EDITORIALWhen I Do a TEE, Am I Ready for What Comes Next?

THE E-CHALLENGES FORMAT lends itself well todiscussions about cases that present dilemmas that force

us to think about the way we practice each day. The casepresented by Garcia-Jacques1 and colleagues poses someinteresting predicaments for anesthesiologists. While peripheralvascular disease is a common clinical entity, such dilemmasamong surgical candidates are unusual. Therefore, the ques-tions posed by this case are relevant to those of us who manageanesthesia for surgical patients with limb ischemia. Most of thepreoperative imaging workup of this patient revealed enoughinformation to warrant the surgical procedure. However, thetransthoracic echocardiogram (TTE) that was performed wasinadequate to determine any intracardiac origin of a thrombusor any intracardiac shunt that could have facilitated a systemicembolic event. It is intriguing that the authors decided toproceed with general anesthesia rather than a regional techni-que. Perhaps the need for an intraoperative transesophagealechocardiogram (TEE) in light of an inadequate TTE study wasthe deciding factor that tilted the balance of the choice ofanesthetic technique in favor of general anesthesia. Once theTEE was performed and revealed extensive aortic atherosclero-tic disease including an intramural thrombus, there werequestions about subsequent management options. Thissequence of events highlights the 1 question that should beinevitably asked before any diagnostic study: What should bedone if the test is positive? The TEE was undertakenpresumably to rule out an intracardiac embolic source orintracardiac shunt. The possibility of an aortic source ofembolism may not have been considered. Regardless, did themanagement team consider the ‘what if’ scenario? What ifthere was a PFO? What if there was a left ventricularthrombus? What if there was a left atrial appendage clot? In

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addition, there was the 1 question that arose after the finding ofthe intramural thrombus: What do we do now?

If the decision to perform a TEE was simply to getinformation and make any therapeutic decision later in con-sultation with the patient and their primary care team, then anyinformation obtained would be valuable and relevant. In thatcase, any discussion of what we would do now is irrelevant.However, if this was not considered prior to performing a TEE,this case provides a valuable lesson for all intraoperativeechocardiographers, that we must consider the consequencesof our actions or, specifically in this case, all possibilities thatcould arise from a diagnostic TEE study.

Had the surgery and anesthesia team considered theprincipal question of what should be done if the test is positiveor negative, then there would have been a clear path forward,and any dilemmas would have been minimized. We allrecognize that the clinical setting is a noisy one and thatclinical decision making is dependent on multiple factors,several of which are difficult to quantify and describe. Theauthors are to be commended for presenting this e-challenge. Itpresents a scenario that is seen infrequently, but a dilemma thatis experienced often and a question that must be asked always.

Madhay Swaminathan, MD*

Feroze Mahmood, MD†

*Department of AnesthesiologyDuke University Health System

Durham, NC†Department of Anesthesiology

Beth Israel Deaconess Medical CenterHarvard Medical School

Boston, MA

REFERENCE

1. Garcia-Jaques M, Montealegre-Gallegos M, Matyal R: Acute limbischemia and transesophageal echo–Making a case. J CardiothoracVasc Anesth 28, 2014

oracic and Vascular Anesthesia, Vol 28, No 4 (August), 2014: pp 1178