Basic Perioperative Transesophageal Echocardiography ...

1 expert CONSENSUS STATEMENTB asic Perioperative TransesophagealEchocardiography examination : A ConsensusStatement of the American Societyof Echocardiography and the Societyof Cardiovascular AnesthesiologistsScott 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 Societyof 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.)

2 Keywords: Transesophageal Echocardiography , Basic certificationTABLE OF CONTENTSI ntroduction 443 History 444 Medical Knowledge 444 Training 445 Basic Perioperative Transesophageal examination 445ME Four-Chamber View 446ME Two-Chamber View 447ME Long-Axis (LAX) View 447ME Ascending Aortic LAX View 447ME Ascending Aortic SAX View 447ME AV SAX View 447ME RV Inflow-Outflow View 447ME Bicaval View 448TG Midpapillary SAX View 449 Descending Aortic SAX and LAX Views 450 Indications 450 Global and Regional LV Function 451RV Function 451 Hypovolemia 452 Basic Valvular Lesions 452 Pulmonary Embolism (PE) 452 Neurosurgery.

3 Air Embolism 452 Pericardial Effusion and Thoracic Trauma 453 Simple Congenital Heart Disease in Adults 453 Maintenance of Competence and Quality Assurance 453 Conclusions 454 Notice and Disclaimer 454 Appendix 454 Members of the Council on Perioperative Echocardiography 454 References 454 INTRODUCTIONThis consensus statement by the American society ofEchocardiography (ASE) and the society of CardiovascularAnesthesiologists (SCA) describes the significant role of a basicFrom the Medical University of South Carolina ( , ); Weill-Cornell MedicalCollege, New York, New York ( ); Duke University, Durham, North Carolina( ); Brigham s and Women s Hospital, Harvard Medical School, Boston,Massachusetts ( ); Emory University, Atlanta, Georgia ( , );Columbia University College of Physicians and Surgeons, New York, New York( , );andMassachusettsGeneralHospital,Boston ,Massachusetts( ).

4 The following authors reported relationships with one or more commercial inter-ests: Scott T. Reeves, MD, FASE, edited and receives royalties forA Practical Ap-proach to Transesophageal EchocardiographyandThe Practice of PerioperativeTransesophageal Echocardiography : Essential Cases(Wolters Kluwer Health).Kathryn E. Glas, MD, FASE, edited and receives royalties forThe Practice of Peri-operative Transesophageal Echocardiography : Essential Cases(Wolters KluwerHealth). Stanton K. Shernan, MD, FASE, has served as a lecturer for Philips Health-care, Inc., and is an editor All other authors reportedno actual or potential conflicts of interest in relation to this of the Councils on Perioperative Echocardiography are listed in ASE Members:The American society of Echocardiography (ASE) has gone green!

5 Earn free continuing medical education credit through anonline activity related to this article. Certificates are available for immediateaccess upon successful completion of the activity. Nonmembers will needto join the ASE to access this great member benefit!Reprint requests: American society of Echocardiography , 2100 Gateway CentreBoulevard, Suite 310, Morrisville, NC 27560 2013 by the American society of Transesophageal (PTE) cardiac examination inthe care and treatment of an un-stable surgical patient. The useof a noncomprehensive basicPTE examination to delineatethe cause of hemodynamic insta-bility was originally proposed forthe emergency room and neona-tal intensive care unit settings andis meant to be complementary tocomprehensive ,2 However, the principalgoal of a Basic PTE examinationis intraoperative this may encompassa broad range of anatomic imag-ing, the intent of noninvasivemonitoring should focus on car-diac causes of hemodynamic orventilatory instability, includingventricular size and function,valvular anatomy and function,volume status.

6 Pericardial abnor-malities and complications frominvasive procedures, as well asthe clinical impact or etiology ofpulmonary dysfunction. The ba-sic PTE examination isnotde-signed to prepare practitionerstouse thefull diagnostic potentialof Transesophageal echocardiog-raphy (TEE). Therefore, a basicPTE practitioner should beprepared to request consultationwithanadvancedPTEpractitione ron issues outside the scope ofpractice as defined within theseguidelines. Echocardiographic as-sessments that influence the surgi-cal plan are specifically excludedfromthisconsensusstatement,be-ca use their acquisition requires anadvanced PTE skill purposes of the currentdocument are1.

7 To review concisely the history ofbasic PTE certification,2. to define the prerequisite 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 examination , and6. to define maintenance of competence and quality was introduced to cardiac operating rooms in the early guidelines have been written that further expand on its utilityto facilitate surgical decision idea of distinguishingbasic PTE skills was incorporated into the American society ofAnesthesiologists (ASA)

8 And SCA practice guidelines forperioperative TEE, published in 2002, training guidelines inperioperative Echocardiography that include specific case number rec-ommendations for training in Basic and advanced PTE echocardiogra-phy were endorsed by the ASE and the evolution of theperioperative echocardiographic guidelines is summarized inTable National Board of Echocardiography (NBE) was created in1998 as a collaborative effort between the ASE and the SCA. Themission of the NBE is to improve the quality of cardiovascular patientcare by developing and administering examinations leading to certifi-cation of licensed physicians with special knowledge and expertise inechocardiography, which is accomplished by1.

9 Overseeing the development and administration of the Adult Special Com-petency in Echocardiography examination , the Advanced PerioperativeTEE examination (PTEeXAM), and the Basic PTEeXAM;2. recognizing physicians who successfully complete the examinations astes-tamurs; and3. certifying physicians who have fulfilled training and/or experience require-ments in Echocardiography asdiplomatesof the 2006, the ASA House of Delegates approved the developmentand implementation of a program focused on Basic echocardiographyeducation. In 2009, a memorandum of understanding between theNBE and the ASA established a strategic partnership to mutually pro-mote an examination and certification process in Basic PTE echocar-diography.

10 Specifically, the Basic PTE scope of practice was defined asthelimited applicationof a Basic PTE examination to non-diagnos-tic monitoring within the customary practice of anesthesiology. Because thegoal of, and training in, Basic PTE Echocardiography is focused on intraoper-ative monitoring rather than specific diagnosis, except in emergent situations,diagnoses requiring intraoperative cardiac surgical intervention or post-operative medical/surgical management must be confirmed by an individualwith advanced skills in TEE or by an independent diagnostic technique.