2025 AHA科学声明：成人心脏手术术中经食管超声心动图的注意事项

Short-Term Outcomes

Intraoperative TEE use in cardiac surgery has been in creasingly associated with improved outcomes after cardiac surgery. The first study published ${\tt>}25$ years ago demonstrated that intraoperative TEE guidance in mitral valve repair leads to better valve durability and reduces the likelihood of subsequent reoperations. 49 Recent large retrospective studies have associated in traoperative TEE use with reduced mortality in patients

Table 1. Potential Impactful Contributions of Intraoperative TEE in Cardiac Surgery

|Intraoperative TEE provides real-time monitoring during cardiac surgery that| |---| |has the potential to alter, reinforce, or modify the preoperative diagnosis,?| |including examples listed below:| |TEE allows real-time monitoring that facilitates prompt diagnosis and| | treatment in a dynamic and changing environment, including identifying the following: | |Cardiogenic source of hypotension| |New iatrogenic abnormality caused by manipulation of catheters inside| |the heart or other external maneuvers| || | Change in ventricular function and filling/distension in response to inotropes or other medications | | Wall motion abnormalities that may indicate inadequate revascularization, poor myocardial protection, or air embolus to a | |coronary artery| |Removal of intracardiac air| || | TEE provides additional information that may change the operative plan, including the following: | |Presence of aortic calcifications| |Intracardiac thrombus| |New reduced EF or a change in valvular function compared with| |preoperative echocardiographic imaging| |Presence of intraoperative aortic dissection| | TEE guides device placement or catheter placement, including the following: | || |Coronary sinus catheter| |Central line, including PA catheter| |Intra-aortic balloon pump placement| |Venous cannula placement| |Wire placement in true lumen during aortic dissection repair| |Aortic balloon placement and inflation| |Mechanical circulatory device cannula placement| || | TEE allows assessment of procedural success, including the following: Valve repair or replacement gradients, degree and location of residual regurgitation, presence of paravalvular leak, or leaflet immobility Presence of continued flow into an LA appendage after closure Presence of continued flow across septal or ventricular defects after closure Incomplete removal of intracardiac masses | | TEE allows assessment of procedural success, including the following: Valve repair or replacement gradients, degree and location of residual regurgitation, presence of paravalvular leak, or leaflet immobility Presence of continued flow into an LA appendage after closure Presence of continued flow across septal or ventricular defects after closure Incomplete removal of intracardiac masses | || || |TEE can identify the presence of significant pericardial or pleural effusion.|

EF indicates ejection fraction; LA, left atrial; PA, pulmonary artery; and TEE, transesophageal echocardiography.

undergoing CABG, valve surgery, and aortic surgery, par ticularly in intermediate- and high-risk cardiac surgery patients (Figure1). 7,50–55 This association suggests that TEE is a critical component of care that has allowed us to care for increasingly complex patients without com promising quality or outcomes.

For CABG, an analysis of the STS Adult Cardiac Sur gery Database in 1255860 isolated CABG surgeries showed that patients with intraoperative TEE had lower adjusted odds of operative mortality overall (adjusted OR [aOR], 0.95; $\scriptstyle{\mathit{P}}=0.025$ ). 7 The study found that patient risk stratified by STS risk score of low $(<\!4\%)$ , intermediate

$.4\%$ to $8\%$ ), or high $(\textgreater8\%)$ risk of operative mortality was an effect modifier of the relationship between TEE use and mortality. Specifically, TEE was associated with lower odds of mortality in the high-risk group (aOR, 0.89 $[95\%$ CI, 0.83–0.95]) and intermediate-risk group (aOR, 0.93 $[95\%$ CI, 0.87–0.99]) but not in the low-risk group (aOR, 0.99 $[95\%$ CI, 0.94-1.04]; $P_{\mathrm{{interaction}}}{=}0.0147$ ), suggesting that the benefits of TEE may be more apparent in higherrisk patients. A smaller propensity-matched analysis of 17330 patients undergoing CABG similarly found that although intraoperative TEE use was associated with a lower 30-day mortality rate in patients overall $\it{(2.63\%$ versus $3.20\%$ ; OR, 0.81 $[95\%$ CI, 0.71–0.92]; $\scriptstyle P=0.002$ ), there was no mortality benefit in patients undergoing CABG without congestive heart failure ( $1.83\%$ versus $2.15\%$ ; OR, 0.85 $[95\%$ CI, 0.70–1.02]; $\scriptstyle{\mathit{P}}=0.089$ ). 52 In another propensity-matched study of 114871 patients undergoing CABG with and without intraoperative TEE, TEE use was associated with a lower risk of 30-day mortality $(3.7\%$ versus $4.9\%$ ; ${\cal P}{<}0.001$ ), lower incidence of the composite outcome of stroke or 30-day mortality $4.5\%$ versus $5.6\%$ ; ${\cal P}{<}0.001$ ), 50,52 and no difference in hospital length of stay (10.32 days versus 10.52 days; $\it{P}{=}0.26,$ ) or incidence of esophageal perforation $(0.01\%$ versus $0.01\%$ ; $\scriptstyle{\rho=0.63}$ ). 50,53

For cardiac valve and aortic surgery, a propensitymatched analysis of 872936 patients in the STS Adult Cardiac Surgery Database, including 161610 matched pairs, found that intraoperative TEE use was associated with a lower 30-day mortality, $3.81\%$ versus $5.27\%$ (OR, 0.69; ${\cal P}{<}0.001$ ); a lower incidence of stroke or 30-day mortality, $5.56\%$ versus $701\%$ (OR, 0.7; ${\cal P}{<}0.001$ ); and a lower incidence of reoperation or 30-day mortality, $7.18\%$ versus $8.87\%$ (OR, 0.78; ${\cal P}{<}0.00\,1$ ). 55 A study using Medi care claims data of 219238 patients who underwent open cardiac valve surgery found that $85\%$ received TEE examinations. After adjustment for patient, surgical, and hospital factors, the patients receiving a TEE had lower odds of 30-day mortality (aOR, 0.77; ${\cal P}{<}0.001$ ) but no difference in hospital length of stay. 54 To date, the STS cohort study provides the strongest evidence for routine intraoperative TEE use for cardiac valvular surgeries. 55

Intraoperative TEE and Decision-Making

Intraoperative TEE also affects decision-making in the operating room. The STS database study of 1255860 patients undergoing CABG found that TEE use was as sociated with a greater frequency of unplanned valve procedures, $0.49\%$ versus $0.09\%$ , and increased odds of an unplanned valve procedure during an isolated CABG (aOR, 4.98; ${\cal P}{<}0.0001$ ), demonstrating that TEE can iden tify occult valvular pathology and alter the surgical plan. 7 A single-center retrospective study of 12566 patients undergoing open valve surgery found that pre–cardiopul monary bypass (CPB) intraoperative TEE changed the

Table 2. Specific Intraoperative TEE Considerations by Type of Cardiac Surgery

|Surgery /intervention| Preprocedural (or before CPB) evaluation | Immediate postprocedural (or during and after CPB) evaluation | Post-chest closure (if applicable) evaluation | |---|---|---|---| |General concepts| Preprocedural TEE allows immediate confirmation and refinement of the preoperative diagnosis, detection of new or unsuspected pathology, adjustments in the anesthesia management, and changes in the surgical plan | assessment of the adequacy of the surgical procedure and the detection of hemodynamicaly significant residual defects, guides the surgical revision when necessary, and facilitates medical management | changes in cardiac or valve function and use imaging to optimize postoperative | ||||| |Coronary surgery2.4|| Global LV and RV function in the context of electrocardiographic changes | LV systolic function and regional function (eg, graft kinking) at time of chest closure | || Global LV and RV function: 2D and 3D techniques, LV and RV strain assessment | LV and RV filling Regional LV functional changes in grafted areas with potential correlation to the flowmeter | RV function and filling and LV diastolic function for fluid management and vasopressor titration | ||||| || Diastolic dysfunction (tissue Doppler, transmitral and pulmonary vein flow) Valvular function, especially mitral and TV function and annular size for possible mitral or tricuspid repair, or both AV function for cardioplegia strategy | Valvular function, especially mitral and TVs in the context of LV or RV dysfunction and filling | Presence of iatrogenic aortic dissection Presence of a pleural effusion,Presence of a pleural effusion, especially left pleural effusion if left | || AV function for cardioplegia strategy Ascending aorta atheroma: determination of off-pump CABG | Ascending and descending aorta for potential cannulation complications (eg, dissection, || | Valve repair or replacement surgery2,3,8,11-13 | Baseline valvular disease severity for comparison immediately after the procedure |Cardiac function|| | Valve repair or replacement surgery2,3,8,11-13 || Presence or absence of residual pathology after valve repair | Change in residual pathology (if applicable) | || Valvular anatomic risk factors prone to postprocedural failure | Paravalvular defect after valve replacement Valvular function after repair or replacement | Ventricular function, as cardiac edema from prolonged surgical course is of | || LV and RV function size and function Cardiac structures adjacent to index valve |New or worsening nonoperative valvular lesions|| |||latrogenic complications:| Postprocedural baseline for comparison during follow-up visits | ||Facilitate surgical cannulation| MV: circumflex artery injury, conduction system disruption, AV groove disruption, LA dissection, systolic anterior motion of mitral leaflet, interatrial septal shunt || ||||| |||PV: RVOT injury or stenosis|| |Aortic surgery2.14- 20| Aortic measurements: LVOT and AV annulus in midsystole from inner edge to inner edge | Aortic root replacement with coronary reimplantation: coronary flow and ventricular segmental wall motion analysis | After aortic root replacement, coronary flow and ventricular wall motion; coronary button or graft kinking may | |Aortic surgery2.14- 20||Presence of iatrogenic aortic dissection|| || Sinuses of Valsalva (sinotubular junction, proximal ascending aorta, mid ascending aorta, distal ascending aorta, aortic arch, descending aorta) from leading edge to leading edge in end diastole' | Aortic graft material for laminar flow with color flow Doppler | After descending thoracic aortic endovascular repair, retrograde aortic dissection | ||Atheroma burden (grade and localize)| Post-aortic dissection repair, flow restoration in true lumen (s) through the extent of the aorta involved in systole | Entire aorta for any new changes in the setting of post-chest closure | || Presence of any aortic pathologies (eg, dissection, intramural hematoma, thrombus, aneurysm, intimal tear, | After endovascular aortic intervention, endoleak interrogation (eg, presence of spontaneous echo contrast or slower flow in a patent || ||endocarditis, wall rupture)||| || Arterial cannulation (eg, cannulation over wire in the descending thoracic aorta,wire in the descending thoracic aorta, proximal ascending positioning in the setting of atheroma burden) ||| || Cannula position, iatrogenic dissection from cannulation |||

Table 2. Continued

|Surgery/intervention| Preprocedural (or before CPB) evaluation | Immediate postprocedural (or during and after CPB) evaluation | Post-chest closure (if applicable) evaluation | |---|---|---|---| |LVAD implantation2.20-23|| Residual air during removal from CPB: LV, RV, LA, RA, coronary ostia, and aorta | Improvement of previously identified abnormalities with chamber structure and function, for example, LV or RV dysfunction | |LVAD implantation2.20-23| LV and RV function and presence of thrombi in all cardiac chambers, devices, and catheters Interatrial septum to exclude ASD or PFO (agitated saline contrast if no shunt is detected by color flow Doppler) All heart valves to identify significant | Note pump type, baseline speed, and any speed change LV size and septal position | Improvement of previously identified abnormalities with chamber structure and function, for example, LV or RV dysfunction | |LVAD implantation2.20-23| and catheters Interatrial septum to exclude ASD or PFO (agitated saline contrast if no shunt is detected by color flow Doppler) All heart valves to identify significantAll heart valves to identify significant pathology; AV for more than mild ARpathology; AV for more than mild AR or the presence and function of aor the presence and function of a prosthetic valve ||| |LVAD implantation2.20-23|| LV size and septal position Position, orientation, and flow of the inflow cannula RV function; compare with baseline All heart chambers, devices, and catheters for any new thrombus Interatrial septum: repeat color Doppler and || |LVAD implantation2.20-23|PA systolic pressure||| |LVAD implantation2.20-23| Aorta: presence of aneurysm, dissection, and complex atheroma | Interatrial septum: repeat color Doppler and agitated saline contrast evaluation' || |LVAD implantation2.20-23|Baseline pericardial effusion| Heart valves: degree of AV opening and exclude new or more than mild AR; inflow cannula interference with MV apparatus; exclude new MR || ||||| ||| Presence of PR, measure RVOT stroke volume, worsening tricuspid regurgitation, PA systolic pressure Pericardium: assess for new effusion/ hematoma Aorta: exclude new dissection Outflow graft: interrogate conduit path adjacent || ||| Outflow graft: interrogate conduit path adjacent to RV/RA, anastomosis to the aorta || | Orthotopic heart transplantation2.24,25 | Intracardiac thrombi, including evaluation of the LV apex, LA, and LA appendage Pacing leads or devices, including LVAD inflow cannula and outflow graft if present | Residual air during removal from CPB: LV, RV, LA, RA, coronary ostia, and aorta | Improvement of previously identified abnormalities with chamber structure and function, for example, LV or RV dysfunction | | Orthotopic heart transplantation2.24,25 || LV and RV function and exclude thrombi in all cardiac chambers, devices, and catheters || | Orthotopic heart transplantation2.24,25 | Anastomosis sites for masses, thrombi or stenoses, including ascending aorta, PA, SVC, and IVC | cardiac chambers, devices, and catheters Atrial or SVC and IVC anastomoses: exclude stenosis or thrombus at the anastomosis site Interatrial septum: exclude ASD or PFO withInteratrial septum: exclude ASD or PFO with color Doppler and agitated saline if appropriatecolor Doppler and agitated saline if appropriate All heart valves to identify significant pathology PA systolic pressure || ||||| ||| Pericardium: assess for new effusion/ hematoma || | Orthotopic lung transplantation26-30 | Presence of PFO by color flow Doppler and agitated saline | RV response to PA clamping RV size and function and RV systolic pressure | PV anastomoses: diameter, turbulence, velocity |

Table 2. Continued

|Surgery/ intervention| Preprocedural (or before CPB) evaluation | Immediate postprocedural (or during and after CPB) evaluation | Post-chest closure (if applicable) evaluation | |---|---|---|---| ||||| | Adult congenital surgery36-44 |Baseline evaluation of anatomy,|Surgical cannulation| Potential extrinsic sternal compression of cardiac structures or prosthetic material | | Adult congenital surgery36-44 |hemodynamics, and ventricular function| Adequacy of cardiac emptying or fiing based on the surgical stage || | Adult congenital surgery36-44 | Preoperative structural or functional abnormalities or both ||| | Adult congenital surgery36-44 ||Intracardiac air and adequate cardiac deairing| Distortion in the anatomy that may result in hemodynamic changes | | Adult congenital surgery36-44 | New or different pathology and exclusion of additional defects | Results of the surgical intervention according to the nature of the procedure(s) (eg,to the nature of the procedure(s) (eg, exclusion of residual shunts, obstructive or | Results of the surgical intervention, particularly if there are concerns related | | Adult congenital surgery36-44 | Presence of intracardiac communications that may affect beating || particularly if there are concerns related to residual pathology or disease severity | | Adult congenital surgery36-44 |heart surgery (color Doppler evaluation| regurgitant pathology of potential hemodynamic significance, confirmation of conduit patency, evaluation of prosthetic valve function) |LV and RV ventricularfilling and function| ||and agitated saline contrast study)|Ventricular size and function|| |||Problems associated with weaning from CPB|| |||Surgical revision when indicated||

2D indicates 2-dimensional; 3D, 3-dimensional; AR, aortic regurgitation; ASD, atrial septal defect; AV, aortic valve; CABG, coronary artery bypass graft; CPB, cardio pulmonary bypass; ECMO, extracorporeal membrane oxygenation; IVC, inferior vena cava; LA, left atrial; LV, left ventricular; LVAD, left ventricular assist device; MR, mitral regurgitation; MV, mitral valve; PA, pulmonary artery; PFO, patent foramen ovale; PR, pulmonary regurgitation; PV, pulmonary valve; RA, right atrial; RV, right ventricle; RVOT, right ventricular outflow tract; SVC, superior vena cava; TEE, transesophageal echocardiography; and TV, tricuspid valve.

scheduled procedure in $6.6\%$ of mitral valve and $4.4\%$ of aortic valve surgeries. In addition, post-CPB TEE evalu ation identified abnormalities that required surgical rein tervention, including perivalvular leak, immobilized leaflet, coronary obstruction, and incompetent xenograft. 51 The occurrence of procedural changes was even greater for multivalvular surgeries $(9.1\%)$ and combined CABG plus valvular surgeries $(12.3\%)$ ). 51 Another study of 417 pa tients undergoing valve replacement showed that unex pected post-CPB TEE findings contributed to $3.6\%$ of patients needing immediate surgical reintervention. 56

The cost-effectiveness of routine use of intraopera tive TEE in cardiac surgery was studied in an innova tive decision analytic simulation in 10000 virtual patients undergoing CABG, aortic valve, and mitral valve surgery. This study found that routine intraoperative TEE use was associated with lower cost $\langle\Downarrow\S\S\uparrow750\rangle$ ) and greater qual ity of life-years per patient (0.036 with an incremental cost-effectiveness ratio of $\S33\,000/$ quality of life-year), making TEE highly cost-effective. In addition, the results showed a decrease in long-term complications, including stroke, cardiac complications, and death. 57

Specific TEE-Related Parameters and Outcomes

Many studies have also demonstrated the association between specific intraoperative TEE parameters and perioperative or in-hospital outcomes. This suggests that TEE may be used (1) to risk-stratify cardiac surgical patients during open valve repair, 58–61 (2) to aid in periop erative stroke risk assessment by identifying aortic dis ease and intracardiac thrombus, 62 or (3) to risk-stratify surgical patients for the likelihood of adverse outcomes according to their left ventricular (LV) and right ventricu lar (RV) functional assessments. 63–70 In summary, the use

of intraoperative TEE allows the identification of higherrisk patients who may benefit from alterations in surgical technique or closer postoperative monitoring to improve outcomes Supplemental Table 1 .

Long-Term Outcomes

Data on the association between intraoperative TEE and long-term outcomes remain sparse. Studies suggest that cardiac surgical patients with more severe valvular re gurgitation on preprocedural TEE have increased risk of long-term mortality. 71,72 A single-center database study over a 24-year period of 23685 patients reported that moderate or severe intraoperative tricuspid regurgitation (TR) was associated with increased all-cause mortality (hazard ratio [HR], 1.24, ${\cal P}{<}0.0001$ ; HR, 2.02, ${\cal P}{<}0.0001$ , respectively), however, patients who subsequently un derwent tricuspid valve surgery had an increased likeli hood of survival (HR, 0.74; $\scriptstyle P=0.004$ ). 71 In patients with moderate MR, prebypass TEE assessment of MR had a better association with long-term mortality compared with preoperative transthoracic echocardiographic (TTE) as sessment (HR, 1.31 versus 1.02; $\scriptstyle P=0.025.$ ). 72 More prospective, granular research on the specific TEE in terventions used for surgical or hemodynamic guidance is needed to expand our knowledge of how exactly TEE contributes to improving outcomes.

SPECIFIC INTRAOPERATIVE TEE CONSIDERATIONS BY TYPE OF CARDIAC SURGERY

CABG Surgery

Many patients undergoing CABG surgery may not have a comprehensive preoperative TTE. The indication for

revascularization hinges on cardiac angiography alone to define anatomy and to assess lesion severity, and routine preoperative TTE is not yet standard of care. 73 The ACC/ AHA 2004 Guideline Update for CABG list preoperative TEE as a Level 2b recommendation in a limited subset of patients with recent anterior myocardial infarction. 73 How ever, TEE is becoming increasingly valued as an intraop erative evaluation tool, as demonstrated by its increased utility and the 2011 ACCF/AHA Guideline for CABG that endorsed intraoperative TEE for CABG surgery with a Class 2a, Level of Evidence B recommendation. 1a

Intraoperative TEE may be the first comprehensive evaluation of valvular function for patients undergoing CABG and provides updated information on regional and global biventricular function, which may have changed since the preoperative assessment. The data from intra operative TEE allow accurate patient risk stratification and inform hemodynamic and fluid management. Mitral and tricuspid valves, which may be affected by myocardial ischemia, are assessed for abnormalities that may require surgical intervention. After separation from CPB, intraop erative TEE is critical for assessing deairing and graft function through regional and global ventricular function evaluation. At chest closure, global and regional function should be reassessed with clinical hemodynamic correla tion to confirm the absence of acute graft ischemia (eg, graft kinking or other occlusive events; Table2).

Valve Repair or Replacement Surgery

Intraoperative TEE has been a mainstay of cardiac valve surgery, and one of its important functions is to confirm valvular lesions identified preoperatively. Detailed intra operative considerations are given in Table2. However, qualitative and quantitative intraoperative TEE findings established before the initiation of CPB should be in terpreted within the context of the altered physiological conditions that exist in the anesthetized surgical patient. These include relative hypovolemia due to preoperative fasting, general anesthesia, mechanical ventilation, and surgical manipulation of the heart, which can significantly alter cardiac and valve function (Figure1). 74 Studies have shown frequent discrepancies in Doppler-derived param eters between the presurgical TTE and intraoperative TEE in mitral, aortic, and tricuspid valve surgery, result ing in discordant valvular pathology grades. 75–78 Certain parameters may be more affected than others. In a study of 319 patients, peak velocity and mean gradient in aortic stenosis were different by $0.59\;\mathrm{m}/\mathrm{s}$ and 12.5 mmHg, re spectively $(P{<}0.001\$ ), and the intraoperative TEE grades of aortic stenosis severity agreed preoperatively only ${\approx}50\%$ of the time. However, when the dimensionless in dex (also known as velocity ratio) was used, agreement with the preoperative TTE increased to $83.3\%.^{77}$ Supple mental Table 2 summarizes studies that have compared valve grading by preoperative TTE and intraoperative TEE.

Anesthesiologists can attempt to mimic normal load ing conditions by giving medications to increase after load and intravenous fluids to increase preload. However, awake or baseline conditions are not necessarily fully replicated. A meta-analysis of 6 studies including 273 patients compared MR severity on preoperative TEE or TTE and intraoperative TEE with hemodynamic matching using pharmacologically increased afterload. Intraopera tive TEE under general anesthesia before hemodynamic matching resulted in a mean misdiagnosis rate of $48\%$ ( $(39\%$ underestimation, $9\%$ overestimation), and misdi agnoses remained high at $41\%$ even after hemodynamic matching. However, only $\approx\!10\%$ of misdiagnoses were clinically relevant in both groups. 74 Other small stud ies have shown that intraoperative MR severity may be underestimated in secondary but not primary MR and that the 3D vena contracta area was less likely to under estimate 2-dimensional (2D) MR assessment in $20\%$ versus $44\%$ of cases. 79 Quantitative assessments such as effective regurgitant orifice area and regurgitant vol ume may be more accurate in grading MR severity under anesthesia because they are less dependent on loading conditions. 74,79,80

Intraoperative TEE is often used to determine the fea sibility of valve repair over replacement. Factors such as leaflet or annular calcium burden, leaflet height, 81 overall valvular symmetry, 82 and chordal length 83 can be evalu ated intraoperatively and used for surgical repair plan ning ( Supplemental Table 1 ). Risk factors for systolic anterior motion of the mitral leaflet after repair can be identified before initiation of CPB, which provides valu able information for the surgeon on the surgical repair strategy and informs the anesthesiologist about postCPB hemodynamic management. 84 Immediate postCPB TEE after valve repair or replacement can identify significant residual pathology, prosthetic valvular mal function, paravalvular defects, and other conditions that may require surgical reintervention (see the Short-Term Outcomes and Intraoperative TEE and Decision-Making sections).

Real-time 3D TEE can be used intraoperatively as an adjunct to the 2D TEE examination. Prospective stud ies have shown that intraoperative 3D compared with 2D TEE can more accurately identify segmental and com plex valvular lesions without compromising examination efficiency. 85,86 For the mitral valve, 3D TEE compared with 2D TEE allows better accuracy and improved sensi tivity and specificity in the identification of clefts and pro lapsed scallops, including multisegment or commissural lesions. 87,88 Three-dimensional analysis assists with iden tifying the risk of postrepair systolic anterior motion. 89 Automated or semiautomated software allows rapid 3D analysis of the valve structure, which correlates well with multidetector computed tomography–derived structure. Quantitative measurements of MR by 3D TEE such as effective regurgitant orifice area and regurgitant volume

have been shown to be accurate and feasible compared with cardiac magnetic resonance. 90 High-resolution 3D TEE images for improved visualization of complex lesions can potentially improve the successful repair rate when valve repair techniques are adapted according to the 3D TEE evaluation. 91 After valve repair or replacement, 3D TEE also incrementally improves paravalvular leak local ization and quantification.

Aortic Surgery

The “2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease” states that intraop erative “TEE is particularly useful in the intraoperative evaluation of patients with aortic aneurysm syndromes in guiding both operative and endovascular repair strate gies and the assessment of true and false lumen flows before and immediately after aortic repair.” 14,15 However, the impact of TEE use on outcomes in aortic surgery has only recently been investigated. 55 Intraoperative TEE of the aorta provides superior image quality compared with TTE and allows imaging of nearly the entire thoracic aorta, aside from a “blind spot” near the distal ascend ing aorta and proximal aortic arch. 15 Tw-dimensional and 3D TEE, simultaneous orthogonal-plane imaging, and Doppler flow interrogations with and without color are the widely used modalities that assist in intraoperative evaluation of the aorta. 16 In proximal aortic surgery, TEE assists decision-making by providing information on ar terial site cannulation guidance, aortic cannula position, identification of true and false lumen in aortic dissection, aneurysm size, thrombus location, and the presence of pericardial effusion (Table2).

Aortic endovascular techniques also benefit from TEE guidance, which enables visualization of the guide wire and stent placement, 17 as well as interrogation for potential poststent endoleak and retrograde aortic dis section. 18 Hybrid procedures combining conventional approaches with endovascular techniques in extensive aortic disease also benefit from intraprocedural TEE for both the conventional and the endovascular surgical segments. Combination aortic valve repairs with aortic procedures benefit from TEE to evaluate the need for aortic annular size adjustment and to confirm adequate external annular stabilization. 92,93 Lastly, use of rescue TEE in blunt thoracic trauma management can also aid in quickly identifying a need for emergency aortic surgi cal intervention. 2,94,95

LV Assist Devices

Durable LV assist devices (LVADs) are surgically im planted in patients with advanced heart failure refractory to medical therapy, as a bridge to transplantation, as a bridge to recovery, or as destination therapy. A thorough intraoperative TEE assessment is essential before and

during LVAD implantation, activation, and optimization (Table2). Implementing a perioperative protocol and checklist facilitates consistent imaging at each proce dural stage.

TEE evaluation before implantation is particularly important in emergency scenarios or when TTE is inad equate. Key parameters include LV and RV size and func tion and valvular function. Evaluation for conditions that would alter the surgical procedure or even exclude the patient from LVAD eligibility should be performed. The presence of more than mild aortic regurgitation, intracar diac thrombi, interatrial and intraventricular defects, and ascending aortic pathology should be assessed (Table2). A qualitative evaluation should be complemented by semiquantitative and quantitative techniques that allow a more reliable assessment of chamber size and function and assist with risk stratification.

After durable LVAD initiation, transient RV dysfunction is common due to increased preload, but worsening RV dysfunction may necessitate decreasing pump speed. Table2 reports specific echocardiographic consider ations preoperatively and after LVAD activation. Echocar diographic predictors of RV failure after LVAD insertion can be measured during the preoperative TTE or TEE evaluation and include indices of RV systolic function, RV diastolic dysfunction (tricuspid E/e’, right atrial strain), and RV–pulmonary artery coupling (incorporating pulmo nary artery systolic pressure). Literature supports inte gration of echocardiographic, clinical, and hemodynamic parameters into risk scores which have been associated with better accuracy in predicting RV failure than any individual parameter. 96 Increased velocities in the outflow graft may suggest obstruction or kinking, an uncommon but serious complication that may require surgical graft adjustment. 21,22

Orthotopic Heart Transplantation

Immediately after orthotopic heart transplantation, a thor ough TEE assessment of LV and RV function is required. Acute RV dysfunction may be due to air embolism; isch emia, stunning, or both; volume overload; acute increase in pulmonary vascular resistance; and primary graft dys function or hyperacute rejection. 24,25 Attention should also be paid to the ascending aortic, pulmonary arterial, caval, and atrial anastomoses, depending on the surgical technique used. 97 Retrospective studies have shown that ${\approx}20\%$ of patients after orthotopic heart transplantation have mild or greater TR on the post-CPB TEE, which has been associated with RV dysfunction and increased mortality. 98 A study including 542 patients with orthotop ic heart transplantation reported that significant (more than mild) TR after CPB was associated with increased mortality at 30 days ( $5.3\%$ versus $0.7\%$ ; $\scriptstyle P=0.002$ ) and 1 year ( $19.3\%$ versus $8.7\%;$ ; $\scriptstyle P=0.004$ ) compared with pa tients whose TR was mild or less. Patients with significant

TR also had longer hospital stays and higher maximum creatinine values. 98

(S’), 102 mitral lateral e’ velocity, tricuspid annular S’ veloc ity, 103 and LV and RV ejection fraction (EF). 104

Orthotopic Lung Transplantation

Clinical practice guidelines on intraoperative TEE from the American Society of Anesthesiology/Society of Car diovascular Anesthesiologists recommend intraoperative TEE use in lung transplantation, 1 particularly for assess ment of hemodynamic instability and evaluation of pulmo nary vasculature anastomoses. 27,28 The 2003 American Society of Echocardiography recommendation for TEE use is Class 2b. 99 Key intraoperative echocardiography assessment considerations are provided in Table2. 26,29,30 Intraoperative TEE is critical to diagnose significant pul monary vein obstruction using velocities >100 cm/s, which occurs in $1\%$ to $24\%$ of patients. 27,28 This can be caused by thrombus, sutures, kinking, or external com pression. In a systematic review and meta-analysis, pul monary cuff dysfunction was diagnosed by intraoperative TEE in 10 of 63 reported cases $\cdot15.7\%$ ), 100 and timely intervention was associated with improved outcomes.

Venoarterial Extracorporeal Membrane Oxygenation

TEE plays a critical role in decision-making at the time of venoarterial extracorporeal membrane oxygenation (ECMO) initiation for cardiogenic shock. The utility of TEE in this setting is linked to appropriate titration of inotropic therapy, determination of the need for pharma cological or mechanical LV unloading, 31 and assessment of LV volume status during extracorporeal cardiopulmo nary resuscitation with venoarterial ECMO. 32,33 Intrapro cedural TEE for central or peripheral venoarterial ECMO helps diagnose potential procedure-related complica tions and allows immediate assessment of LV unloading (Table2). 32–35 In a study of 421 patients, early LV unload ing within 2 hours of ECMO initiation was associated with a $36\%$ lower adjusted relative risk of 30-day allcause mortality compared with delayed active LV unload ing ${\scriptscriptstyle\left(>}2\right.$ hours; HR, 0.64; $\substack{\mathcal{P}<0.01}$ ) and was associated with a higher likelihood of successful ventilator weaning (aOR, 2.17; $\scriptstyle{\mathcal{R}}<0.01$ ). 101

Postprocedural TEE is used to ascertain the absence of new pericardial or pleural effusions and to optimize ECMO flow rate. Qualitative assessment of RV and LV response as ECMO flow is decreased provides useful information in myocardial recovery and predicts the like lihood of successful weaning. TTE studies have shown that improvements in many echocardiography param eters during the period that ECMO flow is reduced are associated with successful ECMO weaning. Useful parameters to monitor for TEE-guided ECMO weaning include the LV outflow tract velocity time integral, tissue Doppler-derived mitral septal annular systolic velocity

Venovenous ECMO

TEE is useful in assisting with dual-lumen bicaval cen tral venovenous ECMO cannula insertion, which requires precise positioning of drainage ports in the superior vena cava and inferior vena cava and the return port in the mid right atrium directed toward the tricuspid valve. Compli cations such as RV wall perforation attributable to can nula migration can be quickly and efficiently visualized on TEE. 105

For peripheral venovenous ECMO, the position of the cannula in the right atrium can be verified with chest radi ography using radiopaque markers at the cannula tips. However, echocardiography is often needed for trouble shooting and for assessing cardiac function. TEE may be required in cases of poor or absent surface sonographic windows in TTE or if there is a need for field avoidance.

In cases of combined respiratory failure and RV dys function, a percutaneous RV assist device that allows an oxygenator connection cannulation may be needed. TEE is used to evaluate the right side of the heart for any structural abnormality or implantable devices that may affect the function and position of the cannula and to verify the correct positioning of the cannula inlet and out let. In cases of biventricular dysfunction with respiratory failure requiring complex cannulation strategies, TEE is similarly used to assess the function and position of can nulas, unloading of both ventricles, significant valvular abnormalities, and intracardiac shunts. 106

Adult Congenital Surgery

Adult congenital heart disease encompasses a wide va riety of cardiovascular malformations from anatomically simple defects to complex anomalies of variable disease severity. The growing adult congenital heart disease population can be attributed to advances in the care of children with congenital heart disease, including those related to advances in intraoperative TEE. 107 Improve ments in long-term clinical outcomes and increased sur vival rates in congenital heart disease account for the growing number of adult patients with congenital heart disease, who are increasingly older with complex pathol ogies. 108,109

Since the introduction of TEE into the perioperative environment, extensive clinical experience has supported the utility of this imaging modality in the care of patients with congenital heart disease. 36 Pre-CPB TEE and postCPB TEE provide real-time assessment of the adequacy of the surgical procedures (Table 2). In 2019, the Ameri can Society of Echocardiography proposed a set of guidelines and recommendations for the comprehensive TEE examination in this patient population, considering

the unique aspects of TEE evaluation in congenital heart disease. 37

Although rigorous scientific data on the impact of intraoperative TEE on clinical outcomes in adult con genital heart disease are lacking, the cumulative litera ture, derived mostly from moderate-quality evidence and observational studies in the pediatric age group, indi cates that intraoperative TEE is critical to evaluate the quality of the surgical intervention in adult patients with congenital heart disease. Recent data show that intra operative TEE in the congenital population can alter the surgical plan in $\approx\!1\%$ to $2\%$ of cases and can facilitate a prompt return to CPB in $4\%$ to $6\%.^{38-40}$ The routine use of TEE during congenital heart surgery is paramount to detect residual lesions such as hemodynamically signifi cant shunts, valve regurgitation, and outflow obstruction, which account for major morbidity and mortality after congenital heart disease repair. 38–44 Therefore, TEE is considered an integral part of intraoperative manage ment in centers that specialize in the surgical care of patients with congenital heart disease and is supported by various clinical practice guidelines. 1,8,110,111

ARTIFICIAL INTELLIGENCE IN PERIOPERATIVE ECHOCARDIOGRAPHY

Artificial intelligence (AI), a new frontier for imaging and clinical decision-making in medicine, is rapidly being developed in echocardiography to assist with atrial and ventricular chamber quantification and clinical diagnosis. High-quality image acquisition that facilitates AI use can be challenging in the perioperative environment. A study of 300 patients who underwent TTE demonstrated that automated 3D echocardiography analysis afforded accu rate quantification of left atrial and LV function in $66\%$ of patients, with unreliable performance in $34\%$ of patients because of image quality. 112 Thus far, perioperative TEE studies on AI have been limited to (1) studies compar ing the accuracy of 3D TEE–based mitral 113 and tricus pid 114 AI-assisted valvular modeling measurements with direct surgical measurements and (2) the application of a convolution neural network, trained and validated with intraoperative data, to predict standardized TEE views. In the latter study, the deep learning–based, multicategory TEE view classification model could accurately identify 8 standard TEE views with area under the curve ranging from 0.898 to 0.971. 115

To date, most studies have focused on AI-assisted automation and analysis of 2D and 3D TTE–based data. The FAST-EFs multicenter study (Fully Automated Versus Standard Tracking of Left Ventricular Ejection Fraction and Longitudinal Strain) tested the agreement between auto mated EF and longitudinal strain from the apical 4- and 2-chamber views and found $98\%$ feasibility of automatic measurements and good agreement between manual

and automatic assessments. 116 Another study compared machine-learning LV ejection estimates derived from api cal 4-chamber, apical 2-chamber, and parasternal longaxis views with biplane measurements by experienced echocardiographers in 166 point-of-care echocardiog raphy examinations. The study found good agreement with the reference EF values in categorizing LV function as hyperdynamic (EF ${>}73\%$ ), normal $(53\%–73\%)$ ), mildly to moderately reduced $(30\%–52\%)$ ), or severely reduced $(<\!30\%)$ ), with intraclass correlation ranging from 0.86 to 0.95 and biases ${<}2\%$ . The accuracy of machine learning– estimated EF compared with physician measurements was also good in $85\%$ to $90\%$ of cases. 117 Automatic vol umetric quantification comparisons have also been con ducted between 3D TTE and cardiac magnetic resonance for evaluating left atrial and LV volumes, 118 LV volumes and associated EF, 119 and RV volumes and EF. 120 Some studies demonstrated excellent agreement between auto matic 3D quantification and cardiac magnetic resonance, but have limited sample sizes, 118 and others showed that full automation of 3D echocardiography RV quantification was possible in only $32\%$ of patients, with the remaining $68\%$ of patients requiring manual endocardial contour editing. 120 In 300 patients with a history of myocardial infarction, deep convolutional neural networks trained on 256 cases and 786 images were used to detect regional wall motion abnormalities on apical and short-axis LV TTE views. The study reported similar results between the deep learning algorithm and cardiologists’ abilities, respectively, for detecting the presence (area under the curve, 0.99 ver sus 0.98; $\ensuremath{\mathcal Ḋ P Ḍ }{=}0.15$ ) and the location (area under the curve, 0.97 versus 0.95; $\scriptstyle{\mathit{P}}=0.61$ ) of wall motion abnormalities. 121 Another study used preoperative 3D TTE clips to accu rately predict RV failure in 121 patients after LVAD place ment with an area under the curve of 0.729. Notably this AI system outperformed clinical risk scores (Penn Score and CRITT score) 122 and traditional echocardiographic metrics of RV function (RV strain, RV EF, tricuspid annular plane systolic excursion). 123

The clinical utility of such AI techniques in intraop erative TEE has the potential to increase the speed and accuracy of diagnoses and predict clinical outcomes. Thus, AI should be the subject of imminent future studies despite its current limitations. Future integration of AI into intraoperative echocardiography practice can enhance the perioperative echocardiography workflow, diagno sis, risk stratification, and management of increasingly complex cardiac surgical patients, ultimately improving patient outcomes.

FUTURE APPLICATIONS OF INTRAOPERATIVE TEE

The utility and practice of intraoperative TEE have evolved dramatically since the latest clinical guidelines

were published. 1–4,8 The indications for intraoperative TEE will need to be expanded and subsequently en dorsed by societies to match the current literature and clinical practice. As intraoperative TEE for cardiac sur gery becomes universal, using TEE for risk stratification and tailored hemodynamic and fluid therapy, especially for high-risk patients, is crucial. TEE use should be con sidered across the entire spectrum of cardiac diseases and should be implemented equitably across all popu lations. Future studies are needed to further define the standardized use of TEE to improve outcomes during cardiac surgery and how the application of AI may en hance these benefits for each patient. The current prog nostic and diagnostic utility of TEE in the intraoperative space is driven largely by clinical experience, expertise, and multidisciplinary decision-making.

ARTICLE INFORMATION

The American Heart Association makes every effort to avoid any actual or poten tial conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Spe

cifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Ad visory and Coordinating Committee on March 20, 2025, and the American Heart Association Executive Committee on April 2, 2025. A copy of the document is available at https://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@wolterskluwer.com

The American Heart Association requests that this document be cited as fol lows: Rong LQ, Shore-Lesserson L, Belani K, Faloye A, Garcia-Sayan E, Lawton J, Maus T, Miller-Hance W, Nicoara A, Sheu R; on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia; and Council on Basic Cardiovascular Sciences. Considerations of intraoperative transesopha geal echocardiography during adult cardiac surgery: a scientific statement from the American Heart Association. Circulation. 2025;151:e•••–e•••. doi: 10.1161/ CIR.0000000000001342

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guide lines & Statements” drop-down menu, then click “Publication Development.”

Permissions: Multiple copies, modification, alteration, enhancement, and dis tribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (https://www.heart.org/en/about-us/ statements-and-policies/copyright-request-form).

Disclosures

Writing Group Disclosures

|Writing group member|Employment| research grant | other research support | speakers' bureau/ honoraria | expert witness | Ownership interest | consultant/ advisory board |other| |---|---|---|---|---|---|---|---|---| |Lisa Q. Rong|Weill Cornell Medicine|NIH (K23)*|none|none|none|none|none|none| |Linda Shore- Lesserson| Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell |none|none|none|none|none|none|none| |Kiran Belani|Northwestern Medicine|none|none|none|none|none| GE Healthcare (unpaid)* |none| |Abimbola Faloye|Emory University|none|none|none|none|none|none|none| |Enrique Garcia-Sayan|Baylor College of Medicine|none|none|none|none|none|none|none| |Jennifer Lawton|Johns Hopkins|none|none|none|none|none|none|none| |Timothy Maus|UC San Diego Health|none|none|none|none|none|none|none| |Wanda Miller-Hance| Memorial Hermann - Texas Medical center |none|none|none|none|none|none|none| |Alina Nicoara|Duke University|none|none|none|none|none|none|none| |Richard Sheu|University of Washington|none|none|none|none|none|none|none|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $\S5000$ or more during any 12-month period, or $5\%$ or more of the person’s gross income; or (b) the person owns $5\%$ or more of the voting stock or share of the entity, or owns $\S5000$ or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. \*Modest.

Reviewer Disclosures

|reviewer|Employment|Research grant| other research support | Speakers' bureau/ honoraria | expert witness | Ownership interest | Consultant/ advisory board |other| |---|---|---|---|---|---|---|---|---| |Jiapeng Huang|University of Louisville| GE Healthcare (research grant)t |none|GE Healthcare*|none|none|none|none| | Kimberly Howard- Quijano | University of Pittsburgh Medical Center |none|none|none|none|none|none|none| |Emily Jane MacKay| Hospital of the University of Pennsylvania |(K23HL166964)*|none|none|none|none|none|none| | Jochen D. Muehlschlegel | Brigham and Women's Hospital, Harvard Medical School |none|none|none|none|none|none|none| |Stanton Shernan| Brigham and Women’s Hospital |none|none|Philipst|none|none|none|none|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $\S5000$ or more during any 12-month period, or $5\%$ or more of the person’s gross income; or (b) the person owns $5\%$ or more of the voting stock or share of the entity, or owns $\S5000$ or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. \*Modest.

†Significant.

REFERENCES

1. American Society of Anesthesiologists, Society of Cardiovascular Anesthesiol ogists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography: an updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anes thesiology . 2010;112:1084–1096. doi: 10.1097/ALN.0b013e3181c51e90 1a. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the Ameri canCollege of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation . 2011;124:e652–e735. doi: 10.1161/CIR.0b013e31823c074e 2. Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, Mankad S, Nyman CB, Pagani F, Porter TR, et al. Guidelines for the use of trans esophageal 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 Anes thesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr . 2020;33:692–734. doi: 10.1016/j.echo.2020.03.002 3. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Associa tion Joint Committee on Clinical Practice Guidelines [published corrections appear in Circulation . 2021;143:e228 and Circulation . 2021;143:e784]. Cir culation . 2021;143:e35–e71. doi: 10.1161/CIR.0000000000000932 4. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, et al. 2021 ACC/ AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in Circulation . 2022;145:e772]. Circulation . 2022;145:e18–e114. doi: 10.1161/CIR.0000000000001038 5. Deleted in proof. 6. Nicoara A, Fielding-Singh V, Bollen BA, Rhee A, Mackay EJ, Abernathy JH, Alfirevic A, John S, Kapoor A, MacDonald AJ, et al. The Society of Tho racic Surgeons Adult Cardiac Surgery Database: intraoperative echocar diography reporting. J Cardiothorac Vasc Anesth . 2024;38:1103–1111. doi: 10.1053/j.jvca.2024.01.009 7. Metkus TS, Thibault D, Grant MC, Badhwar V, Jacobs JP, Lawton J, O’Brien SM, Thourani V, Wegermann ZK, Zwischenberger B, et al. Transesophageal echocardiography in patients undergoing coronary artery bypass graft sur gery. J Am Coll Cardiol . 2021;78:112–122. doi: 10.1016/j.jacc.2021.04.064

8. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, et al; American Society of Echocardiog raphy. Guidelines for performing a comprehensive transesophageal echo cardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg . 2014;118:21–68. doi: 10.1213/ANE.0000000000000016 9. Mathew JP, Glas K, Troianos CA, Sears-Rogan P, Savage R, Shanewise J, Kisslo J, Aronson S, Shernan S; American Society of Echocardiogra phy. American Society of Echocardiography/Society of Cardiovascular Anesthesiologists recommendations and guidelines for continuous quality improvement in perioperative echocardiography. J Am Soc Echocardiogr . 2006;19:1303–1313. doi: 10.1016/j.echo.2006.08.039 10. Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP, et al; American Society of Echocardiography. EAE/ASE recommendations for image acquisition and display using threedimensional echocardiography. J Am Soc Echocardiogr . 2012;25:3–46. doi: 10.1016/j.echo.2011.11.010 11. Lemaire G, Vancraeynest D. Echocardiography of the aortic root: a prac tical approach for aortic valve-sparing surgery. Ann Cardiothorac Surg . 2023;12:194–212. doi: 10.21037/acs-2022-avs1-14 12. Omran AS, Woo A, David TE, Feindel CM, Rakowski H, Siu SC. Intraop erative transesophageal echocardiography accurately predicts mitral valve anatomy and suitability for repair. J Am Soc Echocardiogr . 2002;15:950– 957. doi: 10.1067/mje.2002.121534 13. Zoghbi WA, Jone P-N, Chamsi-Pasha MA, Chen T, Collins KA, Desai MY, Grayburn P, Groves DW, Hahn RT, Little SH, et al. Guidelines for the evalu ation of prosthetic valve function with cardiovascular imaging: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society of Car diovascular Computed Tomography. J Am Soc Echocardiogr . 2024;37:2–63. doi: 10.1016/j.echo.2023.10.004 14. Isselbacher EM, Preventza O, Hamilton Black J 3rd, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, et al; Peer Review Committee Members. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the Ameri can Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation . 2022;146:e334–e482. doi: 10.1161/CIR.0000000000001106 15. Goldstein SA, Evangelista A, Abbara S, Arai A, Asch FM, Badano LP, Bolen MA, Connolly HM, Cuéllar-Calàbria H, Czerny M, et al. Multi modality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr . 2015;28:119–182. doi: 10.1016/j.echo.2014.11.015 16. Agricola E, Slavich M, Rinaldi E, Bertoglio L, Civilini E, Melissano G, Marone E, Fisicaro A, Marini C, Tufaro V, et al. Usefulness of contrast-enhanced transoesophageal echocardiography to guide thoracic endovascular aortic repair procedure. Eur Heart J Cardiovasc Imaging . 2016;17:67–75. doi: 10.1093/ehjci/jev118 17. Rocchi G, Lofiego C, Biagini E, Piva T, Bracchetti G, Lovato L, Parlapiano M, Ferlito M, Rapezzi C, Branzi A, et al. Transesophageal echocardiographyguided algorithm for stent-graft implantation in aortic dissection. J Vasc Surg . 2004;40:880–885. doi: 10.1016/j.jvs.2004.08.041 18. Evangelista A, Maldonado G, Gruosso D, Gutiérrez L, Granato C, Villalva N, Galian L, González-Alujas T, Teixido G, Rodríguez-Palomares J. The cur rent role of echocardiography in acute aortic syndrome. Echo Res Pract . 2019;6:R53–R63. doi: 10.1530/ERP-18-0058 19. Feldman D, Pamboukian SV, Teuteberg JJ, Birks E, Lietz K, Moore SA, Morgan JA, Arabia F, Bauman ME, Buchholz HW, et al; International So ciety for Heart and Lung Transplantation. The 2013 International Society for Heart and Lung Transplantation guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant . 2013;32:157–187. doi: 10.1016/j.healun.2012.09.013 20. Stainback RF, Estep JD, Agler DA, Birks EJ, Bremer M, Hung J, Kirkpatrick JN, Rogers JG, Shah NR; American Society of Echocardiography. Echocar diography in the management of patients with left ventricular assist devices: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr . 2015;28:853–909. doi: 10.1016/j.echo.2015.05.008 21. Mehra MR, Salerno C, Naka Y, Uriel N, Cleveland JC, Horstmanshof D, Goldstein DJ; MOMENTUM 3 Investigators. A tale of the twist in the out flow graft: an analysis from the MOMENTUM 3 trial. J Heart Lung Trans plant . 2018;37:1281–1284. doi: 10.1016/j.healun.2018.08.011 22. Scandroglio AM, Kaufmann F, Pieri M, Kretzschmar A, Müller M, Pergantis P, Dreysse S, Falk V, Krabatsch T, Potapov EV. Diagnosis and treatment algo rithm for blood flow obstructions in patients with left ventricular assist device. J Am Coll Cardiol . 2016;67:2758–2768. doi: 10.1016/j.jacc.2016.03.573 23. Estep JD, Nicoara A, Cavalcante J, Chang SM, Cole SP, Cowger J, Daneshmand MA, Hoit BD, Kapur NK, Kruse E, et al. Recommendations for multimodality imaging of patients with left ventricular assist devices and temporary mechanical support: updated recommendations from the Ameri can Society of Echocardiography. J Am Soc Echocardiogr . 2024;37:820– 871. doi: 10.1016/j.echo.2024.06.005 24. González Saldivar H, Hortal J, Martín de Miguel I, Rodríguez-Abella H, Las CJ, Martínez-Sellés M. A reversible cause of acute right ventricular failure after heart transplant. Rev Esp Cardiol (Engl Ed) . 2017;70:677–679. doi: 10.1016/j.rec.2016.12.005 25. Tan Z, Roscoe A, Rubino A. Transesophageal echocardiography in heart and lung transplantation. J Cardiothorac Vasc Anesth . 2019;33:1548–1558. doi: 10.1053/j.jvca.2019.01.005 26. Evans A, Dwarakanath S, Hogue C, Brady M, Poppers J, Miller $S,$ Weiner MM. Intraoperative echocardiography for patients undergo ing lung transplantation. Anesth Analg . 2014;118:725–730. doi: 10.1213/ane.0000000000000121 27. Schulman LL, Anandarangam T, Leibowitz DW, Ditullio MR, McGregor CC, Galantowicz ME, Homma S. Four-year prospective study of pulmonary venous thrombosis after lung transplantation. J Am Soc Echocardiogr . 2001;14:806–812. doi: 10.1067/mje.2001.111855 28. Leibowitz DW, Smith CR, Michler RE, Ginsburg M, Schulman LL, McGregor CC, Li Mandri G, Weslow RG, Di Tullio MR, Homma S. Incidence of pul monary vein complications after lung transplantation: a prospective trans esophageal echocardiographic study. J Am Coll Cardiol . 1994;24:671–675. doi: 10.1016/0735-1097(94)90013-2 29. Serra E, Feltracco P, Barbieri S, Forti A, Ori C. Transesophageal echocar diography during lung transplantation. Transplant Proc . 2007;39:1981– 1982. doi: 10.1016/j.transproceed.2007.05.004 30. González-Fernández C, González-Castro A, Rodríguez-Borregán JC, López-Sánchez M, Suberviola B, Francisco Nistal J, Martín-Durán R. Pulmo nary venous obstruction after lung transplantation: diagnostic advantages of transesophageal echocardiography. Clin Transplant . 2009;23:975–980. doi: 10.1111/j.1399-0012.2009.01078.x 31. Kuckelman J, Coffey P, Sharkawi M, Bailey C, Hiner E, Patel V. ECPEL LA: beyond a left ventricular venting strategy when to unload the left ventricle and how to decide. ASAIO J . 2024;70:e89–e91. doi: 10.1097/MAT.0000000000002146 32. Anastasius M, Serrao G, Sharma SK, Kini A, Anyanwu A, Adams D, Lerakis S. Use of extracorporeal membrane oxygenation and Impella as bridge to surgery through imaging for cardiogenic shock. CASE (Phila) . 2022;6:223– 227. doi: 10.1016/j.case.2022.03.003 33. Ezad SM, Ryan M, Donker DW, Pappalardo F, Barrett N, Camporota L, Price S, Kapur NK, Perera D. Unloading the left ventricle in venoarterial ECMO: in whom, when, and how? Circulation . 2023;147:1237–1250. doi: 10.1161/CIRCULATIONAHA.122.062371 34. Higashino A, Yahagi K, Taketani T, Miura S, Ohno T. Concomitant use of VA-ECMO and Impella with inhaled nitric oxide to treat cardiogenic shock after cardiac surgery: a case report. J Cardiol Cases . 2022;26:333–335. doi: 10.1016/j.jccase.2022.07.003 35. Park H, Yang JH, Ahn JM, Kang DY, Lee PH, Kim TO, Choi KH, Kang PJ, Jung SH, Yun SC, et al. Early left atrial venting versus conventional treat ment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: the EVOLVE-ECMO randomized clinical trial. Eur J Heart Fail . 2023;25:2037–2046. doi: 10.1002/ejhf.3014 36. Wong PC, Miller-Hance WC. Transesophageal Echocardiography for Pediat ric and Congenital Heart Disease . 2nd ed. Springer Cham; 2022:812. 37. Puchalski MD, Lui GK, Miller-Hance WC, Brook MM, Young LT, Bhat A, Roberson DA, Mercer-Rosa L, Miller OI, Parra DA, et al. Guidelines for per forming a comprehensive transesophageal echocardiographic: examination in children and all patients with congenital heart disease: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr . 2019;32:173–215. doi: 10.1016/j.echo.2018.08.016 38. Guzeltas A, Ozyilmaz I, Tanidir C, Odemis E, Tola HT, Ergul Y, Bilici M, Haydin S, Erek E, Bakir I. The significance of transesophageal echocardiography in assessing congenital heart disease: our experience. Congenit Heart Dis . 2014;9:300–306. doi: 10.1111/chd.12139 39. Jijeh AM, Omran AS, Najm HK, Abu-Sulaiman RM. Role of intraoperative transesophageal echocardiography in pediatric cardiac surgery. J Saudi Heart Assoc . 2016;28:89–94. doi: 10.1016/j.jsha.2015.06.005 40. Madriago EJ, Punn R, Geeter N, Silverman NH. Routine intraoperative trans-oesophageal echocardiography yields better outcomes in surgical repair of CHD. Cardiol Young . 2016;26:263–268. doi: 10.1017/S1047951115000098 41. O’Leary PW, Hagler DJ, Seward JB, Tajik AJ, Schaff HV, Puga FJ, Danielson GK. Biplane intraoperative transesophageal echocardiography in congenital heart disease. Mayo Clin Proc . 1995;70:317–326. doi: 10.4065/70.4.317 42. Bettex DA, Schmidlin D, Bernath MA, Prêtre R, Hurni M, Jenni R, Chassot PG, Schmid ER. Intraoperative transesophageal echocardiography in pediatric congenital cardiac surgery: a two-center observational study. Anesth Analg . 2003;97:1275–1282. doi: 10.1213/01.ANE.0000081794.31004.18 43. Ma XJ, Huang GY, Liang XC, Chen ZG, Jia B, Li X, Ye M. Transoesophageal echocardiography in monitoring, guiding, and evaluating surgical repair of congenital cardiac malformations in children. Cardiol Young . 2007;17:301– 306. doi: 10.1017/S1047951107000303 44. Stevenson JG, Sorensen GK, Gartman DM, Hall DG, Rittenhouse EA. Trans esophageal echocardiography during repair of congenital cardiac defects: identification of residual problems necessitating reoperation. J Am Soc Echocardiogr . 1993;6:356–365. doi: 10.1016/s0894-7317(14)80234-4 45. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr . 2010;23:1115–1127; quiz 1220. doi: 10.1016/j.echo.2010.08.013 46. Patel KM, Desai RG, Trivedi K, Neuburger PJ, Krishnan S, Potestio CP. Complications of transesophageal echocardiography: a review of injuries, risk factors, and management. J Cardiothorac Vasc Anesth . 2022;36:3292– 3302. doi: 10.1053/j.jvca.2022.02.015 47. Freitas-Ferraz AB, Bernier M, Vaillancourt R, Ugalde PA, Nicodème F, Paradis JM, Champagne J, O’Hara G, Junquera L, Del Val D, et al. Safety of transesophageal echocardiography to guide structural cardiac interventions. J Am Coll Cardiol . 2020;75:3164–3173. doi: 10.1016/j.jacc.2020.04.069 48. Apatov DA, Spellman JL, Takayama H, Heath MJ. An unrecognized con traindication to transesophageal echocardiographic probe placement: the aberrant right subclavian artery. CASE (Phila) . 2020;4:448–451. doi: 10.1016/j.case.2020.07.003 49. Gillinov AM, Cosgrove DM, Blackstone EH, Diaz R, Arnold JH, Lytle BW, Smedira NG, Sabik JF, McCarthy PM, Loop FD. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg . 1998;116:734– 743. doi: 10.1016/S0022-5223(98)00450-4 50. MacKay EJ, Zhang B, Heng S, Ye T, Neuman MD, Augoustides JG, Feinman JW, Desai ND, Groeneveld PW. Association between trans esophageal echocardiography and clinical outcomes after coronary artery bypass graft surgery. J Am Soc Echocardiogr . 2021;34:571–581. doi: 10.1016/j.echo.2021.01.014 51. Eltzschig HK, Rosenberger P, Löffler M, Fox JA, Aranki SF, Shernan SK. Impact of intraoperative transesophageal echocardiography on surgical de cisions in 12,566 patients undergoing cardiac surgery. Ann Thorac Surg . 2008;85:845–852. doi: 10.1016/j.athoracsur.2007.11.015 52. MacKay EJ, Talham CJ, Zhang B, Brown CR, Groeneveld PW, Desai ND, Augoustides JG. Testing clinical selection criteria for intraoperative tran soesophageal echocardiography in isolated coronary artery bypass graft surgery. BJA Open . 2024;10:100278. doi: 10.1016/j.bjao.2024.100278 Augoustides JG, Neuman MD. Transesophageal echocardiography, acute kidney injury, and length of hospitalization among adults undergoing coro nary artery bypass graft surgery. J Cardiothorac Vasc Anesth . 2020;34:687– 695. doi: 10.1053/j.jvca.2019.08.042 54. MacKay EJ, Neuman MD, Fleisher LA, Patel PA, Gutsche JT, Augoustides JG, Desai ND, Groeneveld PW. Transesophageal echocardiography, mor tality, and length of hospitalization after cardiac valve surgery. J Am Soc Echocardiogr . 2020;33:756–762.e1. doi: 10.1016/j.echo.2020.01.014 55. MacKay EJ, Zhang B, Augoustides JG, Groeneveld PW, Desai ND. Associa tion of intraoperative transesophageal echocardiography and clinical out comes after open cardiac valve or proximal aortic surgery. JAMA Netw Open . 2022;5:e2147820. doi: 10.1001/jamanetworkopen.2021.47820 56. Shapira Y, Vaturi M, Weisenberg DE, Raanani E, Sahar G, Snir E, Battler A, Vidne BA, Sagie A. Impact of intraoperative transesophageal echocar diography in patients undergoing valve replacement. Ann Thorac Surg . 2004;78:579–583. doi: 10.1016/j.athoracsur.2004.02.075 57. Dieleman JM, Myles PS, Bulfone L, Younie S, van Zaane B, McGiffin D, Moodie M, Gao L. Cost-effectiveness of routine transoesophageal echo cardiography during cardiac surgery: a discrete-event simulation study. Br J Anaesth . 2020;124:136–145. doi: 10.1016/j.bja.2019.10.023 58. Maslow A. Mitral valve repair: an echocardiographic review, part 1. J Cardio thorac Vasc Anesth . 2015;29:156–177. doi: 10.1053/j.jvca.2014.03.007 59. Maslow A. Mitral valve repair: an echocardiographic review, part 2. J Cardio thorac Vasc Anesth . 2015;29:439–471. doi: 10.1053/j.jvca.2014.03.013 60. Augoustides JG, Szeto WY, Bavaria JE. Advances in aortic valve re pair: focus on functional approach, clinical outcomes, and central role of echocardiography. J Cardiothorac Vasc Anesth . 2010;24:1016–1020. doi: 10.1053/j.jvca.2010.08.007 61. Van Dyck MJ, Watremez C, Boodhwani M, Vanoverschelde JL, El Khoury G. Transesophageal echocardiographic evaluation dur ing aortic valve repair surgery. Anesth Analg . 2010;111:59–70. doi: 10.1213/ANE.0b013e3181dd2579 62. Gaudino M, Benesch C, Bakaeen F, DeAnda A, Fremes SE, Glance L, Messe SR, Pandey A, Rong LQ; on behalf of the American Heart Association Coun cil on Cardiovascular Surgery and Anesthesia; Stroke Council; and Council on Cardiovascular and Stroke Nursing. Considerations for reduction of risk of perioperative stroke in adult patients undergoing cardiac and thoracic aortic operations: a scientific statement from the American Heart Association. Cir culation . 2020;142:e193–e209. doi: 10.1161/CIR.0000000000000885 63. Swaminathan M, Nicoara A, Phillips-Bute BG, Aeschlimann N, Milano CA, Mackensen GB, Podgoreanu MV, Velazquez EJ, Stafford-Smith M, Mathew JP; Cardiothoracic Anesthesia Research Endeavors (CARE) Group. Utility of a simple algorithm to grade diastolic dysfunction and predict outcome af ter coronary artery bypass graft surgery. Ann Thorac Surg . 2011;91:1844– 1850. doi: 10.1016/j.athoracsur.2011.02.008 64. Morita Y, Lencho T, Gunasekaran S, Modak R. Modified tricuspid an nular plane systolic excursion using transesophageal echocardiography and its utility to predict postoperative course in heart transplantation and left ventricular assist device implantation. J Cardiothorac Vasc Anesth . 2018;32:1316–1324. doi: 10.1053/j.jvca.2017.11.024 65. Assanangkornchai N, Villeneuve V, McDonald S, Tim DS, Magder S, Mettasittigorn P, Hatzakorzian R. Reduction in postoperative right ventricu lar echocardiographic indices predicts longer duration of vasoactive support after cardiac surgery. J Cardiothorac Vasc Anesth . 2024;39:143–150. doi: 10.1053/j.jvca.2024.02.032 66. Jha AK, Malik V, Gharde P, Chauhan S, Kiran U, Hote MP. Echocardio graphic predictors of immediate postoperative outcomes in patients with severe left ventricular systolic dysfunction undergoing on-pump coronary artery bypass grafting. J Cardiothorac Vasc Anesth . 2017;31:184–190. doi: 10.1053/j.jvca.2016.04.025 67. Kumar A, Puri GD, Bahl A. Transesophageal echocardiography, 3-dimensional and speckle tracking together as sensitive markers for early outcome in patients with left ventricular dysfunction undergoing cardiac surgery. J Cardiothorac Vasc Anesth . 2017;31:1695–1701. doi: 10.1053/j.jvca.2017.04.006 68. Zhang K, Sheu R, Zimmerman NM, Alfirevic A, Sale S, Gillinov AM, Duncan AE. A comparison of global longitudinal, circumferential, and radial strain to predict outcomes after cardiac surgery. J Cardiothorac Vasc Anesth . 2019;33:1315–1322. doi: 10.1053/j.jvca.2018.10.031 69. Rong LQ, Yum B, Abouzeid C, Palumbo MC, Brouwer LR, Devereux RB, Girardi LN, Weinsaft JW, Gaudino M, Kim J. Echocardiographic predic tors of intraoperative right ventricular dysfunction: a 2D and speckle tracking echocardiography study. Cardiovasc Ultrasound . 2019;17:11. doi: 10.1186/s12947-019-0161-3 70. Rong LQ, Di Franco A, Rahouma M, Dimagli A, Patel A, Lopes AJ, Walline M, Chan J, Chadow D, Olaria RP, et al. Baseline intraoperative left ven tricular diastolic function is associated with postoperative atrial fibril lation after cardiac surgery. Anesthesiology . 2023;139:602–613. doi: 10.1097/ALN.0000000000004725 71. Kelly BJ, Ho Luxford JM, Butler CG, Huang CC, Wilusz K, Ejiofor JI, Rawn JD, Fox JA, Shernan SK, Muehlschlegel JD. Severity of tricuspid regur gitation is associated with long-term mortality. J Thorac Cardiovasc Surg . 2018;155:1032–1038.e2. doi: 10.1016/j.jtcvs.2017.09.141 72. Asher SR, Malzberg GW, Ong CS, Malapero RJ, Wang H, Shekar P, Kaneko T, Pelletier MP, Mallidi H, Heydarpour M, et al. Joint preoperative transtho racic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality. Interact Cardiovasc Thorac Surg . 2020;32:9–19. doi: 10.1093/icvts/ivaa230 73. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis LD, Hutter AM Jr, et al; on behalf of the Ameri can College of Cardiology and American Heart Association. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) [published correction appears in Circulation. 2005;111:2014]. Circulation . 2004;110:e340–e437. doi: 10.1161/01.CIR.0000138790.14877.7D 74. Sanfilippo F, Johnson C, Bellavia D, Morsolini M, Romano G, Santonocito C, Centineo L, Pastore F, Pilato M, Arcadipane A. Mitral regurgitation grading in the operating room: a systematic review and meta-analysis comparing preoperative and intraoperative assessments during car diac surgery. J Cardiothorac Vasc Anesth . 2017;31:1681–1691. doi: 10.1053/j.jvca.2017.02.046 75. Neuman YM, Brasch AV, Kobal S, Khan SS, Mirocha JM, Naqvi TZ, Siegel RJ. Comparison of transthoracic and intraoperative transesophageal col or flow Doppler assessment of mitral and aortic regurgitation. Cardiology . 2003;99:145–152. doi: 10.1159/000070671 76. Wang H, Oran A, Butler CG, Fox JA, Shernan SK, Muehlschlegel JD. Preop erative tricuspid regurgitation is associated with long-term mortality and is graded more severe than intraoperative tricuspid regurgitation. J Cardiotho rac Vasc Anesth . 2023;37:1904–1911. doi: 10.1053/j.jvca.2023.06.016 77. Uda Y, Cowie B, Kluger R. Comparison of preoperative and intraoperative assessment of aortic stenosis severity by echocardiography. Br J Anaesth . 2017;118:699–704. doi: 10.1093/bja/aex055 78. Whitener G, Sivak J, Akushevich I, Samad Z, Swaminathan M. Grading aortic stenosis with mean gradient and aortic valve area: a comparison between preoperative transthoracic and precardiopulmonary bypass transesopha geal echocardiography. J Cardiothorac Vasc Anesth . 2016;30:1254–1259. doi: 10.1053/j.jvca.2016.05.012 79. Alachkar MN, Kirschfink A, Grebe J, Schälte G, Almalla M, Frick M, Schröder JW, Vogt F, Marx N, Altiok E. General anesthesia leads to underestima tion of regurgitation severity in patients with secondary mitral regurgitation undergoing transcatheter mitral valve repair. J Cardiothorac Vasc Anesth . 2022;36:974–982. doi: 10.1053/j.jvca.2021.10.024 80. Banks DA. Con: mitral regurgitation can be reliably assessed under gen eral anesthesia. J Cardiothorac Vasc Anesth . 2009;23:558–560. doi: 10.1053/j.jvca.2009.05.004 81. Karciauskas D, Mizariene V, Jakuska P, Ereminiene E, Vaskelyte JJ, Nedzelskiene I, Kinduris S, Benetis R. Long-term outcomes and predictors of recurrent aortic regurgitation after aortic valve-sparing and reconstructive cusp surgery: a single centre experience. J Cardiothorac Surg . 2019;14:194. doi: 10.1186/s13019-019-1019-3 82. Stern KW, White MT, Verghese GR, Del Nido PJ, Geva T. Intraop erative echocardiography for congenital aortic valve repair: predic tors of early reoperation. Ann Thorac Surg . 2015;100:678–685. doi: 10.1016/j.athoracsur.2015.05.002 83. Obase K, Jeevanandam V, Saito K, Kesner K, Barry A, Hollatz A, Farooqui F, Addetia K, Roberts JD, Ota T, et al. Visualization and measurement of mitral valve chordae tendineae using three-dimensional transesophageal echocardiography from the transgastric approach. J Am Soc Echocardiogr . 2015;28:449–454. doi: 10.1016/j.echo.2015.01.015 84. Varghese R, Itagaki S, Anyanwu AC, Trigo P, Fischer G, Adams DH. Predict ing systolic anterior motion after mitral valve reconstruction: using intraoper ative transoesophageal echocardiography to identify those at greatest risk. Eur J Cardiothorac Surg . 2014;45:132–137. doi: 10.1093/ejcts/ezt234 85. Pisano C, Calia C, Ricasoli A, Fabio Triolo O, Argano V. Intraoperative trans esophageal echocardiography for surgical repair of degenerative mitral re gurgitation. J Heart Valve Dis . 2017;26:547–556. 86. Grewal J, Mankad S, Freeman WK, Click RL, Suri RM, Abel MD, Oh JK, Pellikka PA, Nesbitt GC, Syed I, et al. Real-time three-dimensional transesophageal echocardiography in the intraoperative assessment of mitral valve disease. J Am Soc Echocardiogr . 2009;22:34–41. doi: 10.1016/j.echo.2008.11.008 87. Chandra S, Salgo IS, Sugeng L, Weinert L, Tsang W, Takeuchi M, Spencer KT, O’Connor A, Cardinale M, Settlemier S, et al. Characterization of degen erative mitral valve disease using morphologic analysis of real-time threedimensional echocardiographic images: objective insight into complexity and planning of mitral valve repair. Circ Cardiovasc Imaging . 2011;4:24–32. doi: 10.1161/CIRCIMAGING.109.924332 88. Maffessanti F, Marsan NA, Tamborini G, Sugeng L, Caiani EG, Gripari P, Alamanni F, Jeevanandam V, Lang RM, Pepi M. Quantitative analysis of mitral valve apparatus in mitral valve prolapse before and after annulo plasty: a three-dimensional intraoperative transesophageal study. J Am Soc Echocardiogr . 2011;24:405–413. doi: 10.1016/j.echo.2011.01.012 89. Jungwirth B, Adams DB, Mathew JP, Swaminathan M, Glower DD, Mackensen GB. Mitral valve prolapse and systolic anterior motion illustrated by real time three-dimensional transesophageal echocardiography. Anesth Analg . 2008;107:1822–1824. doi: 10.1213/ane.0b013e318185d12e 90. Shanks M, Siebelink HM, Delgado V, van de Veire NR, Ng AC, Sieders A, Schuijf JD, Lamb HJ, Ajmone Marsan N, Westenberg JJ, et al. Quantitative assessment of mitral regurgitation: comparison between three-dimensional transesophageal echocardiography and magnetic resonance imaging. Circ Cardiovasc Imaging . 2010;3:694–700. doi: 10.1161/circimaging.110.947176 91. Castillo JG, Anyanwu AC, Fuster V, Adams DH. A near $100\%$ repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg . 2012;144:308–312. doi: 10.1016/j.jtcvs.2011.12.054 92. Benedik J, Wendt D, Perrey M, Price V, Jakob H. Adjustment of aortic an nulus size during David re-implantation (how to do it). Scand Cardiovasc J . 2013;47:245–246. doi: 10.3109/14017431.2013.779018 93. Marino BS, Pasquali SK, Wernovsky G, Pudusseri A, Rychik J, Montenegro L, Shera D, Spray TL, Cohen MS. Accuracy of intraoperative transesopha geal echocardiography in the prediction of future neo-aortic valve function after the Ross procedure in children and young adults. Congenit Heart Dis . 2008;3:39–46. doi: 10.1111/j.1747-0803.2007.00156.x 94. Benjamin ER, Tillou A, Hiatt JR, Cryer HG. Blunt thoracic aortic injury. Am Surg . 2008;74:1033–1037. doi: 10.1177/000313480807401033 95. Santini F, Gatti G, Cannarella A, Mazzucco A. Diagnosis and early surgi cal management of traumatic thoracic aortic disruption. G Ital Cardiol . 1999;29:1426–1430. 96. Sert DE, Karahan M, Aygun E, Kocabeyoglu SS, Akdi M, Kervan U. Prediction of right ventricular failure after continuous flow left ventricu lar assist device implantation. J Card Surg . 2020;35:2965–2973. doi: 10.1111/jocs.14952 97. Essandoh M, Whitson BA. Caval stenosis after bicaval orthotopic heart transplantation: routine transesophageal echocardiography assessment of the caval anastomoses may avert this complication. J Cardiothorac Vasc Anesth . 2020;34:568–569. doi: 10.1053/j.jvca.2019.07.140 98. Bishawi M, Zanotti G, Shaw L, MacKenzie M, Castleberry A, Bartels K, Schroder J, Velazquez E, Swaminathan M, Rogers J, et al. Tricuspid valve regurgitation immediately after heart transplant and longterm outcomes. Ann Thorac Surg . 2019;107:1348–1355. doi: 10.1016/j.athoracsur.2018.10.065 99. Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, Douglas PS, Faxon DP, Gillam LD, Kimball TR, et al; on behalf of the American College of Cardiology; American Heart Association; American Society of Echocardiography. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation . 2003;108:1146–1162. doi: 10.1161/01.CIR.0000073597.57414.A9 100. Kumar N, Essandoh M, Bhatt A, Whitson BA, Sawyer TR, Flores A, Awad H, Dimitrova G, Gorelik L, Bhandary S, et al. Pulmonary cuff dysfunction after lung transplant surgery: a systematic review of the evidence and analysis of its clinical implications. J Heart Lung Transplant . 2019;38:530–544. doi: 10.1016/j.healun.2019.01.005 101. Schrage B, Sundermeyer J, Blankenberg S, Colson P, Eckner D, Eden M, Eitel I, Frank D, Frey N, Graf T, et al. Timing of active left ventricular unload ing in patients on venoarterial extracorporeal membrane oxygenation ther apy. JACC Heart Fail . 2023;11:321–330. doi: 10.1016/j.jchf.2022.11.005 B, Chastre J, Combes A. Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refrac tory cardiogenic shock. Intensive Care Med . 2011;37:1738–1745. doi: 10.1007/s00134-011-2358-2 103. Kim D, Jang WJ, Park TK, Cho YH, Choi JO, Jeon ES, Yang JH. Echocardiographic predictors of successful extracorporeal membrane oxygenation weaning after refractory cardiogenic shock. J Am Soc Echocardiogr . 2021;34:414–422.e4. doi: 10.1016/j.echo.2020.12.002 104. Huang KC, Lin LY, Chen YS, Lai CH, Hwang JJ, Lin LC. Three-dimensional echocardiography-derived right ventricular ejection fraction correlates with success of decannulation and prognosis in patients stabilized by venoarte rial extracorporeal life support. J Am Soc Echocardiogr . 2018;31:169–179. doi: 10.1016/j.echo.2017.09.004 105. Hirose H, Yamane K, Marhefka G, Cavarocchi N. Right ventricular rup ture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation. J Cardiothorac Surg . 2012;7:36. doi: 10.1186/1749-8090-7-36 106. Platts DG, Sedgwick JF, Burstow DJ, Mullany DV, Fraser JF. The role of echocardiography in the management of patients supported by extracor poreal membrane oxygenation. J Am Soc Echocardiogr . 2012;25:131– 141. doi: 10.1016/j.echo.2011.11.009 107. Mazor Dray E, Marelli AJ. Adult congenital heart disease: scope of the prob lem. Cardiol Clin . 2015;33:503–512, vii. doi: 10.1016/j.ccl.2015.07.001 108. Webb G, Mulder BJ, Aboulhosn J, Daniels CJ, Elizari MA, Hong G, Horlick E, Landzberg MJ, Marelli AJ, O’Donnell CP, et al. The care of adults with congenital heart disease across the globe: current assessment and future perspective: a position statement from the International Society for Adult Congenital Heart Disease (ISACHD). Int J Cardiol . 2015;195:326–333. doi: 10.1016/j.ijcard.2015.04.230 109. Brida M, Gatzoulis MA. Adult congenital heart disease: past, present and future. Acta Paediatr . 2019;108:1757–1764. doi: 10.1111/apa.14921 110. Flachskampf FA, Wouters PF, Edvardsen T, Evangelista A, Habib G, Hoffman P, Hoffmann R, Lancellotti P, Pepi M; European Association of Cardiovascular Imaging document reviewers: Erwan Donal and Fausto Rigo. Recommendations for transoesophageal echocardiography: EACVI update 2014. Eur Heart J Cardiovasc Imaging . 2014;15:353–365. doi: 10.1093/ehjci/jeu015 111. Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation . 2019;139:e833–e834]. Circulation . 2019;139:e698–e800. doi: 10.1016/j.jacc.2018.08.1029 112. Medvedofsky D, Mor-Avi V, Byku I, Singh A, Weinert L, Yamat M, Kruse E, Ciszek B, Nelson A, Otani $\mathsf{K},$ et al. Three-dimensional echocardio graphic automated quantification of left heart chamber volumes using an adaptive analytics algorithm: feasibility and impact of image quality in nonselected patients. J Am Soc Echocardiogr . 2017;30:879–885. doi: 10.1016/j.echo.2017.05.018 113. Calleja A, Poulin F, Woo A, Meineri M, Jedrzkiewicz S, Vannan MA, Rakowski H, David T, Tsang W, Thavendiranathan P. Quantitative modeling of the mitral valve by three-dimensional transesophageal echocardiogra phy in patients undergoing mitral valve repair: correlation with intraopera tive surgical technique. J Am Soc Echocardiogr . 2015;28:1083–1092. doi: 10.1016/j.echo.2015.04.019 114. Fatima H, Mahmood F, Sehgal S, Belani K, Sharkey A, Chaudhary O, Baribeau Y, Matyal R, Khabbaz KR. Artificial intelligence for dy namic echocardiographic tricuspid valve analysis: a new tool in echo cardiography. J Cardiothorac Vasc Anesth . 2020;34:2703–2706. doi: 10.1053/j.jvca.2020.04.056 115. Steffner KR, Christensen M, Gill G, Bowdish M, Rhee J, Kumaresan A, He B, Zou J, Ouyang D. Deep learning for transesophageal echocardiography view classification. Sci Rep . 2024;14:11. doi: 10.1038/s41598-023-50735-8 116. Knackstedt C, Bekkers SC, Schummers G, Schreckenberg M, Muraru D, Badano LP, Franke A, Bavishi C, Omar AM, Sengupta PP. Fully automated versus standard tracking of left ventricular ejection fraction and longitudinal strain: the FAST-EFs multicenter study. J Am Coll Cardiol . 2015;66:1456– 1466. doi: 10.1016/j.jacc.2015.07.052 117. Asch FM, Mor-Avi V, Rubenson D, Goldstein S, Saric M, Mikati I, Surette S, Chaudhry A, Poilvert N, Hong H, et al. Deep learning-based automated echocardiographic quantification of left ventricular ejection fraction: a point-of-care solution. Circ Cardiovasc Imaging . 2021;14:e012293. doi: 10.1161/CIRCIMAGING.120.012293 118. Narang A, Mor-Avi V, Prado A, Volpato V, Prater D, Tamborini G, Fusini L, Pepi M, Goyal N, Addetia K, et al. Machine learning based automated dy namic quantification of left heart chamber volumes. Eur Heart J Cardiovasc Imaging . 2019;20:541–549. doi: 10.1093/ehjci/jey137 119. Levy F, Dan Schouver E, Iacuzio L, Civaia F, Rusek S, Dommerc C, Marechaux S, Dor V, Tribouilloy C, Dreyfus G. Performance of new auto mated transthoracic three-dimensional echocardiographic software for left ventricular volumes and function assessment in routine clinical practice: comparison with 3 Tesla cardiac magnetic resonance. Arch Cardiovasc Dis . 2017;110:580–589. doi: 10.1016/j.acvd.2016.12.015 120. Genovese D, Rashedi N, Weinert L, Narang A, Addetia K, Patel AR, Prater D, Gonçalves A, Mor-Avi V, Lang RM. Machine learning-based threedimensional echocardiographic quantification of right ventricular size and function: validation against cardiac magnetic resonance. J Am Soc Echocardiogr . 2019;32:969–977. doi: 10.1016/j.echo.2019.04.001 121. Kusunose K, Abe T, Haga A, Fukuda D, Yamada H, Harada M, Sata M. A deep learning approach for assessment of regional wall motion abnormality from echocardiographic images. JACC Cardiovasc Imaging . 2020;13:374– 381. doi: 10.1016/j.jcmg.2019.02.024 122. Atluri P, Goldstone AB, Fairman AS, MacArthur JW, Shudo Y, Cohen JE, Acker AL, Hiesinger W, Howard JL, Acker MA, et al. Predicting right ventricular failure in the modern, continuous flow left ven tricular assist device era. Ann Thorac Surg . 2013;96:857–863. doi: 10.1016/j.athoracsur.2013.03.099 123. Shad R, Quach N, Fong R, Kasinpila P, Bowles C, Castro M, Guha A, Suarez EE, Jovinge S, Lee S, et al. Predicting post-operative right ventricular fail ure using video-based deep learning. Nat Commun . 2021;12:5192. doi: 10.1038/s41467-021-25503-9