensive Care, GB Pant Hospital, New Dehli, India Transoesophageal echocardiography (TOE) is a semi invasive technique that allows a real time evaluation of cardiac anatomy, regional and global function. Its use is becoming an irreplaceable tool for the assessment and therapeutic management of critical patients in the perioperative setting. A systematic search for reports describing indications for intraoperative TOE monitoring was carried out. Search terms were perioperative TEE/TOE, intraoperative monitoring, TEE/TOE and vascular surgery, neurosurgery, orthopaedic surgery, transplant surgery. In several surgical specialties, including vascular surgery, neurosurgery, laparoscopic, orthopaedic, and transplant surgery, the intraoperative TOE monitoring found specific indications. The early recognition of haemodynamic changes, pulmonary and paradoxical embolism and ischaemic events, often not diagnosed through standard monitoring such as electrocardiography and pulmonary artery catheterization, allows a prompt therapeutic intervention and a reduction in mortality and morbidity in patients with a failing cardiac function. This paper is a review of the current uses of TOE in noncardiac surgery such as vascular surgery, neurosurgery, laparoscopic, orthopaedic, and transplant surgery. In these situations, significant haemodynamic instabilities are known to occur, which require rapid identification and solutions. TOE may have a prominent role in perioperative monitoring in several noncardiac surgical procedures. (Annals of Cardiac Anaesthesia 2006; 9: 108–113) Key words: Noncardiac surgery, Transoesophageal echocardiography, Haemodynamics

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ransoesophageal echocardiography (TOE) is a semi invasive technique that allows a real time evaluation of anatomy and function of the heart and great vessels. In 1996 the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists have published the guidelines for perioperative TOE.1 According to these guidelines, perioperative TOE monitoring is a mandatory indication in some cardiac surgery procedures (valve repair, congenital heart surgery, repair of hypertrophic obstructive cardiomyopathy, endocarditis and thoracic aortic aneurysms and Address for Correspondence: Federico Bilotta, MD, PhD, Viale Somalia 81, Rome 00199, Italy, Tel/fax ++39 06 860 82 73 E-mail: [email protected]

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dissection) and in patients with acute, persistent and life-threatening haemodynamic disturbances in which, ventricular function and its determinants are uncertain and not responding to treatment.2-4 In cardiac surgery setting we proposed TOE monitoring for preoperative assessment of myocardial segments responding to coronary revascularization 5 and for evaluation of cardioplegia distribution.6 In 1999, in order to facilitate the training in intraoperative TOE by providing a framework in which to develop the necessary knowledge and skill, a joint task force of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists, have published the guidelines for performing a comprehensive intraoperative TOE examination.7

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In this paper the current indications for perioperative TOE monitoring in noncardiac surgery are reviwed and the clinical clues that an anaesthesiologist should answer are discussed. Intraoperative TOE monitoring The probe for intraoperative TOE monitoring should be placed in the oesophagus after tracheal intubation and adequately securing the tracheal tube. Because some surgical approaches (brain surgery, neck surgery, etc) limit the access to mouth and consequently to the probe, in some cases one projection should be selected at the beginning of the operation and kept constant for monitoring throughout the procedure. In these cases, omniplane probes offer an additional advantage, because of the possiblity of visualizing various cardiac and vascular structures while keeping the probe position constant. There are two possible approaches to a TOE study. The first is to begin imaging from transgastric position (normally obtained when the transducer is at 40-45 cm from incisors) and then pull the probe out to examine various sections of the heart from apex to base and to view aorta by posterior rotation of transducer. The second approach is to start at the base of the heart (25-30 cm from the incisors) and progress towards transgastric views and examination of aorta during withdrawal. Each TOE projection helps to collect information of specific anatomical and functional correlates. Midoesophageal 4chamber view allows visualization of part of both ventricles, the atria and atrio-ventricular valves, thus also leading to information on the filling pattern. Although this projection is not the best for accurate evaluation of ventricular global and segmental function, it is probably the most useful at large. Other projections of interest are obtained with short axis imaging of the heart and the great vessels. From above downwords : cross section of ascending and descending aorta, the aortic valve imaging and the coronary ostia, the inter-atrial septum with atrial chambers, the cross section of the atrioventricular valves and by pushing the TOE probe down into the gastric fundus, the ventricular short axis.8

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Bilotta et al. TOE in Noncardiac Surgery 109

Vascular Surgery Adverse cardiac events are a major cause of morbidity and mortality after noncardiac surgery, particularly in patients with several risk factors as those undergoing vascular surgery. A large proportion of patients also suffer from coronary artery disease. The entire perioperative period is stressful and characterized by complex and rapidly changing physiological responses that may be poorly tolerated by patients with compromised coronary circulation or poor left ventricular (LV) function.9 Cardiovascular instability and its heart, brain, kidney, spinal cord and gut ischaemia consequences, remain the main reasons of death and morbidity in patients undergoing thoracoabdominal aorta repair. 10-12 The TOE has been shown to be both an excellent method for detecting myocardial ischaemia13 and an accurate technique for assessing LV filling. 14 In addition, several studies have demonstrated that pulmonary capillary wedge pressure measurements are inaccurate in dynamic situations such as aortic cross-clamping and clamp release.15 Of particular interest in this setting can be the evaluation of aortic competence through the transgastric view of the LV that can be acquired by advancing the probe into the stomach and anteflexing the tip until the heart comes into view or by the upper oesophageal view at 110 degrees.16 Other projections potentially useful in this setting are the mid-oesophageal aortic valve short and long axis view. The myocardial response to aortic cross-clamping are well known. The higher the level of the clamp, the greater is the haemodynamic disturbance. A significant advantage of TOE is that it can effectively determine in real-time the extent of ventricular function impairment as a result of haemodynamic disturbance. In the setting of vascular surgery, the use of TOE monitoring is particularly promising while endovascular repair of thoracic aortic aneurysm is attempted. 17 TOE is particularly valuable for: identifying aortic wall pathology, visualizing the true lumen during guidewire advancement, checking the stent graft positioning and real-time visualization of perigraft leak. Perioperative TOE

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monitoring is a useful imaging modality that provides to the endovascular team, real-time vital information regarding stent positioning, endoleaks, cardiac performance and the branch arteries of the aortic arch. The sensitivity of TOE in detecting small amounts of flow within the aneurysmal sac makes it ideal for detection of both type I and type II endoleaks.18 The timely detection of endoleaks may be one of the most important benefits of TOE monitoring during thoracic endovascular aorta repair. Neurosurgery Intraoperative TOE monitoring has found specific application in the management of neurosurgical patients: detection of venous air embolism (VAE), identification of patent foramen ovale, localization of the distal end of ventriculoatrial shunt at the cavo-atrial junction of the heart during surgical placement, monitoring of adequate filling in patients with subarachnoid haemorrage and heamodynamic monitoring during extracorporeal circulation for giant cerebral artery aneurysm surgery. Intraoperative VAE is a well-recognized complication in neurosurgical patients operated in sitting position. The incidence of Doppler-detected VAE in patients undergoing posterior fossa surgery is approximately 12% in the non-sitting position (i.e., supine, prone, park bench, and lateral), and 45% in the sitting position.19 The most important factors that limit morbidity and mortality related to VAE are early diagnosis and prompt treatment. Presently precordial Doppler and TOE monitoring are the most sensitive methods of intraoperative VAE detection.20 Laparoscopic Surgery Laparoscopic surgery has gained increasing popularity over open surgical approach because of several postoperative advantages: less pain associated with the small and limited incision, an improved postoperative pulmonary function, a lower rate of postoperative ileus, a shorter hospital stay and a faster return to normal activities. Several studies have used TOE monitoring to evaluate haemodynamic changes during laparoscopic surgery.21-23

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To summarize, changes in loading conditions during laparoscopic surgery could lead to deleterious consequences in patients with significant cardiovascular disease, TOE monitoring allows early diagnosis and prompt evaluation of haemodynamic effects and therapeutic interventions during laparoscopic procedures. Orthopaedic Surgery Total hip arthroplasty can be associated with systemic arterial hypotension, hypoxaemia, increase in pulmonary shunt and pulmonary hypertension. In 0.6% to 10% of patients, intraoperative cardiac arrest occurs, with a mortality rate of 0.02%. 24 One of the several hypotheses proposed to explain these intraoperative complications, is pulmonary microembolism with the degree of embolism determined by intramedullary pressure generated at the time of insertion of prosthesis.25 In patients under general anaesthesia, mechanical positive pressure ventilation could increase both intrathoracic pressure and right atrial pressure, possibly causing functional right to left shunt, and exposing patients with interatrial communication to systemic embolization.26 A prospective clinical study27 concluded that TOE is a reliable method for detecting and quantifying pulmonary embolism during cemented total hip arthroplasty. Furthermore, it gives information on the effect of therapeutic strategies to prevent embolization. Intraoperative TOE yields real-time information on the frequency of embolic events during intramedullary procedures. 28 When paradoxical fat embolism syndrome is diagnosed, intramedullary procedures should be discontinued and other treatment options for long-bone fracture considered.29 In conclusion, in patients undergoing general anaesthesia for total hip arthroplasty, the employment of TOE could be a great help in monitoring air, fat, bone marrow, and bone debris embolic events that could be associated with cardiopulmonary and neurological impairment, and it could be of help in determining the most appropriate surgical and anaesthesiological techniques.

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Transplant Surgery Patients undergoing major noncardiac organ transplantation such as lung and liver have underlying cardiopulmonary dysfunction that is severely challenged during the respective surgical procedures.30 Intraoperative TOE can complement and even provide significant advantages over traditional monitoring.31 During orthotopic lung transplantation, intracardiac or intrapulmonary shunting are common mechanisms involved in pulmonary artery embolic events that can occur with severe neurological consequences. Such a complication can occur when a vein is opened and intravascular pressure is lower than atmospheric pressure. In both liver and lung transplant, perioperative TOE monitoring has a prominent role. Because of its retrocardiac position, TOE is ideally suited to evaluate the pulmonary arterial and venous anastomoses for obstruction and the intracardiac structures for the potential of shunting during lung transplantation.31 The TOE has been reported to visualize 100% of right pulmonary artery anastomoses and 71% of left pulmonary artery.32 Obstruction of pulmonary blood flow and intracardiac shunting are the major anatomical causes of post-transplantation hypoxaemia and the intraoperative evaluation of pulmonary vein and artery anastomoses allows a prompt surgical correction of any stenosis avoiding a reoperation.33 During orthotopic liver transplantation (OLT), overall LV function appears to be maintained but segmental wall motion abnormalities can occur. Furthermore, right heart dysfunction (myocardial and/or valvular) might account for some of the haemodynamic instability observed during OLT. Paradoxic pulmonary thromboembolism and VAE have been observed with TOE, especially at the time of reperfusion of the donor liver and removal of the suprahepatic cross clamp. 34,35 A comprehensive TOE evaluation should be performed before reperfusion of the donor liver. Furthermore, TOE is a reliable and rapid method during OLT placement of percutaneous venovenous bypass cannulae.36 Other indications for the use of TOE are in patients who have haemodynamic instability of unknown cause, such as pericardial effusion, lung

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evaluation and any other unexpected findings that the TOE may provide, which may influence the clinical management. Some complications can happen during the procedure. They include respiratory compromise such as laryngospasm, hypoxia and bronchospasm, or cardiovascular compromise such as ventricular tachycardia, third degree atrioventricular block and transient hypotension or hypertension. Other complications can be, bacteraemia and minor pharyngeal bleeding. Conclusions With TOE, the ability to measure heart ventricular cavity size on-line in real-time permits to evaluate intravascular volume status and to diagnose hypovolaemia, which is particularly important during operations associated with blood loss and fluid shifts. The introduction of TOE into the operating room means that we have the opportunity to compare intravascular pressure preload. In doing this we also increase our understanding and knowledge of central haemodynamics. Moreover, the development of TOE has made perioperative monitoring of LV wall motion abnormalities that occur during myocardial ischaemic dysfunction prior to ECG changes, and are more sensitive marker of myocardial ischaemia than the ECG. However, the most important contribution to the analysis of function is offered by Doppler echocardiography. Semi-quantitative, real-time registrations of flow velocity give important functional data. Flow velocity can be transformed into pressure differences using the Bernoulli equation. Finally, through a combination of dimensional data and estimations of velocity profiles (flow velocity integrals), true volume flow can be estimated as well as true assessments of valve area and vascular lumen. Thus, echocardiograpy offers a wide range of primary and secondary, directly measured or derived, calculations of variables used in classic haemodynamic analysis of cardiac and vascular function. Although there is controversy regarding both the advisability of limited-scope training in TOE and the use of non-comprehensive “goallimited” TOE studies, we are focusing the training for use of TOE monitoring on defined clinical

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problems that are related to surgical procedure or to the clinical condition of the patient. In 1998 the European Perioperative Transesophageal Echocardiography Research Group 37 has investigated its use and impact on clinical management in a prospective cohort of 224 patients with acute or chronic haemodynamic disturbances or at risk for myocardial ischaemia. TOE was the most important monitor in guiding the following therapeutic interventions: anti-ischaemic therapy, fluid administration, vasopressor or inotrope administration, vasodilator therapy and depth of anaesthesia. Benjamin and colleagues38 tested the feasibility of training intensivists to perform a goal-directed, limited scope TOE to assess global and regional LV function in critically ill patients using a paediatric monoplane TOE probe. The results of this study demonstrated that, if an adequate expert backup is available, such training is feasible and can be done safely and can rapidly yield information pertinent to patient management even during the early stages of skill acquisition. In 62% of patients, TOE provided additional information, beyond that provided by the pulmonary artery catheter that resulted in therapeutic changes. In

three patients, TOE revealed unexpected findings requiring radical changes in the diagnosis and therapeutic plan. Intraoperative TOE monitoring is contraindicated in patients with known absolute or relative contraindications such as all oesophageal pathologies, atlantoaxial joint disease, history of upper gastrointestinal surgery, prior radiation to the chest or bleeding hiatal hernia. Preoperative consultation with a gastroenterologist may be prudent in such patients. Maintenance of a high clinical index of suspicion for gastrointestinal injury in the perioperative period may further reduce TOE-associated morbidity. Echocardiography is evolving as an important diagnostic modality in the perioperative setting. The real time assessment of cardiac anatomy and function with the TOE available at any time can significantly complement or potentially replace pulmonary artery catheter under certain specific circumstances, leading to a cost containment in terms of reduced morbidity and mortality. Contrast echocardiography may further expand the diagnostic application of TOE monitoring in the perioperative setting.39, 40

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