[Intraoperative use of three-dimensional echocardiography : A survey of German hospitals]

Since the introduction of three-dimensional transesophageal echocardiography (3D-TEE) in 2007, the technique has been incorporated into the guidelines of both national and international societies for intraoperative and peri-interventional TEE examinations. It is recommended for most cardiac surgical procedures and interventional transcatheter interventions but the actual use in the clinical routine has not been investigated.

Despite its growing adoption, data on the clinical application of 3D-TEE remains limited. To address this gap, the research group, in collaboration with the German Society of Anesthesiology and Intensive Care Medicine (DGAI), conducted a survey of all German departments performing cardiac surgery. The survey aimed to assess the intraoperative and peri-interventional use of 3D-TEE, structural conditions, equipment availability, imaging modalities and potential limitations encountered in daily clinical practice.

A representative individual for echocardiography from each of the 81 German departments offering cardiac surgery was invited via email to participate in a 25-item online survey. The survey was created using LimeSurvey software, and the results were subsequently analyzed. Subanalyses were performed for two subgroups: 1) proportion of certified anesthesiologists in the department (high vs. low certification rate) and 2) presence of a standardized image acquisition protocol (available vs. not available). Responses to the remaining questions were analyzed for these subgroups.

Of the 81 German departments, 54 (67%) completed the questionnaire. More than half of the respondents reported a low TEE certification rate and 82% of departments lacked a formal 3D-TEE training program. Of the departments 4% did not have 3D-capable TEE devices, while 68% of departments had 1 device available per operating room. The 3D-TEE was frequently used in 91% of cases for transcatheter edge-to-edge repair (TEER) of the mitral and tricuspid valves, in 74% of cases for surgical valve procedures and in 57% of cases for coronary artery bypass graft (CABG) surgery. The presence of a standardized 3D image acquisition protocol was associated with more frequent TEE examinations and a greater perceived impact of 3D-TEE on daily cardiac surgical practice. A higher certification rate was linked to more frequent use of 3D modalities, increased use of 3D measurements and greater utilization of 3D-TEE for anatomical understanding and educational purposes. In Germany, intraoperative TEE for common procedures, such as heart valve surgery and bypass surgery is almost exclusively performed by cardiothoracic anesthesiologists. The most significant limitations in daily clinical practice were insufficiently trained personnel (61%) and insufficient time (57%).

The survey reveals that the implementation of 3D-TEE in German departments offering cardiac surgery does not fully align with the recommendations of international guidelines. The reasons for this discrepancy are likely multifactorial. While equipment availability is high by international standards, more than half of the departments report low certification rates. The presence of a standardized 3D image acquisition protocol positively influences the frequency of 3D-TEE use. In Germany, intraoperative TEE is predominantly performed by cardiothoracic anesthesiologists, who play a more central role than their international counterparts. Educational initiatives, the integration of 3D image acquisition into certification programs, enhanced departmental equipment with 3D-capable TEE devices and the implementation of standardized TEE image acquisition protocols could further promote the guideline-based application of 3D-TEE in both surgical and interventional procedures.