Bradley S. Taylor, MD, MPH

Mary Beth Brady, MD, FASE

Confucius is credited with saying “To know what you know and what you do not know, that is true knowledge.” This certainly applies to intraoperative echocardiography and the unique challenges presented during cardiac surgery. The cardiac operating room is a dynamic environment. In many ways, it is stressful, action packed, and fast paced. A team approach that is respectful of its members’ expertise and that utilizes clear communication and standard parlance is paramount for optimal perioperative patient care.

When it comes to perioperative echocardiography, the National Board of Echocardiography is very clear on the requirements needed to attain certification in Advanced Perioperative Transesophageal Echocardiography (TEE). On the other hand, when it comes to the American Board of Thoracic Surgery, the requirements regarding echocardiography are less precise. This regulatory board provides neither definitive numbers nor objective content on the topic. As such, training on this varies dramatically from program to program and surgeon to surgeon. The results of this are often evident in the operating room. Some surgical colleagues are quite facile in echo interpretation, while others strongly depend on the echocardiographer to make the call. This poses the question “What do cardiothoracic surgeons really need to know about echocardiography?” It’s a very important question as the impact of echocardiography results are felt by surgeons on a daily basis. These results might lead to a trip to the OR, to a revised surgical plan, or to additional bypass time. There is much to know in echocardiography, and it takes years to be an expert in the field. With that said, it’s obvious that cardiac surgeons cannot know it all, and making an attempt to do so is totally impractical. Though echocardiography may not be something many cardiac surgeons consider themselves expert in, their perspective on the topic is widely considered critical to patient care. Routinely, cardiothoracic surgeons are included in presentations and panel discussions at national meetings on echocardiography. Their contribution during these meetings is priceless and quite often the highlight of the meeting.

From a cardiac surgeon’s perspective, TEE is essential to the perioperative decision making process as the echocardiographic data acquired, in combination with the hemodynamic status of the patient, is used to formulate a surgical treatment plan. The specific data required varies from patient to patient. It depends on the proposed operation, patient factors that impact the operation, and the anticipated results of the operation. For example, in a standard coronary artery bypass operation it is requisite that biventricular function, general valve function, and atheromatous disease of the aorta be assessed preoperatively. More precise valvular analysis is necessary in the case of valve repair procedures in order to determine surgical approach as well as to predict the likelihood of success. Often the surgical plan is simply confirmed by TEE, however, the surgeon must be prepared to change those plans based on the intraoperative TEE. Ultimately, what the surgeon needs to know depends on patient pathology and his/her ability to fit this pathology into a classification system with the goal to direct the decision making process. In addition, post cardiopulmonary bypass TEE is vital for safe weaning from bypass and for assessing adverse intraoperative events.

Of course, it is important to note that there are many imaging modalities utilized in the treatment of cardiothoracic patients. As such, cardiothoracic surgeons need to be well versed in these modalities as well. They include coronary angiography, computerized tomography, cardiac magnetic resonance, and X-rays. Although they are all certainly of significant value, nothing comes close to the powerful tool of intraoperative echocardiography. As opposed to the other modalities mentioned above, intraoperative echocardiography is unique in a few ways. It is most definitely a dynamic tool, where the findings vary depending on the stage of the case, the procedure itself, inotropic support, or on something as simple as volume status. The previously mentioned modalities are static, with imaging completed prior to or after the surgical procedure; certainly not during the procedure. In addition, intraoperative echocardiography uniquely offers immediate feedback. A diagnosis made in the echo laboratory, the catheterization laboratory, or the radiology suite may take weeks or months to confirm. On the contrary, when it comes to intraoperative echo, the diagnosis can easily be confirmed or refuted once the surgeon opens the heart and reviews the anatomy.

Effective communication with clear articulation of the TEE findings as well as articulation of the surgical plan and/or surgical concerns should be part of the standard preoperative time-out. Through this, the ability to encourage echocardiographic dialogue is increased. As such, even if the topic of the conversion is difficult (i.e. the repair is not perfect, systolic anterior motion of the mitral valve, perivalvular leak, new wall motion abnormality), the actual conversation should not be. This open-minded team work demonstrates the brilliance of Confucius’ wise words that knowing what you know and don’t know is indeed knowledge.

Dr. Bradley Taylor, MPH, is Director of Coronary Revascularization at the University of Maryland Medical Center. He performs robotic assisted coronary artery bypass grafting and hybrid revascularization of multi-vessel coronary artery disease.

Dr. Mary Beth Brady, FASE, is director of the Intraoperative Transesophageal Echocardiography Program at Johns Hopkins University School of Medicine in Baltimore, Maryland, where she is on faculty in the Department of Anesthesiology and Critical Care Medicine.

Both authors serve on ASE’s Council on Perioperative Echocardiography Steering Committee.