This is the current release of the guideline.

This guideline updates a previous version: Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 1996 Apr;84(4):986-1006. [21 references]

Any condition that requires transesophageal echocardiography, including:

• Myocardial ischemia, coronary artery disease
• Hemodynamic disorders and other intraoperative complications
• Valvular disease (native and prosthetic valves)
• Congenital heart defects
• Cardiomyopathy
• Cardiac aneurysms
• Endocarditis
• Cardiac tumors
• Air emboli
• Intracardiac thrombi
• Pulmonary emboli
• Traumatic cardiac injuries
• Thoracic aortic aneurysms and dissections
• Traumatic thoracic aortic disruption
• Aortic atheromatous diseases or other sources of aortic emboli
• Pericarditis
• Pericardial effusions and tamponade
• Pleuropulmonary diseases
• Heart and/or lung transplantation

Adult and pediatric surgical patients and potential surgical patients in the setting of cardiac surgery, noncardiac surgery, and postoperative critical care

Note: The Guidelines do not apply to the assessment of nonsurgical patients or to postdischarge follow-up assessment of surgical patients.

Transesophageal echocardiography (TEE)

For all American Society of Anesthesiologists (ASA) practice parameters, the initial electronic search is conducted using Pubmed. This search is followed by focused searches, where needed, of databases such as the Cochrane or other specialty databases (e.g., nursing), or the Web sites of targeted journals. Finally, all articles reviewed will include a manual search of listed references.

For these Guidelines, a literature review was used in combination with opinions obtained from expert consultants and other sources (e.g., ASA members, open forums, Internet postings). Both the literature review and opinion data were based on evidence linkages or statements regarding potential relationships between clinical interventions and outcomes. The efficacy and outcomes from the use of transesophageal echocardiography (TEE) were examined for the following procedures:

1. Cardiac and thoracic aortic surgery
2. Transcatheter intracardiac procedures
3. Pacemaker and implanted cardioverter defibrillator lead extraction
4. Neurosurgery
5. Liver transplantation
6. Orthopedic surgery
7. Vascular/endovascular surgery
8. Other major surgery (i.e., lung, renal, abdominal, and head/neck/chest wall)
9. Postoperative critical care

The impact of the use of perioperative TEE was assessed on the basis of the following:

1. Perioperative detection or diagnosis of new or unsuspected pathology
2. Confirming or refinement of previous perioperative diagnoses
3. Preoperative or intraoperative refinement of a surgical plan
4. Detecting complications during surgery
5. Assessing surgery outcomes
6. Planning and confirming device placement
7. Beneficial or adverse patient outcomes from the use of TEE

For the literature review, potentially relevant clinical studies published after 1994 were identified via electronic and manual searches of the literature. The electronic and manual searches covered a 16-yr period from 1994 through 2009. More than 8000 citations were initially identified, yielding a total of 861 nonoverlapping articles that addressed topics related to the evidence linkages. After review of the articles, 404 studies did not provide direct evidence and were subsequently eliminated. A total of 457 articles contained direct linkage-related evidence. A complete bibliography used to develop these Guidelines, organized by section, is available as Supplemental Digital Content 2, http://links.lww.com/ALN/A568 .

A total of 457 articles contained direct linkage-related evidence.

Scientific Evidence

Study findings from scientific literature published after 1994 (not excluding sentinel articles published prior to 1994) were aggregated and reported in summary form by evidence category, as described later. All literature (e.g., randomized controlled trials, observational studies, and case reports) relevant to each topic was considered when evaluating the findings. For reporting purposes in this document, only the highest level of evidence (i.e., levels 1, 2, or 3 identified below) within each category (i.e., A, B, or C) is included in the summary.

Category A: Supportive Literature

Randomized controlled trials report statistically significant (P<0.01) differences among clinical interventions for a specified clinical outcome.

Level 1: The literature contains multiple randomized controlled trials, and the aggregated findings are supported by meta-analysis.*

Level 2: The literature contains multiple randomized controlled trials, but there is an insufficient number of studies to conduct a viable meta-analysis for the purpose of these Guidelines.

Level 3: The literature contains a single randomized controlled trial.

*All meta-analyses are conducted by the American Society of Anesthesiologists (ASA) methodology group. Meta-analyses from other sources are reviewed but not included as evidence in this document.

Category B: Suggestive Literature

Information from observational studies permits inference of beneficial or harmful relations among clinical interventions and clinical outcomes.

Level 1: The literature contains observational comparisons (e.g., cohort, case-control research designs) of two or more clinical interventions or conditions and indicates statistically significant differences between clinical interventions for a specified clinical outcome.

Level 2: The literature contains noncomparative observational studies with associative (e.g., relative risk, correlation) or descriptive statistics.

Level 3: The literature contains case reports.

Category C: Equivocal Literature

The literature cannot determine whether there are beneficial or harmful relations among clinical interventions and clinical outcomes.

Level 1: Meta-analysis did not find significant differences among groups or conditions.

Level 2: There is an insufficient number of studies to conduct meta-analysis and (1) randomized controlled trials have not found significant differences among groups or conditions or (2) randomized controlled trials report inconsistent findings.

Level 3: Observational studies report inconsistent findings or do not permit inference of beneficial or harmful relations.

Category D: Insufficient Evidence from the Literature

The lack of scientific evidence in the literature is described by the following conditions.

1. No identified studies address the specified relationships among interventions and outcomes.
2. The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the "Focus" of the Guidelines or it does not permit a clear interpretation of findings due to methodologic concerns (e.g., confounding in study design or implementation).

Opinion-based Evidence

All opinion-based evidence relevant to each topic (e.g., survey data, open-forum testimony, Internet-based comments, letters, and editorials) was considered in the development of these Guidelines. However, only the findings obtained from formal surveys are reported.

Opinion surveys were developed by the Task Force to address each clinical intervention identified in the document. Identical surveys were distributed to two groups of respondents: expert consultants and ASA members.

Category A: Expert Opinion

Survey responses from Task Force–appointed expert consultants are reported in summary form in the text. A complete listing of consultant survey responses is reported in Table 2 in the original guideline document.

Category B: Membership Opinion

Survey responses from a sample of members of the ASA are reported in summary form in the text. A complete listing of ASA member survey responses is reported in Table 3 in the original guideline document.

Expert consultant and ASA membership survey responses are recorded using a 5-point scale and summarized based on median values.**

Strongly Agree: Median score of 5 (at least 50% of the responses are 5)

Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5)

Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contains at least 50% of the responses)

Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2)

Strongly Disagree: Median score of 1 (at least 50% of responses are 1)

Category C: Informal Opinion

Open-forum testimony, Internet-based comments, letters, and editorials are all informally evaluated and discussed during the development of Guideline recommendations. When warranted, the Task Force may add educational information or cautionary notes based on this information.

**When an equal number of responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. Ties are calculated by a predetermined formula.

Literature reporting the detection of new abnormalities by transesophageal echocardiography (TEE) was summarized, followed by a summary of literature reporting the confirmation of previously diagnosed abnormalities by TEE. The sensitivity, specificity, and positive and negative predictive values for the efficacy of TEE in detecting new abnormalities and in confirming or redefining previous diagnoses were also obtained (see table 1 in the original guideline document). Study findings reporting the misdiagnosis or limited effectiveness of TEE to detect pathology are also listed in table 1.

Interobserver agreement among Task Force members and two methodologists was established by interrater reliability testing. Agreement levels using a kappa (k) statistic for two-rater agreement pairs were as follows: (1) type of study design, k = 0.50–1.00; (2) type of analysis, k= 0.50–0.83; (3) evidence linkage assignment, k = 0.75–1.00; and (4) literature inclusion for database, k = 0.78–1.00. Three-rater chance-corrected agreement values were as follows: (1) study design, Sav = 0.66, Var (Sav) = 0.006; (2) type of analysis, Sav = 0.66, Var (Sav) = 0.007; (3) linkage assignment, Sav = 0.83, Var (Sav) = 0.005; and (4) literature database inclusion, Sav = 0.84, Var (Sav) = 0.046. These values represent moderate to high levels of agreement.

Consensus-based Evidence

Consensus was obtained from multiple sources, including (1) survey opinion from consultants who were selected based on their knowledge or expertise in the perioperative use of TEE, (2) survey opinions solicited from active members of the American Society of Anesthesiologists (ASA) who personally perform TEE as part of their practice, (3) testimony from attendees of a publicly held open forum at an international anesthesia meeting, (4) Internet commentary, and (5) Task Force opinion and interpretation. The survey rate of return was 53% (n = 55 of 103) for the consultants, and 818 surveys were received from active ASA members who indicated that they personally performed TEE as part of their practice. Results of the surveys are reported in tables 2 and 3 in the original guideline document and summarized in the text of the Guidelines.

The consultants were asked to indicate which, if any, of the recommendations would change their clinical practices if the Guidelines were instituted. The rate of return was 14% (n =14 of 103). The percent of responding consultants expecting a change in their practice associated with each linkage topic was as follows: (1) major cardiac and thoracic aortic surgery, 7%; (2) transcatheter intracardiac procedures, 0%; (3) pacemaker and implanted cardioverter defibrillator lead extraction, 7% (4); neurosurgery, 7% (5); liver transplantation, 0% (6); orthopedic surgery, 7% 7) vascular/endovascular surgery, 7%, (8) other major surgery (i.e., lung, renal, abdominal, and head/neck/chest wall), 14%; and (9) postoperative critical care, 21%. Eighty-six percent indicated that their clinical practice will not need new equipment, supplies, or training to implement the Practice Guidelines. Eighty-six percent indicated that the Guidelines would not require ongoing changes in their practice which will affect costs. One hundred percent of the respondents indicated that the Guidelines would have no effect on the amount of time spent on a typical case.

The American Society of Anesthesiologists (ASA) and Society of Cardiovascular Anesthesiologists jointly appointed a task force of 13 members, including anesthesiologists in both private and academic practice from various geographic areas of the United States, 2 cardiologists (1 representing the American College of Cardiology and the other representing the American Society of Echocardiography), and 2 consulting methodologists from the ASA Committee on Standards and Practice Parameters.

The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to transesophageal echocardiography (TEE) were reviewed and evaluated. Third, expert consultants were asked (1) to participate in opinion surveys on the effectiveness of TEE imaging and (2) to review and comment on a draft of the Guidelines developed by the Task Force. Fourth, opinions about the Guideline recommendations were solicited from a sample of active members of the ASA who personally perform TEE as a part of their practice. Fifth, the Task Force held an open forum at a major international meeting† to solicit input on its draft recommendations. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines (see Appendix 1 in the original guideline document).

†Society of Cardiovascular Anesthesiologists, 30th Annual Meeting, Vancouver, British Columbia, Canada, June 20, 2008.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Expert consultants were asked (1) to participate in opinion surveys on the effectiveness of transesophageal echocardiography (TEE) imaging and (2) to review and comment on a draft of the Guidelines developed by the Task Force. Opinions about the Guideline recommendations were solicited from a sample of active members of the American Society of Anesthesiologists (ASA) who personally perform TEE as a part of their practice. The Task Force held an open forum at a major international meeting to solicit input on its draft recommendations.

Cardiac and Thoracic Aortic Procedures

• Cardiac and Thoracic Aortic Surgery
  • For adult patients without contraindications, transesophageal echocardiography (TEE) should be used in all open heart (e.g., valvular procedures) and thoracic aortic surgical procedures and should be considered in coronary artery bypass graft (CABG) surgeries as well
    • to confirm and refine the preoperative diagnosis
    • to detect new or unsuspected pathology
    • to adjust the anesthetic and surgical plan accordingly
    • to assess the results of the surgical intervention
  • In small children, the use of TEE should be considered on a case-by-case basis because of risks unique to these patients (e.g., bronchial obstruction).
• Catheter-Based Intracardiac Procedures
  • For patients undergoing transcatheter intracardiac procedures, TEE may be used.

Noncardiac Surgery

• TEE may be used when the nature of the planned surgery or the patient's known or suspected cardiovascular pathology might result in severe hemodynamic, pulmonary, or neurologic compromise.
• If equipment and expertise are available, TEE should be used when unexplained life-threatening circulatory instability persists despite corrective therapy.

Critical Care

• For critical care patients, TEE should be used when diagnostic information that is expected to alter management cannot be obtained by transthoracic echocardiography or other modalities in a timely manner.

Contraindications for the Use of TEE

• TEE may be used for patients with oral, esophageal, or gastric disease, if the expected benefit outweighs the potential risk, provided the appropriate precautions are applied. These precautions may include:
  • Considering other imaging modalities (e.g., epicardial echocardiography)
  • Obtaining a gastroenterology consultation
  • Using a smaller probe
  • Limiting the examination
  • Avoiding unnecessary probe manipulation
  • Using the most experienced operator

None provided

Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence.

Appropriate use of transesophageal echocardiography (TEE) to evaluate cardiac risk in patients undergoing surgery

Studies with observational findings and case reports indicate that, although rare, potential complications associated with transesophageal echocardiography (TEE) may include esophageal perforation, esophageal injury, hematoma, laryngeal palsy, dysphagia, dental injury, or death. However, there is insufficient literature to assess whether there are contraindications for the use of TEE.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American Society of Anesthesiologists

American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists Task Force on Perioperative Transesophageal Echocardiography

Task Force Members: Daniel M. Thys, M.D. (Chair), New York, New York; Martin D. Abel, M.B.B.Ch., Rochester, Minnesota; Robert F. Brooker, M.D., Wausau, Wisconsin; Michael K. Cahalan, M.D., Salt Lake City, Utah; Richard T. Connis, Ph.D., Woodinville, Washington; Peggy G. Duke, M.D., Atlanta, Georgia; David G. Nickinovich, Ph.D., Bellevue, Washington; Scott T. Reeves, M.D., Charleston, South Carolina; Marc A. Rozner, Ph.D., M.D., Houston, Texas; Isobel A. Russell, M.D., San Francisco, California; Scott C. Streckenbach, M.D., Boston, Massachusetts; Pamela Sears-Rogan, M.D., Washington, DC (American Society of Echocardiography); and William J. Stewart, M.D., Cleveland, Ohio (American College of Cardiology)

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 1996 Apr;84(4):986-1006. [21 references]

Electronic copies: Available in Portable Document Format (PDF) or EPUB for eBook devices from the Anesthesiology Journal Web site .

Print copies: Available from the American Society for Anesthesiologists, 520 North Northwest Highway, Park Ridge, IL 60068-2573.

None available

None available

This summary was completed by ECRI on February 20, 1999. The information was verified by the guideline developer on April 23, 1999. This summary was updated by ECRI Institute on November 4, 2010.

This NGC summary is based on the original guideline, which is copyrighted by the American Society of Anesthesiologists.