GUIDELINES AND INDICATIONS

In 1996, a joint task force of the American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA) published guidelines for perioperative TEE in which two levels of practice (basic and advanced) were defined. ^[6] Anesthesiologists with basic training in perioperative TEE "should be able to use TEE for indications that lie within the customary practice of anesthesiology" and "must be able to recognize their limitations in this setting and request assistance, in a timely manner, from a physician with advanced training." Anesthesiologists with advanced training in perioperative TEE "should, in addition to the above, be able to exploit the full diagnostic potential of TEE in the perioperative period." These guidelines defined the general principles for training in perioperative TEE, including cognitive and technical objectives. In addition, the guidelines delineate three categories of evidence-based indications for TEE, including category I indications, for which TEE was judged to be frequently useful in improving clinical outcomes in the setting of hemodynamic instability, valvular pathology, cardiac source of emboli, and aortic pathology ( Table 33-1 ). These indications were based on available data in 1995 when the task force wrote the guidelines. With the additional studies published on TEE since then, the number of category I indications would almost certainly increase should the task force revise the guidelines.

In 1999, a joint task force of the ASE and SCA published guidelines for a comprehensive TEE examination.^[7] This examination will be presented in detail in a subsequent section of this chapter.

In 2002, a joint task force of the ASE and SCA published guidelines for training in perioperative TEE, including the prerequisite medical knowledge and training, echocardiographic knowledge and skills ( Table 33-2 ), training components and duration, training environment and supervision, and equivalence requirements for postgraduate physicians already in practice.^{[8] [9]} Minimum numbers of cases are delineated ( Table 33-3 ); however, these numbers are less important than the depth and diversity of the clinical experience and the quality of training. Like previous published guidelines, these guidelines provide training recommendations for a basic level and an advanced level of perioperative echocardiography. Unlike previous guidelines, these guidelines do not specify the duration of training. Instead, they emphasize the goals of training and the number and diversity of cases required to meet these goals. The time required for perioperative training will vary markedly and depends on the volume and diversity of the affiliated cardiac surgical program.