ROTATION: Transesophageal Echocardiography / Advanced Cardiovascular Anesthesia Rotation  (TECV) 
TYPE: Elective (CA-3 rotation) 
DURATION: 1 month
FACULTY:  Gregory Janelle, MD (TEE and CV)
PREREQUISITES: Completion of cardiovascular anesthesia rotations; available elective time
TEE Basic Rotation (TEE portion of TECV)

General Goal:  After completing the TEE Basic course rotation the Anesthesiology resident will competent to perform a basic TEE exam including recognizing wall motion abnormalities and normal / abnormal valvular function.

PATIENT CARE SKILLS

  • Be able to properly and safely insert a TEE probe into an anesthetized patient
  • Complete a basic TEE examination, including evaluation of left ventricle function, heart valves, and aorta
  • Be able to demonstrate the three primary views used for intraoperative TEE to examine the heart and great vessels
  • Measure normal cardiac dimensions, area and volume
  • Measure global systolic function and recognize abnormal systolic function
  • Recognize the different segments for regional wall motion analysis and the numeric scoring system

Basic Evaluation of the Aortic Valve

  • Demonstrate the three primary views used for intraoperative assessment of the aortic valve
  • Recognize the normal aortic valve leaflets, velocities, area and opening
  • Calculate the aortic valve area using the continuity equation
  • Perform a basic assessment of aortic valve stenosis and regurgitant lesions

Basic Evaluation of the Mitral Valve

  • Recognize the normal mitral valve leaflets, velocities, area and opening
  • Recognize the typical 2D echocardiographic features of mitral stenosis
  • Learn the basic assessment of mitral valve regurgitation and prolapse
  • Basic Evaluation of the Aorta
    • Learn the views used for intraoperative assessment of the ascending, arch and descending aorta
    • Identify the typical 2D echocardiographic features of aortic dissection
    • Identify the typical 2D echocardiographic features of atheromatous plaque in the aorta
    • Recognize abnormal cardiac function that requires immediate therapy.
    • Be able to assess the results of therapy on cardiac function
    • Be able to evaluate the hemodynamically unstable patient - specifically:
      • Identify the typical 2D echocardiographic features of  pericardial tamponade
      • Identify the typical 2D echocardiographic features of  severe right and left ventricular dysfunction
      • Identify the typical 2D echocardiographic features of pulmonary embolus
      • Identify the typical 2D echocardiographic features of hypovolemia
      • Identify the typical 2D echocardiographic features of atrial and ventricular septal defects
      • Be able to recognize when findings are beyond your expertise level and you need to call for help.
        •

    MEDICAL KNOWLEDGE

    • Understand the basic principles of ultrasound and how it is incorporated into 2D Echo, Spectral and color Doppler echocardiography;
    • Understand the difference between continuous and pulse wave Doppler ultrasound and their different applications
    • Know basic cardiac anatomy and be able to recognize corresponding structures on a TEE examination
    • Understand the indications, limitations, contraindications, and complications of TEE
    • Learn different artifacts that may interfere with reading an echocardiographic image, i.e. reverberations, side lobes and shadowing

    • Typical Rotation Schedule  (2 weeks during TECV rotation)

    1st Monday     7:30-8:00 am Welcome, Introduction and distribution of Basic materials -
                              Resident's Library - Kristen Imler and CV faculty

    8:15-10:30 am         Internal Jugular Vein US examination
                                                    Hands-on intraoperative TEE examination in OR 6&7
                                                   Kristen Imler , CV Anesthesia Attending Physicians

                10:45-12:00 pm      Workshops: Discussion of Basic Topics - CV Attending OR 6 or 7

                               1st Monday: Basic Principles of 2D Echo
                               1st Tuesday: Basic Principles of Spectral and Color Doppler
                               1st Wednesday: Basic cardiac anatomy & TEE
                               1st Thursday: Global and Regional LV Function
                               1st Friday: Basic Evaluation of the Aortic Valve

                               2nd Monday: Basic Evaluation of the Mitral Valve
                               2nd Tuesday: Basic Evaluation of the Aorta
                               2nd Wednesday: Evaluation of the Hemodynamically   Unstable patient
                               2nd Thursday: Indications, Complications and pitfalls
                               2nd Friday: Simulator hands-on training session CV case Monica Botero, MD

                1:00 - 3:30 pm     Interactive Hands-on review on Basic topics - Kristen Imler, CV Faculty      

    PLEASE NOTE:  YOU MUST KEEP A LOG OF THE CASES WHERE YOU PERFORM A COMPLETE EXAM.  THE LOG MUST CONTAIN THE DATE, MAJOR DIAGNOSIS, AND OPERATIVE PROCEDURE.  THIS LOG MUST BE TURNED IN TO THE RESIDENCY OFFICE (DEBBIE BROWN) AT THE COMPLETION OF THE ROTATION, AND YOU SHOULD KEEP A COPY FOR YOURSELF.  ALSO, AT THE COMPLETION OF THE ROTATION, YOU MUST OBTAIN A CERTIFICATE OF BASIC COMPETENCE IN TEE USE AS AN OR MONITOR FROM DR. PENG.  A COPY OF THE CERTIFICATE MUST ALSO BE TURNED IN TO THE RESIDENCY OFFICE (DEBBIE BROWN), AND YOU SHOULD KEEP A COPY.  WITHOUT THE LOG AND CERTIFICATE, I WILL BE UNABLE TO VERIFY TO CREDENTIALING HOSPITALS THAT YOU HAVE COMPLETED APPROPRIATE TRAINING SATISFACTORILY TO USE TEE AS PART OF YOUR ANESTHETIC CARE.

     

    Cardiovascular Anesthesia (2 weeks during TECV rotation)

    Goals: In addition to those outlined for the basic rotation in Cardiothoracic Anesthesia:

    • Expand the knowledge base with regards to cardiovascular and pulmonary physiology and pharmacology and pathophysiology developed during CA-1 and CA-2 years. 
    • Develop clinical judgment to provide anesthetic care for more complex cardiovascular and thoracic procedures. 
    • Develop technical skills necessary to conduct more complex cardiothoracic cases.
    • Gain sufficient experience for independent practice of high-volume cardiovascular anesthesiology in private practice.  

    Patient Care Skills and Medical Knowledge: In addition to those outlined for the basic rotation in Cardiothoracic Anesthesiology:

    • Be able to complete a thorough preoperative evaluation for all cardiothoracic patients, 
      recognizing impact of their disease states on perioperative management. For routine cardiothoracic procedures, accomplish preoperative preparation and anesthetic planning independently.  For complex procedures, preoperative preparation and planning will occur with assistance from the attending anesthesiologist as needed and as appropriate.
    • Plan and carry out anesthetics for routine cardiothoracic procedures with minimal assistance from the attending physician. 
    • Perform anesthetics for complex cardiothoracic procedures with as needed assistance from the attending anesthesiologist. 
    • Perform all invasive monitoring techniques and interpret information obtained reliably with minimal assistance from the attending anesthesiologist. 
    • Develop beyond a basic understanding of transesophageal echocardiography, be able to insert the probe.  Be able to obtain and interpret 4-chamber and short-axis views, recognize most common pathology including valvular lesions and wall motion abnormalities.  Be aware of and able to discuss documented advantages and disadvantages of the use of TEE monitoring during cardiothoracic procedures. 

    INTERPERSONAL AND COMMUNICATION SKILLS, PROFESSIONALISM

    • See general competencies section
    • Function as a consultant regarding cardiovascular function to Anesthesiology and Surgical Colleagues during surgery
    • Learn to interact professionally and compassionately with these often critically ill patients and their families

     PRACTICE-BASED LEARNING AND IMPROVEMENT

    • See general competencies section
    • Vascular section:  Function simultaneously as the anesthesiologist for the case and as the person responsible for TEE monitoring and interpretation
    • Rapidly assess and prepare the vascular patient requiring emergency surgery

    SYSTEMS-BASED PRACTICE

    Evaluation to Determine Goal Achievement 

    • Performed by the TEE rotation coordinator, Dr. Greg Janelle and the attending anesthesiologists involved with cardiovascular anesthesiology. 
    • Basis for evaluation 
      • Daily (if possible) discussions based on your cases of the day and the readings 
      • Completion of assigned duties
      • Faculty assigned to the cardiovascular ORs will be requested to complete
        an on-line resident evaluation form if they had significant contact with you during any case. 
    • You will complete a Departmental Rotation Evaluation Form, which will be shared periodically with the rotation director 

    Teaching Resources to Accomplish the Objectives 

    • Patients 
      • TEE: up to 80 patients per month undergoing cardiovascular, vascular, and other procedures
      • Cardiovascular Surgery (See CV Rotation)
    • Reading material
      • Texts 
        • Sako: Transesophageal Echocardiography 
        • De Brujin and Clemens: Perioperative Transesophageal Echocardiography
      • Reading file provided by the Department containing handouts and peer-reviewed articles. (Classic Anesthesia Articles Library)
    • Faculty
      • TEE and CV Anesthesia: Laurie K. Davies, M.D.; Nikolaus Gravenstein, M.D.;Gregory Janelle, MD; Emilio B. Lobato, M.D.; David A. Paulus, M.D.; Yongang Peng, M.D., Ph.D., Albrecht Wobst, MD, PhD, Felipe Urdaneta, MD

    Dr. Peng is the faculty members responsible for this rotation.

    RETURN TO INDEX FOR GOALS AND OBJECTIVES
    Revised 7/14/2006