Ken Horton RCS, RDCS, FASE

Do you remember the day when you would pick up the phone and learn that there was a stat echo in the cath lab? You would get a surge of adrenaline, gather up your machine, and head there with thoughts of a crashing patient, hypotensive, maybe CPR in progress, and arrive to a scene of chaos with people everywhere, everyone talking at once, packages being torn open—needles and catheters being dropped on a sterile field. You would have to squeak your machine into a tight place and get it fired up, and suddenly all eyes were on you as they looked to you for an answer as to why this patient is coding. It is probably one of the most stressful things that we do as sonographers, but for me it is also one of the more rewarding. And while a lot of us still go through that scenario regularly, there is a new role emerging for sonographers in the cath lab.

Over the last 5 years or so, an increasing number of complex interventional procedures are placing more and more sonographers in the cath lab under more controlled situations. We are being required to assist with the imaging of patients in ways that have never been asked of us before. Transcatheter aortic valve interventions (TAVI), percutaneous mitral valve repair, percutaneous perivalvular leak closures, percutaneous pulmonary valve replacement, and left atrial appendage closure devices are all procedures that sonographers are commonly finding on the echo lab schedule. Many facilities have now constructed “hybrid labs” that combine the equipment and function of a cardiac cath lab with that of a full on operating suite. These hybrid labs are sterile environments where, if needed, your case can go from cardiac cath procedure to open heart surgery via a complete thoracotomy within minutes. In preparation for this expanding of our horizon, I would like to share some of my thoughts and some of the challenges that our facility has experienced in this migration of our sonographer staff into the cath lab.

I think assisting with these complex interventional procedures is going to bring our field to a whole new level and perhaps provide an opening for another new pathway for sonographers. In addition to the procedures already mentioned, more are being developed that will require us to spend more and more time in the cath lab. I can even see the day when cath lab managers will hire their own full time sonographers to work full time in the cath lab. I have also already been asked about the possibility of developing an “interventional sonographer” credential. So I say to you: be prepared to wear scrubs, lead aprons, and radiation badges.

Getting a sonographer ready to assist with these cases takes some time. We all learn cardiac anatomy in school and we are faced with questions about it every day, but I suggest you be prepared to bring your knowledge of cardiac anatomy to a whole new level. Most of these procedures involve transesophgeal echo (TEE), so you will have to have a thorough understanding of what you are looking at with TEE. Be prepared to be asked questions like: “Is that the P2 or P3 segment of the mitral valve? Which pulmonary vein is that? Show me that in three-dimensional from the ventricular side.” It is all stuff that we can learn, but it will take some time and mentoring by your physicians and senior sonographers and it can be a little intimidating. If you look at the preliminary program for this year’s Scientific Sessions you will find a fair amount devoted to interventional procedures, including a live telecast of a TAVI procedure from the Washington Hospital Center.

I would like to tell the managers that implanting these devices and performing the follow-up echoes on these patients already comprises a fair amount of our schedule. We have performed as many as 3 implantation procedures in one day, which can easily mean a 12 hour day in the cath lab. Follow up echoes can take up to an hour because they are so detailed and the data is so important to the patient and to the trial. Staffing your labs can be a challenge, as the interventional schedule in the cath lab is a moving target, with cases being added and dropped from the schedule at a moment’s notice. These procedures can really play havoc with your full-time equivalents and relative value units because the lab receives the same credit for a tech tied up in the cath lab for 3-4 hours gets as it gets for one who assists with an intra-operative TEE in the OR for 20-30 minutes. You will need to allow more time for training and education of your sonographers for working in a sterile environment, for a better understanding of detailed cardiac anatomy, for radiation safety and the additional risks of prolonged esophageal intubation and imaging in these rather lengthy cases.

I recommend that sonographers learn as much as they can about these procedures because they are undoubtedly here to stay and will be more and more part of our daily routine. Many of these patients are very, very sick, with little or no room for complications, and sonographers have to be able to quickly identify what is happening and be ready to assist with the images that will be needed. Use resources such as meetings, publications, Webcasts, and your co-workers to be more aware of these procedures and the role of the sonographers in your particular setting. And for the managers, the time is now to begin preparing your staff, equipment, schedules and budgets. Network with managerial colleagues who are going through this expansion to get tips from them about how it affected their department and how they are dealing with the changes.

In my very first Society column I mentioned that we are always at a crossroad in our profession, and this is a prime example of that. “Interventional ultrasound” has arrived and it is going to continue to grow. Let’s all embrace that challenge. Let’s show how we “use ultrasound to provide an exceptional view of the cardiovascular system to enhance patient care.”