The Accidental Echocardiographer

James D. Thomas, MD, FASE, FACC, FAHA, FESC

Do you recall the first time you encountered echocardiography? The first time you realized that sound could be used to make pictures of the heart? And do you remember the people and events that made you want to make echocardiography a part of your life? For me, it was the summer of 1979 during my medicine clerkship at the Beth Israel Hospital in Boston. I had an elderly patient who presented with fever and bacteremia with a loud diastolic descrescendo murmur. We ordered an echo and soon the patient was in the skillful hands of Dr. Patricia Come, head of the Best Israel echo lab, who guided the M-mode probe (yes, I hail from the Paleozoic era of echo) over his chest to detect the tell-tale echo density on the aortic valve prolapsing in and out of the left ventricular outflow tract. The patient was treated with antibiotics and soon sent to the operating room for a curative aortic valve replacement. Amazing! In five minutes, Dr. Come had made a diagnosis that might have saved a man’s life. I was fascinated by this technique, but equally adamant that I would never want to spend my life as the “echo guy”. So much for my powers of self-direction!

As my training progressed, I kept coming across cases where echo was pivotal in patient management, noting the dramatic progress in echo technology: 2D echo, pulsed Doppler, continuous wave Doppler, and color—(wow!)—Doppler. In my cardiology fellowship at the University of Vermont, Tom Gibson and Burt Tabakin infected me once and for all with the echo bug. These two attendings, who each had taken late-career sabbaticals to master this evolving technique, showed me how Doppler could be used to tease out the hemodynamics of a case and gave me the idea that my undergraduate studies in physics and fluid dynamics could be used in research to push the echo field forward. This led me to my most influential mentor, Ned Weyman at Massachusetts General Hospital, who taught everyone in his lab the importance of asking important questions and answering them carefully. My stay in the Mass General lab also taught me the critical value of collaboration, with my early “fellow fellows” Gerry Wilkins and Chris Choong, the other staff members Bob Levine, Mary Etta King, and Mike Picard, and all the fellows and sonographers in the lab. Very few questions of any importance can be answered by a single person. It takes a team, bringing together many different skills, to address complex research and clinical issues. My last 19 years at the Cleveland Clinic have only emphasized these lessons, the importance of teamwork, collaboration, and friendship.

And my, how echocardiography has progressed during my career! It must be difficult for today’s fellows to imagine a time when the echo lab was not the hub of cardiology, a diagnostic nexus through which virtually all cardiovascular patients pass in their assessment and treatment; a time when patients went to the cath lab to diagnose aortic stenosis or mitral regurgitation; when there was no TEE, no stress echo, no 3D, no contrast, no strain; when surgeons operated blindly without the guidance and safety net of intraoperative echo; and when assessment of diastolic function required conductance and Millar catheters.

In spite of all this glory, the echocardiography community today can sometimes feel under siege. Reimbursement is cut on a yearly (or is it monthly?) basis; the rigors of accreditation, certification, and licensure grow ever more onerous; and we face a period of great change as we accommodate millions of new patients and adjust to entirely new models of care. And we are no longer the shiny new toy on the fellows’ toy shelf, as CT and MRI threaten to lure away the best and the brightest of our young trainees.

Standing foursquare for all that echo is now and can be in the future is the ASE. As we enter our 37 th year as an organization, ASE is the leading advocate for excellence in cardiovascular ultrasound in the United States and around the world. As a society of over 13,000 members with 22 outstanding full-time staff at our North Carolina headquarters, we provide the most (and best) education, drive an ever widening array of guidelines, fight for appropriate support for quality in echo services, and promote the research and technological developments that will lead us into the future. I am deeply honored for the opportunity to serve as your president and hope that I may be worthy of your confidence. In upcoming president’s pages, I will focus on some of the key initiatives for the year: promoting standardization and interoperability in strain assessment, expanding our international outreach (exemplified by this month’s first World Summit of Echo Societies in Buenos Aires), fighting to increase research funding in echocardiography, working to preserve and enhance support for clinical echocardiography, and building the ASE Foundation into a potent force to promote our missions.

For the moment, however, I would like all reading this to reflect for a moment just how fortunate we are to be associated with echocardiography. I know we all have had numerous ah-ha moments—placing the transducer and instantly diagnosing the myxoma responsible for the patient’s dyspnea, piecing together the Doppler and imaging data to prove the flail mitral valve—that completely change the course of our patients’ lives. It is a privilege indeed to help so many people with an exciting, ever-changing technique. And please think about the people who got you into this field in the first place and let them know how grateful you are for their inspiration, as I hope I have done in this column.

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Jun 11, 2018 | Posted by in CARDIOLOGY | Comments Off on The Accidental Echocardiographer
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