Echocardiography Use i

Multinational Institutional Survey on Patterns of Intraoperative Transesophageal

n Adult Cardiac Surgery

Heather A. Dobbs, MD,* Elliott Bennett-Guerrero, MD,* William White, MPH,*

Stanton K. Shernan, MD, FAHA, FASE,† Alina Nicoara, MD, FASE,* J. Mauricio Del Rio, MD,*

Mark Stafford-Smith, MD, FRCP(C), FASE,* and Madhav Swaminathan, MD, FASE, FAHA*

Objectives: To assess institutional patterns of periopera-

tive transesophageal echocardiography (TEE) usage.

Design: The authors hypothesized that TEE is performed

more frequently and comprehensively in academic centers,

mainly by anesthesiologists, and barriers to performing

TEE are due to inadequate resources. A survey was

deployed to selected participants. Collated responses were

assessed for demographic patterns in TEE practice, and 2-

category comparisons were made with Chi-squared

association tests.

Setting: Web-based survey.

Participants: Practitioners in cardiovascular anesthesia/

surgery in 200 institutions.

Interventions: None.

Measurements and Main Results: Surveys were com-

pleted by respondents representing 200 centers in 27 coun-

tries and 1,727 anesthesiologists with a mean annual

institutional volume of 924 cases. Most centers were in the

USA (53%) and were defined as academic (83%). Anesthesi-

ologists performed (85%) and also read/reported TEEs (78%)

From the *Division of Cardiothoracic Anesthesiology and CriticalCare Medicine, Department of Anesthesiology, Duke University Med-ical Center, Durham, NC; and †Department of Anesthesiology andPerioperative Pain Medicine, Brigham and Women’s Hospital, Har-vard Medical School, Boston, MA.

Address reprint requests to Madhav Swaminathan, MD, FASE,FAHA, Duke University Medical Center, Department of Anesthesiol-ogy, Box 3094, Erwin Road, Durham, NC 27710. E-mail: madhav.swaminathan@duke.edu© 2014 Elsevier Inc. All rights reserved.1053-0770/2601-0001$36.00/0http://dx.doi.org/10.1053/j.jvca.2013.09.014

54 Journal of Cardiothora

in most centers. Three-dimensional TEE is performed rou-

tinely at 40% of centers. TEE is used routinely for valve

surgery in 95% of institutions compared to 68% for coronary

artery bypass graft surgery. Academic institutions assessed

diastolic function more often than nonacademic centers

(46% v 19%; p ¼ 0.006). The most important reason cited

for not using TEE in all cases was insufficient resource

availability (47%).

Conclusions: These results suggest that TEE is performed

more comprehensively in academic centers, mainly by

anesthesiologists, and that lack of resources is a significant

barrier to routine TEE usage. TEE is used more often for

valve surgery than for coronary artery bypass graft surgery,

and many centers use 3D TEE. This survey describes interna-

tional TEE practice patterns and identifies limitations to

universal adoption of TEE in cardiac surgery.

& 2014 Elsevier Inc. All rights reserved.

KEY WORDS: survey, echocardiography, transesophageal,clinical practice patterns, international

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)has become an integral part of the management of adult

cardiac surgical patients in many practice settings worldwideand has been shown to impact surgical decision-making andpatient management.1,2 Since the first descriptions of the usageof intraoperative TEE in the early 1980s, the field has grownsignificantly and continues to see new technologies andapplications such as real-time 3-dimensional TEE (3D TEE).In the cardiac surgical operating room, it is used to assess bothnecessity and quality of surgical interventions, guide fluid andinotrope selection, and provide a comprehensive evaluation ofcardiac structure and function. Since its introduction, it hasbecome standard of care in many institutions throughout theworld where cardiac surgery is performed. However, little isknown about the global patterns of institutional usage of TEE.

Previous surveys on TEE usage have focused only on academiccenters in North America, or assessed TEE usage patterns forspecific surgery types only.3–6 The authors sought to betterunderstand the institutional TEE usage patterns for all cardiacsurgeries at a more global level. They, therefore, conducted a

survey to better define the global practice of TEE, including (a)determining who performs TEE, (b) describing how and whenthey conduct TEE procedures, and (c) identifying barriers that limita more universal adoption of intraoperative TEE in their practice.The authors hypothesized that intraoperative TEE in adult cardiacsurgery is performed more frequently and comprehensively inacademic centers, mainly by anesthesiologists, and that barriers toperforming TEE for all cases are primarily due to lack of resources.

METHODS

Survey Development

A 31-question survey was created by a team of anesthesiologistscertified in perioperative TEE (HAD, EBG, WW, SKS, AN, JDR,MSS, MS). The survey consisted of multiple-choice and fill-in-the-blank questions (Appendix 1).

Objective (a): Who Performs TEE?

Demographic questions included identifying which specialty therespondent practiced (anesthesia, surgery, cardiology, critical care, orother), where the institution was located (country and state or provinceif in the United States or Canada), and an option to enter the name ofthe institution where the respondent practices. Questions focusing oninstitutional characteristics assessed the presence of academic trainingprograms in cardiothoracic surgery, cardiothoracic anesthesia, cardiol-ogy, or critical care and the number of surgeons and anesthesiologistsproviding care for patients undergoing cardiac surgery. These questionsalso assessed how many anesthesiologists had formal post-residencytraining in cardiac anesthesia, passed the Examination of SpecialCompetence in Advanced Perioperative TEE conducted by the NationalBoard of Echocardiography (NBE), and received the AdvancedPerioperative TEE Certification by the NBE. The survey then assessedthe annual institutional case volume for each type of adult cardiacsurgical case, including coronary artery bypass graft surgery (CABG),mitral or aortic valve surgery, aortic surgery, heart or lung trans-plantation, assist devices, adult congenital, combinations thereof, and

cic and Vascular Anesthesia, Vol 28, No 1 (February), 2014: pp 54–63

Table 1. Demographics of Respondents by Country

Country of Respondent Count Percent

1 Argentina 1 0.5

2 Australia 1 0.5

3 Austria 1 0.5

4 Belgium 4 2.0

5 Brazil 2 1.0

6 Canada 8 4.1

7 China 1 0.5

8 Colombia 3 1.5

9 Czech Republic 3 1.5

10 Denmark 1 0.5

11 France 1 0.5

12 Germany 5 2.6

13 Greece 2 1.0

14 India 29 14.8

15 Israel 1 0.5

16 Italy 5 2.6

17 Kenya 1 0.5

18 Netherlands 3 1.5

19 Romania 1 0.5

20 Saudi Arabia 1 0.5

21 Serbia 1 0.5

22 Singapore 1 0.5

23 South Africa 1 0.5

24 Sweden 1 0.5

25 Switzerland 5 2.6

26 United Kingdom 8 4.1

27 United States 104 53.3

Missing data 5 2.6

Total 200 100.0

Fig 1. Respondents were listed by country and grouped accord-

ing to the six major regions of the world they represented.

SURVEY ON INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY USE 55

other cardiac surgery and assessed how often TEE was utilized forthese cases.

Objective (b): How and When Is TEE performed?

The survey also asked respondents to identify the indications forTEE and how they use TEE during surgery. The respondents wereasked to quantify how often they assessed specific parameters in theirTEE examination, including left and right ventricular function, regionalwall motion abnormalities, chamber size, qualitative and quantitativevalvular function, diastolic function, presence of patent foramen ovale(PFO), presence of left atrial appendage thrombus, aortic atheroma, andaortic dissection. The authors also asked technical questions of how theTEE probe is inserted and if an orogastric tube is used to empty thestomach prior to probe insertion. The survey asked how often specialTEE modalities are utilized, such as epiaortic scanning and 3D TEE.

Objective (c): Logistics and Barriers in TEE Practice

Finally, questions focused on the logistics of the TEE service, suchas storage, archiving, interpretation, reporting, and reimbursement ofTEE studies. Additionally, ownership of TEE equipment also wasassessed. Respondents were asked about barriers that existed to themore universal adoption of TEE practice in all cardiac surgical cases.

Definitions of Variables

An academic center is defined as one that had at least 1 subspecialtytraining program in cardiothoracic surgery, cardiology, cardiothoracicanesthesiology, or critical care medicine. When defining how often acertain TEE parameter is assessed, such as left ventricular ejectionfraction, the authors defined it as routinely if the institution assessed itroutinely or always and as not routinely if they assessed the parameter

sometimes or never. For how TEE is used, such as guiding inotropeselection, the authors defined it as routinely if the respondent answeredthat they use TEE for that indication most of the time or always and asnot routinely if they answered sometimes, rarely, or never. Whendefining how often TEE was used for each type of surgery, the authorsdefined it as routinely when TEE was used more than 50% of the time.

Some of the questions contained branch logic to facilitate the flowof questions. For example, the option for state or province was onlyavailable to those respondents who selected USA or Canada as countryof location of institution.

Survey Distribution

The survey was distributed by email using the Qualtrics web surveyprogram customized for Duke University. The authors followed therecommendations for the conduct of web-based surveys described bythe CHERRIES checklist.7 Prior to distribution, the survey’s function-ality was tested by sending it to a small group of attending physicianswho responded to the survey as various types of potential respondents.The final survey then was sent in September 2012 via email to contactsat 545 institutions with known cardiac surgical programs. Each contactrepresented a single institution. The list of contacts at these institutionsconsisted of investigators who had participated previously in cardiacsurgical research through the Duke Clinical Research Institute andprevious trainees (alumni) from the authors’ institution. The institutionscomprised both academic and nonacademic practice locations. Anemail reminder was sent to non responders after 1 week. The surveywas locked after 2 weeks, and data were submitted for analysis with apriori questions. Personal information was protected by saving thesurvey results to a password-protected server accessible only to keystudy personnel. The survey and its distribution methodology wereapproved by the Duke IRB prior to its deployment.

Statistical Analysis

Most of the analysis comprised descriptive statistics for the surveyresults. Two-category Chi-squared association tests were used to assessstatistical significance between groups. A statistically significantassociation was defined as p o 0.05. All tests were conducted usingthe SAS statistical software package (v9.3, SAS Inc, Cary, NC)

RESULTS

Demographics of Respondents

The survey was opened by 220 of the 545 institutionalcontacts to whom it was distributed. These are hereafter

Fig 2. Average annual case volume in institutions of respondents grouped by academic or nonacademic practice type.

DOBBS ET AL56

referred to as respondents. Of the 220 respondents, the surveywas completed by 187 and almost completed entirely by 13.These 200 surveys that were completed either mostly orentirely were included in the analysis. This represented aresponse rate of 36.7%. The survey responses reflected practicepatterns in 27 countries (Table 1) (Fig 1) among 200institutions, of which 53% were in the US and 83% had atraining program in at least one subspecialty. The averageannual cardiac surgical case volume was 924 (� 742), with amedian case volume of 750 and a maximum of 5,200 cases peryear. The average annual case volume for academic centers was1,006 (� 763) and lower for nonacademic centers at 519(� 457) (Fig 2). Furthermore, CABG surgeries were the mostfrequently performed, with 78% of respondents indicating aninstitutional caseload of more than 150 CABG surgeriesper year. In contrast, adult congenital, heart transplant,lung transplant, and cardiac assist device implantation were

Table 2. Distribution and Frequency of Cardiac Su

Type of Surgery None 1-25 25-50

CABG only 1 5 5

MV repair/replacement 0 19 28

AV repair/replacement 0 16 28

Multi valve surgery 1 45 42

CABG þ valve 1 29 31

Aortic surg on CPB 6 59 39

Adult congenital 25 97 25

Heart transplant 105 43 18

Lung transplant 132 13 16

Cardiac assist devices 56 76 27

Other cardiac surgery 32 81 17

Abbreviations: AV, aortic valve; CABG, coronary artery bypass graft sur

the least common surgery types, with a majority of institu-tions performing r 25 cases for each type of surgery per year(Table 2).

Of the 194 responses received for the specific question onprofession of the respondent, there were 173 anesthesiologists,12 surgeons, 7 cardiologists, 2 intensivists, and 1 anesthesiol-ogist/intensivist (Fig 3). Institutions had an average of 6(� 3.5) cardiac surgeons (adult cases only) and 9 (� 5.8)anesthesiologists providing care for adult cardiac surgery cases(Fig 4). The survey represented the practice patterns of 1,727anesthesiologists, of whom 1,193 (69%) had post-residencysubspecialty training in cardiac anesthesia; 746 (43%) hadpassed the Examination of Special Competence in AdvancedPerioperative TEE conducted by the NBE, and 570 (33%) werecertified in Advanced Perioperative TEE by the NBE. Theaverage institutional response indicated remarkably similarnumbers. Additionally, at 4 institutions, the number of

rgery Case Types in Responding Institutions

Annual caseload frequency

51-100 101-150 151-200 4200

14 14 27 111

45 27 23 34

38 28 33 32

38 16 18 16

32 41 21 21

36 12 8 15

15 7 5 2

10 0 0 0

10 3 1 0

14 2 1 0

13 6 7 13

gery; CPB, cardiopulmonary bypass; MV, mitral valve.

Fig 3. Respondents grouped by profession. A majority of respon-

dents were anesthesiologists. The group “other” mainly represented

intensive care physicians.

SURVEY ON INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY USE 57

anesthesiologists who were fellowship trained was greater thanthe number of practicing cardiac anesthesiologists, which maybe due to having fellowship-trained doctors no longer provid-ing care for cardiac surgery patients.

Conduct of TEE Procedures

While anesthesiologists were responsible for performingTEEs in 85% of institutions, this group also was responsible forreading and reporting TEEs in most centers (78%). In a smallnumber, cardiologists read and reported the TEE findings butdid not perform the TEE exam (6%), (Table 3) (Figs 5A and5B). Three-dimensional TEE was performed routinely at 40%of institutions, occasionally at 32%, and never at 27% of

Fig 4. Average number of personnel by profession in respondent’s ins

who were subspecialty trained and had either passed (testamurs) o

Echocardiography.

institutions. Only 13% perform epiaortic ultrasound routinely,and 28% of institutions never use this modality. The mostcommon indication for TEE was valve surgery in which TEE isused routinely (450% of the time) at 95% of institutions.However, only 67% use TEE routinely for CABG (Fig 6).Most centers use TEE for evaluating surgical results (95%)and guiding surgical decision-making (94%) but less often toguide inotrope selection (50%) (Figs 7 and 8). Compared tononacademic centers, academic institutions were more likely touse TEE to guide device placement, such as venous cannulae orintra-aortic balloon pumps (62.4% v 41.9%; p ¼ 0.04), andperform TEE exams that routinely include the assessment ofdiastolic function (46% v 19%; p¼ 0.006), aortic dissection (72%v 52%, p ¼ 0.033), and valve pathology (83% v 68%; p 0.04).

When placing the TEE probes, the stomach routinely isemptied with an orogastric tube prior to probe insertion at 49%of institutions. The probe is placed blindly (like an orogastrictube) at 44% of sites, always placed with the assistance ofdirect laryngoscopy at 6% of institutions, and with laryngos-copy if blind insertion fails at 48% of institutions.

TEE Archiving, Reporting and Billing (Table 4)

Most institutions (156 of the 168 respondents; 93%) storetheir TEE images. Of these, 68% store their images digitallyover a network, 24% store their images on a local or portablehard drive, and 7% store them on a DVD or optical disc. Amajority of institutions (150/182; 82%) generate a report for theTEE examination. Of these, the report is described as compre-hensive at 68% of institutions and limited to pertinent data at31% of sites. The reports generated were either electronic,digital, or web based (45%), or paper reports (49%). Only 57%of institutions bill for their TEE examinations (5% of respond-ents indicated they did not know which entity submitted a bill

titution. Also indicated are the average number of anesthesiologists

r were certified in Advanced TEE by the U.S. National Board of

Table 3. Distribution of Personnel Who Read and/or Perform

TEE Exams

Person reading TEE

Person performing TEE Anesthesiologist Cardiologist Other Total

Anesthesiologist 142 11 1 154

Cardiologist 1 25 0 26

Other 0 0 1 1

Total 143 36 2 181

Abbreviation: TEE, transesophageal echocardiography.

DOBBS ET AL58

for TEE), with the anesthesia department billing at 65% ofthose, the cardiology department billing at 12%, and thehospital submitting the bill at 11% of institutions (3% indicatedthey did not know).

Barriers to the Use of TEE

The inadequate availability of machines or personnel werecited most often as the most important reasons for notperforming TEE on all cardiac cases (37% and 10%, respec-tively, among 97 respondents). The potential risk of injury was

Fig 5. Percentage of respondents who indicated the person

responsible for performing TEE exams at their institution (A) and

person responsible for reading/reporting TEE exams (B) grouped by

profession.

noted most frequently as the least important reason for notusing TEE (26%). Interestingly, 21% of the respondents feltthat the most important reason for not performing TEE in allcases was because it was not indicated in all cases, while 17%of respondents felt it was the least important reason.

DISCUSSION

The authors confirmed their hypotheses that intraoperativeTEE in adult cardiac surgery is performed more comprehen-sively in academic centers, mainly by anesthesiologists, andthat barriers to performing TEE for all cases are due primarilyto lack of TEE equipment. To the best of the authors’knowledge, this is the first report to examine intraoperativeTEE usage patterns at a multinational level. The authors’survey highlights the universal acceptance of TEE as animportant diagnostic and monitoring tool for the intraoperativemanagement of cardiac surgical patients in the 27 countriessurveyed. Furthermore, TEE is not only being used as amonitor to assess volume status and global biventricularfunction, but is also being used as an intraoperative tool toguide surgical management, such as guiding the decision torepair or replace a dysfunctional valve. Although the authorswere unable to confirm that academic centers perform TEEmore frequently than nonacademic centers (Fig 6), they didconfirm their hypothesis that academic centers perform morecomprehensive exams, as evidenced by the more frequent useof TEE to guide device placement, check for aortic dissections,assess diastolic function, and quantify valvular abnormalities.

Practice patterns in echocardiography have been studiedpreviously, although these have been limited mainly to trans-thoracic echocardiography8 and TEE use limited to NorthAmerican centers3–5 or specific indications such as liver trans-plant or pediatric cardiac surgery.6,9 Poterack first describedintraoperative TEE usage patterns in 1995 when he surveyedprogram directors at US anesthesiology training programs.3

However, this survey only looked at TEE use in academiccenters and had a smaller number of responses compared to theauthors’ survey (108 v 200 surveys). In addition, the authors’results suggest that TEE use has expanded since this survey.While Poterack reported that TEE was used consistently only forvalve surgery at about 50% of institutions, the authors’ findingwas that 95% of institutions regularly use TEE for valve surgery.Another important change in practice observed between these 2surveys pertained to the use of TEE for CABG surgery. WhilePoterack’s survey found that only about 20% consistently usedTEE for CABG, this was in contrast to the authors’ finding that68% of institutions now regularly use TEE for CABG.

A large survey from Sukernik et al in 2005 focused on TEEusage during CABG surgery and how TEE findings of PFOaffected surgical management.4 Their survey had 438 respond-ents who were all cardiac surgeons, which was a larger anddifferent demographic compared to the authors’ survey, whichwas comprised mostly of anesthesiologists. Sukernik andcolleagues found a significant difference in frequency of TEEuse for CABG surgery between academic and nonacademicinstitutions (67% v 32%). In contrast, the authors did not findas much disparity, with academic and nonacademic institu-tions routinely performing TEE 69% and 61% of the time,

Fig 6. Percentage of cases in which TEE is used routinely (more than 50% of the time) in academic and nonacademic centers grouped by type

of surgery.

SURVEY ON INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY USE 59

respectively, for CABG surgery. This may represent a shifttoward more universal use of TEE for cardiac surgical casesregardless of the training status of the institution.

Practitioners in most centers introduce the TEE probe blindly(unassisted) or with laryngoscope assistance following anunsuccessful blind insertion attempt. Few sites use a laryngo-scope routinely, and only half of the respondents indicated thatthe stomach was decompressed routinely with an orogastric tubeprior to TEE probe insertion. The use of laryngoscopy hasbeen suggested to reduce risk of oropharyngeal trauma in

Fig 7. Percentage of respondents indicating how TEE is used at thei

some studies including 1 randomized trial.10 However, theuse of routine gastric decompression prior to probe insertionhas not been shown to conclusively enhance image quality.11

The authors’ results may reflect institutional practice bias withregard to gastric decompression, but most centers indicate thatTEE probe insertion with laryngoscope assistance is reason-able. They did not specifically address those who respondedthat they perform unassisted probe insertion with a furtherquestion as to what they would do should the blind insertionfail.

r institution. Academic and nonacademic status also is indicated.

Fig 8. Responses to questions on how TEE is used for specific echocardiographic parameters grouped by academic status of respondent’s

institution. Asterisk indicates significant difference between academic and nonacademic practices.

DOBBS ET AL60

The authors also found that about 63% (746/1,193) of specialty-trained anesthesiologists (majority in North America) had passedthe advanced TEE examination conducted by the US NBE. Thisrepresented a significant increase from previous surveys thatreported a lower fraction of similarly qualified anesthesiologists,20% in Poterack’s 1995 survey3 and 54% in a Canadian survey byLambert et al.5 This likely represents a gradual increase in thenumber of physicians who have passed the exam over the years.

The authors found that anesthesiologists were the predom-inant providers of TEE services in most institutions (154/181;

Table 4. Logistics of TEE A

R

Are TEE images archived? (n ¼ 200) Yes

No

No response

If yes, how are images stored? (n ¼ 156) Digital (porta

Digital (netw

Digital (optic

Video tape

Other

Is a TEE report generated? (n ¼ 200) Yes

No

No response

In what form is the TEE reported? (n ¼ 150) Paper report

Electronic/Di

Audiotape

Other

Description of TEE report (n ¼ 150) Comprehens

Limited (pert

No response

Abbreviation: TEE, transesophageal echocardiography.

85%). In a survey of 124 members of the cardiovascularsection of the Canadian Society of Anesthesiologists, Lambertet al reported that from 60 respondents, TEE services wereprovided by both anesthesiologists and cardiologists in amajority of centers (52%), while anesthesiologists exclusivelyprovided this service in 35% of institutions.5 This is despitethe fact that the Canadian survey was distributed exclusively toanesthesiologists, while the authors’ survey was sent toanesthesiologists, surgeons, cardiologists, and research coor-dinators. This difference may reflect differences in practice

rchiving and Reporting

esponse Number Percentage

156 78%

12 6%

32 16%

ble hard drive) 37 24%

ork) 106 68%

al/DVD disc) 11 7%

1 o1%

1 o1%

150 75%

32 16%

18 9%

73 49%

gital 68 45%

1 o1%

8 5%

ive (all findings) 102 68%

inent findings only) 47 31%

1 o1%

3.

SURVEY ON INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY USE 61

patterns since the Canadian survey and/or a shift in responsi-bility for intraoperative TEE services to anesthesia providersas training and education in TEE become more widespreadamong anesthesiologists.

The barriers the authors identified to the universal adoptionof TEE for all cardiac surgical cases were not surprising. Thelack of resources (equipment/probes/training) often is cited asan explanation. While there is insufficient evidence relating tobarriers to the practice of echocardiography, the lack ofexpertise or training has been cited in some studies thatdescribe training in ultrasound.12 Interestingly, safety of TEEwas not a significant concern among the authors’ respondents.This likely reflects a universal agreement with existing liter-ature on the safety of TEE.13

Limitations

The authors’ survey is strengthened by the response rateacross several countries that represented practice patterns of alarge cohort of intraoperative echocardiographers. However, thesurvey also has some limitations mainly related to surveydeployment and response demographics. The survey resultsmay not be generalizable due to selection bias. Although thesurvey was distributed to centers that represented both academicand nonacademic institutions, the responses were weightedheavily toward respondents from academic institutions. Simi-larly, the results do not reflect practice across the world.Although the authors had a broad range of countries representedin their sample, there was a large proportion of respondents fromthe United States. Another limitation relates to the highpercentage of anesthesiologists indicated in the survey as theprimary intraoperative echocardiographers. Therefore, institu-tions where cardiologists or other non-anesthesiologists are theresponsible echocardiographers in the operating room are under-represented. This also may reflect the fact that a majority ofrespondents were from academic centers where anesthesiologistsmay, indeed, be the primary intraoperative echocardiographers.Nevertheless, the authors are confident that this survey providesvaluable information on practice patterns in intraoperative TEEin several countries, especially in academic institutions.

Summary

The authors report their results of a multinational surveyevaluating institutional TEE usage patterns. Their findings suggestthat intraoperative TEE is being performed routinely in mostinstitutions during cardiac surgery, mainly by anesthesiologists,more comprehensively in academic centers, and that lack ofequipment or trained personnel are significant barriers to routineTEE usage in cardiac surgery. TEE is used more often for valvesurgery than for CABG and for surgical evaluation and decision-making than inotrope selection. It also is being used more oftenthan in previously-described studies, especially for CABG sur-gery, and by more qualified personnel. Notably, many centers arenow using 3D TEE, a relatively recent advance in TEE imaging.Although limited by potential for selection bias towards academicinstitutions and anesthesiologists, this survey helps the authorsunderstand international TEE practice patterns and identifieslimitations to the universal adoption of TEE in cardiac surgery.

APPENDIX 1. SURVEY QUESTIONS

1.

Please enter the name of your INSTITUTION (optional). 2. I am a/an

a. Anesthesiologistb. Surgeonc. Cardiologistd. Intensiviste. Other (please specify)

In which of the following sub-specialties does yourinstitution have a PHYSICIAN training program? (Pleasecheck all that apply)a. Cardiothoracic Surgeryb. Cardiothoracic Anesthesiac. Cardiologyd. Critical Caree. None of the above

4.

Which country is your institution located in? 5. Which state is your institution located in? (If answer to #4

is USA)

6. Which province is your institution located in? (If answer

to# 4 is Canada)

7. How many attending surgeons perform ADULT cardiac

surgery at this institution?

8. How many anesthesiologists (post-training) in your group/

department provide care to patients undergoing cardiacsurgery (cardiac anesthesiologists)?

9.

How many cardiac anesthesiologists in your group havecompleted formal training in cardiac anesthesia either aspart of a fellowship or a dedicated post-residency trainingprogram?

10.

How many cardiac anesthesiologists have PASSED the Examof Competency in Advanced Perioperative TEE conducted bythe National Board of Echocardiography, USA?

11.

How many cardiac anesthesiologists have been CERTI-FIED in Advanced Perioperative TEE conducted by theNational Board of Echocardiography, USA?

12.

Approximately how many total ADULT heart surgeriesdoes your institution perform (CABG, OPCABS, Valves,Redos, etc.) per year?

13.

Approximately how many of each type of surgery areperformed at your institution annually? (choose from:None, 1-25, 26-50, 51-100, 101-150, 151-200, 4200)a. CABG (All isolated CABG cases)b. Mitral valve repair/replacementc. Aortic valve repair/replacement (not including TAVR)d. Multi valve surgerye. CABG þ valve surgeryf. Aortic surgery (using cardiopulmonary bypass)g. Adult congenitalh. Heart Transplanti. Lung Transplantj. Cardiac assist devicesk. Other cardiac surgery

14.

Do you perform three-dimensional (3D) TEE? (choosefrom: never, occasionally, very often or always)

15.

Do you perform epiaortic scanning? (choose from: never,occasionally, very often or always)

DOBBS ET AL62

16.

18.

19.

20.

Do you empty the stomach (with an orogastric tube) priorto TEE probe placement? (choose from: never, occasion-ally, very often or always)

17.

How do you routinely insert the TEE probe?a. Blind insertion technique (similar to orogastric tube

placement)b. Use laryngoscope if blind insertion failsc. Use a laryngoscope alwaysd. Other

How often (percent) is TEE used in the followingsurgeries? (choose from: Not applicable/ Surgery notperformed, Never, 1-25%, 25-50%, 51-75%, 475%, butnot all cases, and 100% (always))a. Isolated CABGb. Any valve surgery (þ/- CABG)c. Aortic surgery (using cardiopulmonary bypass)d. Heart transplante. Lung transplantf. Liver transplantg. Adult congenitalh. Cardiac assist devices If TEE is NOT used routinely at your institution in allcardiac surgery cases, which of the following apply inorder of importance (1¼ MOST important, 5¼ LEASTimportant reason)?a. Not enough machines availableb. Not enough trained personnelc. Not requested by surgeon in all casesd. TEE is not indicated in all casese. Risk of injury outweighs benefit of routine use Please answer the following question considering how TEEis used at your institution. How often is TEE used for thefollowing? (choose from: Never, Rarely, Sometimes, Mostof the Time, and Always)a. To guide drug therapy (e.g. inotrope selection)b. To assist with device placement (e.g. IABP, venous

cannulae)c. To evaluate valve pathology to guide surgical manage-

ment (e.g. repair vs.replacement)

d. Post bypass to assess surgical results (e.g. paravalvularleaks, aortic dissection)

e. Post bypass to assess new abnormalities (e.g. wallmotion defects)

f. Other (please specify)

21. Please answer the following questions about what is

included while performing a TEEexam at your institution.Is TEE used to ASSESS the following parameters? (chosefrom:Never, Sometimes or only when indicated, or Rou-tinely or always)a. Left Ventricular Function (Ejection Fraction)b. Left Ventricular segmental wall motion abnormalitiesc. Right Ventricular Functiond. Chamber size (e.g. atrial or ventricular enlargement)e. Valvular functionf. Quantification of valve pathologyg. LV Diastolic functionh. Presence of patent foramen ovale

i. LA appendage thrombusj. Aortic atheromak. Aortic dissection

22.

Do you store echo images? (yes or no) 23. How are these images stored? (if answer to #22 was

“yes”)a. Digital over a networkb. Digital on local/portable hard drivec. Optical/DVD discd. Video tapee. Other

24.

Do you report the TEE findings in the patient’s medicalrecord? (yes or no)

25.

Is the report (if answer to #24 was “yes”)a. Electronic/web-based/digitalb. Audiotapec. Paper reportd. Other

26.

What best describes the TEE report at your institution?a. Comprehensive. Includes all findings and all aspects of

the exam.b. Limited. Includes only pertinent positive or negative

findings.

27. Who owns the TEE equipment?

a. Anesthesiologyb. Cardiologyc. Surgeryd. Intensive caree. Hospitalf. Don’t knowg. Other

28.

Who is primarily responsible for PERFORMING the TEE?a. Anesthesiologistb. Cardiologistc. Surgeond. Intensiviste. Nurse Anesthetistf. Sonographer/Technologistg. Other

29.

Who is primarily responsible for INTERPRETING ANDREPORTING the TEE?a. Anesthesiologistb. Cardiologistc. Surgeond. Intensiviste. Nurse anesthetistf. Sonographer/Technologistg. Other

30.

Is there a bill for the TEE exam? (choose from: Yes, No, orDon’t know)

31.

Who bills or charges for the TEE exam?a. Anesthesiologyb. Cardiologyc. Surgeryd. Intensive caree. Hospitalf. Don’t knowg. Other

SURVEY ON INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY USE 63

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