Review Article

Transesophageal Echocardiography During Orthotopic Liver Transplantation: Maximizing Information Without the Distraction

Evidence-Based Effect of TEE on Anesthetic Management During OLT

TEE provides real-time visual information regarding dynamic function, volume status, overall contractility, regional wall motion, embolization of large vessels, and pericardial effusion. Several quantitative hemodynamic measurements can be obtained with TEE, including pulmonary artery (PA) pressure, cardiac output, and left atrial pressure. Because chamber pressures may be influenced by factors such as intermittent positive-pressure ventilation, pulmonary hypertension, valvular dysfunction, and

TEE Utilization and Limitations During OLT

TEE usage among liver transplantation centers is extremely variable. Wax et al²² surveyed 40 high-volume liver transplantation centers in the United States to evaluate TEE utilization. Among 217 anesthesiologists, 86% performed TEE in some or all OLT cases, with most performing a limited-scope examination. Of TEE users, 12% were board certified to perform TEE. In addition, only 1 center reported having a policy pertaining to TEE credentialing requirements. Schumann²³ also conducted a survey of

Training and Proficiency

Despite the widespread availability of TEE equipment in US hospitals, <30% of anesthesiologists are formally trained in TEE techniques.¹⁰ Specific guidelines for training and certification in both basic and advanced perioperative echocardiography have been developed by the ASE/SCA in partnership with the National Board of Echocardiography. The scope of practice for basic perioperative TEE certification is focused on intraoperative monitoring rather than specific diagnosis, except in emergent

Preoperative Evaluation and TEE Safety

Morbidity from TEE insertion and manipulation ranges from lip and dental injury (13%) to mortality (0.2%).27, 28 Studies have reported that the overall odds ratio for dysphagia is 7.8 times greater for patients in whom TEE was performed and is associated with increased incidence of aspiration and length of intensive care unit stay.29, 30 Hypopharyngeal or esophageal perforation occurs infrequently (0.4%), but is associated with a high mortality rate.³¹ Diagnosis of TEE-associated esophageal

Preoperative TEE Assessment of Ventricular Function and Volume Status

A comprehensive TEE examination is important for baseline assessment and monitoring trends of both volume status and ventricular function as the procedure evolves. The authors refer to the 20 standard TEE views and standard probe manipulation set forth in the ASE/SCA guidelines (Fig 1).⁹ To obtain maximum information from this paper, the reader is encouraged to refer to these guidelines and other TEE-based references.

In the authors' experience, the most common hemodynamic changes during OLT are

TEE Examination and Surgical Phases of OLT

As previously mentioned, initial TEE examination should include documentation of the left ventricular function in all 16 segments as outlined in the ASE/SCA guidelines. Pathologic findings also may be encountered during the initial examination. For example, pleural effusions are a known complication of portal hypertension, with an estimated frequency of 5% in patients with cirrhotic ascites.⁴² The descending aortic SAX view allows for visualization of left-sided pleural effusions. To visualize

Conclusion

Intraoperative management of liver transplant recipients is challenging and significantly affected by cardiovascular manifestations of ESLD, coexisting cardiovascular disease processes, and acute hemodynamic derangements. Although controversy exists regarding optimal intraoperative monitoring, TEE is a powerful method for assessing hemodynamic alterations, guiding resuscitative and inotropic therapy, and identifying potential complications during OLT. The authors agree that significant data can