The practice of perioperative medicine is often said to be unique; in what other arena do two or three physicians from completely different specialties work on the same patient, at the same time? As Dr. Stanton Shernan, past chair of the Council on Perioperative Echocardiography, has stated, an echocardiologist (whether they have received formal subspecialty training as an anesthesiologist, intensivist, or cardiologist) is responsible for integrating diagnostic imaging information into the practice of medicine specifically for the intention of using this data to guide clinical decision-making. Thus, the perioperative echocardiologist assumes an important role similar to that of the navigator of an airplane, by directly assisting in the development of a flight plan (approach to the procedure) for the pilot (surgeon or interventionalist) to consider, as decisions are jointly reviewed and discussed. While the practice of perioperative echocardiography has evolved to include various modalities such as transthoracic and three-dimensional transesophageal echocardiography, so has the health care environment in which we practice. Efficiency in resource management is becoming increasingly important, especially in areas such as pre-surgical testing and planning.
As cardiologists, anesthesiologists, intensivists, and surgeons we all play an important role “from door to door” in cardiovascular care for our patients. If we were to survey the ASE membership, the majority of members would most likely indicate involvement in a morbidity and mortality conference, a standard in many institutions and training programs. While most physicians agree to look back on medical errors as a group, how many of us take the time to look forward together? While quality improvement databases, such as the Society of Thoracic Surgeons National Database, and preoperative risk assessment tools, such as the EuroSCORE, exist, these numbers do not often provide the big picture—a look at one patient from many different looking glasses. Just as it is important to know the patient’s greatest presurgical hurdles, the surgical plan is mostly developed around a central theme we should all agree on: the echocardiography examination.
In 2011, the University of Nebraska Medical Center (UNMC) began a bimonthly conference involving key players in echocardiology, interventional cardiology, cardiothoracic anesthesiology, and cardiothoracic surgery with the focus on imaging. Led by Dr. Thomas Porter, Professor of Cardiology and former ASE Feigenbaum Lecturer, patients are presented preoperatively to the collective group with imaging at the core. We review the patient’s transthoracic and transesophageal echocardiograms, computed tomography scans, and cardiac magnetic resonance imaging, and have a frank and open discussion. Every provider has a say in the treatment and course; concerns are addressed, and the team is aware of any “hidden” challenges that may complicate a transition to intervention. Immediate postoperative patients are also discussed, as well as six-month follow-ups on postsurgical patients.
The results of this conference have been quite astounding. Opening up lines of communication, centered on cardiac imaging, has proven to increase communication among team members during and after the procedure. For example, in a patient with significant mitral valve disease undergoing repair, the team decides on appropriate evaluation of concomitant tricuspid valve disease prior to the day of surgery. Patients with ischemic disease with significant ventricular dysfunction are risk stratified and a surgical plan for intraoperative ventricular support is defined. Congenital heart disease patients with significant organ dysfunction are discussed and anesthetic risks determined. This has resulted in fewer surprises in the operating room or hybrid suite, and more availability of appropriate equipment, personnel, and scheduling. Not only has patient care improved, the educational experience has been invaluable. We in cardiac anesthesiology are able to review preoperative pathology, and our colleagues in cardiology are able to see dynamic changes captured in the operating room that may differ from a more static preoperative study. As one colleague stated, this multidisciplinary approach has allowed us to “swim in each other’s waters.”
A multidisciplinary approach to clinical decision making to improve outcomes is not novel. Many hospitals employ multidisciplinary group collaboration for postoperative cardiovascular care and centers involved in transcatheter aortic valve replacement have routine preoperative planning meetings. However, preoperative imaging conferences including colleagues from both anesthesiology and cardiology are a rather unique approach to improve outcomes for general cardiovascular procedures. Because of its success, patients with significant cardiovascular disease requiring noncardiac surgery at the UNMC may also be brought to the table for discussion.
The ASE, through groups like the Council on Perioperative Echocardiography, promotes multidisciplinary collaboration of various specialties committed to excellence in imaging. The COPE, as other ASE councils, seeks to improve education, patient care, and research involving the practice of perioperative echocardiography. COPE appreciates the role that the practice of echocardiography provides to each specialty. Just as diversity of specialization within our membership strengthens our educational meetings and research initiatives, multispecialty imaging collaboration may arguably play its most important role in direct patient care.