TOE is now commonplace in the cardiac operating theatre and critical care setting. The practising cardiac anaesthetist must be fully trained and proficient at performing TOE, both as a haemodynamic monitor and as a diagnostic tool. This chapter will cover the basic physics of ultrasound and Doppler, the indications and contraindications of TOE and the format of a comprehensive TOE examination.

The heart is the driving force behind this system. It consists of a right-sided low-pressure pump and a left-sided high-pressure pump. Each of these pumps is composed of an atrium and a ventricle. The atria prime the ventricles which in turn eject the cardiac output into either the pulmonary or the systemic circulation. This chapter examines the heart and its functions.

Over the past decade there has been a dramatic increase in the use of transoesophageal echocardiography (TOE) in the perioperative setting among all disciplines caring for the cardiac patient. Where TOE used to be used mainly by cardiologists in the echocardiography laboratory, we now recognize its value in the operating theatre, cardiac catheter laboratory, and intensive care unit. TOE has become the gold standard perioperative cardiac monitor and diagnostic tool for certain cardiac surgical procedures. Its role has also been extended to critically ill or unstable patients for non-cardiac procedures and the general intensive care arena. The increasing involvement of anaesthetists and of other specialities at an advanced level has promoted the team approach to perioperative patient care. The rapid advances in the use of this technology have also resulted in a critical need for interdisciplinary training.

The development of training and certification in echocardiography has been a long and intensive process in Europe and the USA. Excellent comprehensive TOE courses have been available and working groups on TOE have published extensive practice and training guidelines on both sides of the Atlantic and in Japan. The American Society of Cardiovascular Anesthesiologists (SCA) developed the first formal examination in perioperative TOE in 1998. The SCA and the American Society of Echocardiography (ASE) then combined forces to establish the National Board of Echocardiography (NBE), which had the responsibility to further administer examinations and develop a certification process in clinical echocardiography.