TEE at Duke–By Fiona Clements, MD

It was a warm summer’s evening in 1983 at the Carolina Inn. Norbert de Bruijn and I sat, rapt, listening to Dr. Mike Cahalan recount his early experience with TEE at The University of California, San Francisco. The renowned cardiologist, Dr. Kremer, had come over from Hamburg to work with cardiologist Nelson Schiller, and brought TEE into the operating room and the waiting arms of Mike Cahalan.

Norbert and I decided we had to have TEE at Duke. When Dr. Jerry Reves arrived as the new division chief for the Cardiac Division, we announced that this was our ambition. Dr. Reves, who came to Duke from the University of Alabama at Birmingham (UAB), recalled that UAB had a Diasonics machine languishing unloved in an anonymous warehouse that could be expediently diverted to Duke.

Knowing we should soon have our hands on this converted gastroscope, Norbert and I hastened over to the Duke South Clinics for an appointment with Dr. Joseph Kisslo, pre-eminent echocardiographer, developer of the phased array transducer, founder member of the American Society of Echocardiography, and conveniently, Duke faculty and director of the echo lab. Joe was excited at the idea of introducing TEE at Duke. What luck! What expertise! What an incredible teacher! Joe came frequently into the operating room and gave freely of his own time and that of his first class echocardiographers, notably David Adams, and his own wife, Kitty Kisslo. There was none of the resentment, suspicion, or turf-tension that is sometimes found between cardiologists and anesthesiologists.

Joe was a valuable consultant to Hewlett-Packard. When HP developed its TEE probe with Doppler color flow, Joe received a prototype and promptly brought it over to the operating room. Consequently, we were using TEE with color flow before most cardiologists had even seen color for their regular echo studies. Even in 1989 when HP supplied me with a machine at the Royal Melbourne Hospital in Australia, it was the only machine with color flow in the entire hospital.

Our first book on TEE was painfully put together in 1987 with the early, primitive word processing program available at the time. Dr. Sabiston kindly referred to our “little monograph” when Norbert and I were invited to give Grand Rounds to the Department of Surgery. A second book followed in 1991, but was almost dated by the time it was published, as single plane and bi-plane transducers were supplanted by omniplane imaging. The early transducers had only 32 piezoelectric elements. This quickly increased to 64, and then to 128 elements, with improvements in image quality occurring also through rapid changes in software processing.

Because color flow came on the scene about the time that Dr. Alain Carpentier introduced mitral valve repair techniques, everyone realized that intraoperative TEE was becoming indispensible. At Duke, the responsibility of interpreting the intraoperative images fell to the anesthesiologist. However, none of us had the least reservation about calling Joe or another cardiologist-echocardiographer if anything was in question. The collegial relationship had been established.