Comparative Effectiveness and Harms of Intraoperative Transesophageal Echocardiography in Noncardiac Surgery: A Systematic Review

Abstract

Intraoperative use of transesophageal echocardiography (TEE) has become commonplace in high-risk noncardiac surgeries but the balance of benefits and harms remains unclear. This systematic review investigated the comparative effectiveness and harms of intraoperative TEE in noncardiac surgery. We searched Ovid MEDLINE, PubMed, EMBASE, and the Cochrane Library from 1946 to March 2017. Two reviewers independently screened the literature for eligibility. Studies were assessed for the risk of selection bias, confounding, measurement bias, and reporting bias. Three comparative and 13 noncomparative studies were included. Intraoperative TEE was employed in a total of 1912 of 3837 patients. Studies had important design limitations. Data were not amenable to quantitative synthesis due to clinical and methodological diversity. Reported incidence of TEE complications ranged from 0% to 1.7% in patients undergoing various procedures (5 studies, 540 patients). No serious adverse events were observed for mixed surgeries (2 studies, 197 patients). Changes in surgical or medical management attributable to the use of TEE were noted in 17% to 81% of patients (7 studies, 558 patients). The only randomized trial of intraoperative TEE was grossly underpowered to detect meaningful differences in 30-day postoperative outcomes. There is lack of high-quality evidence of effectiveness and harms of intraoperative TEE in the management of non-cardiac surgeries. Evidence, however, indicates timely evaluation of cardiac function and structure, and hemodynamics. Future studies should be comparative evaluating confounder-adjusted impact on both intraoperative and 30-day postoperative clinical outcomes.

Bleeding Complications from Transesophageal Echocardiography for Liver Transplantation: A Systematic Review

“…8,[24][25][26] Although on the higher end of this range, it may still be acceptable when the TEE provides valuable information, particularly when considering the combined major bleeding complication rate was lower at .16%. 9,21 It is notable that most of the significant bleeds had identifiable high-risk features including a history of sclerotherapy, ruptured esophageal varices within the year prior to transplant, and variceal banding the day prior to surgery. Based on their analysis, Bui et al 19 concluded that active GI bleeding and recent esophageal banding should be contraindications to TEE.…”

“…7,8 A recent systematic review found an incidence of complications from TEE of 0% to 1.7% in 5 studies of 540 patients undergoing noncardiac surgery. 9 Historically, TEE for liver transplant has been avoided due to the perceived risk of bleeding from esophageal varices. However, several recent studies, as well as increasing clinical experience, have indicated that TEE may be performed safely in many circumstances.…”

“…7,8 A recent systematic review found an incidence of complications from TEE of 0% to 1.7% in 5 studies of 540 patients undergoing noncardiac surgery. 9…”

Perioperative applications of focused cardiac ultrasound

“…31 Despite its value, recent studies have questioned the evidence when assessing the effectiveness versus potential harms of TEE. 32 With the recent discussion of harms associated with rescue TEE, the discussion of applicability of TTE based FOCUS examination in the OR becomes relevant. A recent systematic review on intraoperative FOCUS found a high percentage of adequate image acquisition, and supported FOCUS as a method to differentiate causes of intraoperative hypotension and guide correcting interventions.…”

An Update in Abdominal Organ Transplantation Anesthesia in 2018: Society for the Advancement of Transplant Anesthesia (SATA)

“…Fayad and colleagues systematically review the risk and benefits of intraoperative TEE in noncardiac surgery reported from 1946 to March 2017. 3 They synthesize the existing evidence to defend the use of TEE during noncardiac surgery. Zerillo and colleagues expand on previous observations reported by Fayad et al in an original study that characterizes the current use, training, and attitudes toward TEE by liver transplant anesthesiologists in the United States.…”