ASE POSITION PAPER Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists Scott T. Reeves, MD, FASE, Kathryn E. Glas, MD, FASE, Holger Eltzschig, MD, Joseph P. Mathew, MD, FASE, David S. Rubenson, MD, FASE, Gregg S. Hartman, MD, and Stanton K. Shernan, MD, FASE, for the Council for Intraoperative Echocardiography of the American Society of Echocardiography, Charleston, South Carolina; Atlanta, Georgia; Tübingen, Germany; Durham, North Carolina; La Jolla, California; and Lebanon, New Hampshire During the last few decades, the utility of intraop- erative echocardiography has become increasingly evident as anesthesiologists, cardiologists, and sur- geons continue to appreciate its potential applica- tion as an invaluable tool for monitoring cardiac performance and diagnosing pathology in patients undergoing cardiac surgery. 1,2 The essential infor- mation provided by intraoperative echocardiogra- phy regarding hemodynamic management, cardiac valve function, congenital heart lesions, and great vessel pathology has contributed to its widespread popularity. In fact, perioperative echocardiography has been shown to influence cardiac anesthetic and surgical management in as many as 50% of cases. 3 The publication of guidelines describing the indica- tions for performing intraoperative echocardiogra- phy based on reviews of the literature and expert opinion of task force members from the Society of Cardiovascular Anesthesiologists (SCA), American Society of Anesthesiologists, and American Society of Echocardiography (ASE) has also facilitated the growth of this important diagnostic tool. 4,5 Despite its overwhelming popularity and favor- able influence on perioperative clinical decision- making and outcomes, 1,2,6 the transesophageal echocardiographic (TEE) approach to a comprehen- sive echocardiographic examination has some limi- tations. For example, TEE imaging of the distal ascending aorta and aortic arch may be impaired by the interposition of the trachea and main bronchi. 7-9 In addition, a TEE probe may occasionally be diffi- cult or impossible to advance into the esophagus or, in patients with significant gastroesophageal pathol- ogy, TEE probe placement may even be contraindi- cated. 10 Furthermore, TEE may be rarely associated with perioperative morbidity from oropharyngeal and gastroesophageal injury (eg, dysphagia, gastro- intestinal hemorrhage, gastroesophageal rup- ture). 10,11 Thus, an experienced echocardiographer must be familiar with other imaging approaches to conduct a comprehensive perioperative echocardio- graphic examination. More than a decade before the introduction of TEE, epicardial echocardiography was already in use as a diagnostic imaging modality to assist cardiac surgeons, anesthesiologists, and cardiologists with clinical decision-making. 12 A comprehensive epicar- dial echocardiographic examination can be per- formed efficiently and safely, 13 and may be the most practical intraoperative imaging technique when a TEE probe cannot be inserted or when probe place- ment is contraindicated. Epicardial echocardiogra- phy may be superior to TEE because it can provide optimal image resolution when using higher fre- quency probes. 14 In addition, epicardial echocardi- ography may offer better windows for imaging anterior cardiac structures including the aorta, aortic valve (AV), pulmonic valve, and pulmonary arteries, and, therefore, may have a favorable influence on perioperative surgical decision-making. 15,16 How- ever, epicardial imaging requires direct access to the anterior surface of the heart, and consequently cannot be performed without a sternotomy. Further- more, the epicardial approach does not permit continuous monitoring, and requires interruption of the surgical procedure for imaging. From the Medical University of South Carolina (S.T.R.), Emory University School of Medicine (K.E.G.), Tübingen University Hospital (H.E.), Duke University Medical Center (J.P.M.), Scripps Clinic (D.S.R.), Dartmouth Hitchcock Medical Center (G.S.H.), Brigham and Women’s Hosptial (S.K.S.). Members of the Council for Intraoperative Echocardiography are listed in the Appendix. Reprint requests: American Society of Echocardiography, 1500 Sunday Dr, Suite 102, Raleigh, NC 27607 (E-mail: aprather@asecho.org). J Am Soc Echocardiogr 2007;20:427-437. 0894-7317/$32.00 Copyright 2007 by the American Society of Echocardiography. doi:10.1016/j.echo.2007.01.011 427