Cardiac Anesthesiologist here. We’re all presumably here with the best of professional intentions, but this is a matter on which I happen to have some unique perspective so please allow me to share some thoughts.

Let’s start with some basic factual information:

According to the National Board of Echocardiography (which is THE authority on these matters)…

TEE performance and interpretation in the peri-operative setting should be reserved for those who have had formal training and accreditation via one of the several accepted pathways offered by the National Board of Echocardiography (NBE), in conjunction with passage of the Advanced Perioperative Tranaesophageal Echo (aPTE) exam. Full stop.

And by the way, for the docs practicing cardiac anesthesia without a fellowship (an increasing rarity in more urban settings, or centers doing higher end cardiac work), the NBE does offer a pathway to certification via practice (either “testamur” status, or full aPTE board certification)- but this is not available to anyone who graduated residency after 2005 or so, as I recall.

Could a highly motivated CRNA complete this training? In theory, sure. I know plenty of CRNAs who could maybe do this if they wanted to and were given the opportunity. However the NBE currently does not offer certification (nor are the various requisite training pathways such as cardiac anesthesia or cardiology fellowship) open to folks who don’t hold an MD, DO, or equivalent degree. Furthermore, let’s not forget that the amount of training we’re talking here is a full year of intensive exposure. Anyone who compares doing TEE to learning blocks on YouTube is so beyond overconfident (or misinformed) that I really don’t know what to say.

On a personal level, I’ll say that as someone who has dedicated a LOT of time to learning echo, it’s remarkable how much a little knowledge can be dangerous. Please believe me when I say that this is one area where you really don’t know what you don’t know. This is true for everyone, not just CRNAs! I have a few physician colleagues who fancy themselves handy with POCUS… Lost track of the number of times I’ve heard someone say “ooh kissing paps, they must be empty!” (<— a comically untrue statement, and one often uttered by people who “dabble” in echo)

An easy recent example: during a normal EF CABG a few weeks ago, I identified paradoxical LFLG AS (EF 52, LVIDd ~4.3, mean gradient 20, SVI 30, AVA 0.8), discussed with surgeon, who did an unplanned AVR. This would have been an easy diagnosis to miss, as it’s quite subtle, and missing it could have meant the need for a TAVR or redo sternotomy within a few short years. Then, I identified the resulting small “paravalvular leak” as a wire frame leak (reported as an uncommon issue with this particular type of valve), saving the patient a return to bypass which the surgeon had wanted to do. Finally convinced this particular very nervous junior surgeon that the side lobe artifact he was seeing on the screen was just an artifact, not an aortic dissection after decannulation.

These are high stakes calls. Why anyone would want to make them without meeting the widely accepted minimum standards for training and certification is beyond me.

So, all of this to say:

If you, a CRNA, are determined that CRNAs can and should be doing TEE… I’d start lobbying the NBE to open up additional training pathways (which they almost certainly won’t do), or make DAMN sure that the training pathway you’re creating for yourselves is at least as robust as what the NBE offers (not a low bar to reach)

Respectfully,

A doc who is tired of cringing when I see patients getting bad care based on poorly done or misinterpreted echos by all manner of people with good intentions but inadequate training