Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room

Publication Date: June 1, 2020
Last Updated: March 14, 2022

Key Points

Key points for the pre- and postprocedure assessment for intracorporeal LVAD placement

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 A complete pre-implantation examination should be performed in order to rule out hemodynamically significant valvular lesions, intracardiac shunts and thrombus, and evaluate baseline RV function.
 Evaluation of TR should include assessment of the tricuspid annulus, tricuspid leaflet tethering, RA and RV size, and position and motion of IAS and IVS during the cardiac cycle.
 Aortic regurgitation is likely to progress after LVAD implantation and to impair adequate systemic forward flow. It can be easily underestimated in patients with advanced heart failure. Re-evaluation of AR should be performed after institution of CPB, which may mimic the hemodynamic conditions during LVAD support.
 RV function should be evaluated by integrating several echocardiographic parameters.
 The same elements of the pre-implantation examination should be re-evaluated in the post-implantation period: intracardiac shunts, degree of TR, degree of AR, and RV function.
 The position of the IAS and IVS and the relative size of the LV and RV provide information regarding causes of decreased LVAD flow.
 Leftward shift of the IAS and IVS, decreased LV size, RV dilation and dysfunction indicate decreased preload to the LVAD due to RV failure.
 Decreased LV and RV size indicate decreased LVAD preload in the setting of hypovolemia or extrinsic compression.
 Position and flow by CFD and spectral Doppler should be evaluated and documented for both the inflow cannula and the outflow graft as outlined in the text.
Abbreviations: AR, Aortic regurgitation; CFD, color flow Doppler; CPB, cardiopulmonary bypass; IAS, interatrial septum; IVS, interventricular septum; LVAD, left ventricular assist device; RA, right atrium; RV, right ventricle; TR, tricuspid regurgitation.

Key points for imaging in patients undergoing total artificial heart placement

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 Examine left and right atria as well as the LAA and exclude the presence of thrombus.
 Examine left and right pulmonary veins and document size and pulmonary vein flow (flow profile and velocities by PW Doppler).
 Inspect RA-SVC and RA-IVC junctions for the presence of medical devices, thrombus, stenosis.
 Monitor for the presence of air in the native atria, and in the main PA and ascending aorta.
 Re-evaluate size of the atria and pulmonary vein flow (flow profile and velocities) to rule out torsion or extrinsic compression.
 Obstruction of PV flow should be suspected if there is loss of phasic systolic and diastolic flow patterns, CFD flow acceleration is detected, and peak velocities are increased above normal or baseline values.
 Mean gradients and the corresponding ventricular rate should be recorded for the tricuspid and mitral prostheses in order to serve as a reference for subsequent examinations.
Abbreviations: CFD, Color flow Doppler; IVC, inferior vena cava, LAA, left atrial appendage; PA, pulmonary artery; PV, pulmonary vein; RA, right atrium.

Key points for imaging during intra-aortic balloon pump placement

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 Exclude the presence of moderate or severe aortic regurgitation
 Examine the presence of mobile atheromatous disease
 Note the presence of the tip of the intra-aortic balloon pump 1-2 cm below the distal aortic arch (left subclavian artery)
 Balloon inflation during diastole will generate characteristic acoustic shadowing and reverberation artifacts

Key points for intraoperative imaging in patients undergoing resection of intracardiac masses

 Evaluate location, size, type of attachment
 Evaluate effect on neighboring structures and associated findings (e.g., pericardial effusion)
 Evaluate malignant vs. benign features as outlined in the text
 Evaluate extent of resection
 Exclude iatrogenic damage that may have occurred to neighboring structures during resection
 Perform a complete examination following resection in order to uncover pathologies that may have been obscured by the presence of the tumor/mass

Recommendation Grading




Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room

Authoring Organizations

Publication Month/Year

June 1, 2020

Last Updated Month/Year

July 10, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Physician, nurse, nurse practitioner, physician assistant



Diseases/Conditions (MeSH)

D017548 - Echocardiography, Transesophageal


cardiac surgery, Transesophageal echocardiography, intraoperative, Transesophageal

Source Citation

Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, Mankad S, Nyman CB, Pagani F, Porter TR, Rehfeldt K, Stone M, Taylor B, Vegas A, Zimmerman KG, Zoghbi WA, Swaminathan M. Guidelines for the Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room: A Surgery-Based Approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr. 2020 Jun;33(6):692-734. doi: 10.1016/j.echo.2020.03.002. Erratum in: J Am Soc Echocardiogr. 2020 Nov;33(11):1426. PMID: 32503709.

Supplemental Methodology Resources

Data Supplement