David Rubenson, MD, FASE

As a long-time echocardiographer there are days when I wonder: “Where is my home?” At the end of the day, I have interpreted echocardiograms in the echo laboratory and the stress lab, answered questions for colleagues about difficult and vexing echos, and spent time in the operating room, the cardiac catheterization laboratory, the electrophysiology suite, the ICU, and the congestive heart failure clinic. “Homebase” for the echocardiographer, whether a physician or a sonographer, seems to be just about anywhere in the Clinic and hospital these days.

Every patient with important cardiovascular disease is evaluated, at some point, with an echocardiogram as the technique extends beyond its historical use only as an imaging tool. The echocardiography service is now the most important for hemodynamic and physiologic assessments, the study of myocardial mechanics, and increasingly clinically critical three-dimensional display of anatomy. In my opinion, however, what has really altered the workplace for the echocardiographer are those advances that involve collaboration with others during structural interventions.

The variety, complexity, and rapidly-increasing numbers of these collaborative interactions impact the practices of physician echocardiographers, virtually all of whom have other clinical duties. For sonographers the laboratory workflow is increasingly unpredictable. An incomplete list of the more common procedures and locations might include the following:

In the operating room : cases of valvular heart disease, particularly valve repair, assessed pre and post-pump for adequacy of repair and unanticipated findings;

In the stress laboratory : hemodynamic manipulation and assessment in cases of aortic and mitral valve disease to determine timing and suitability for operative intervention;

In the congestive heart failure clinic : optimization of cardiac resynchronization devices, assessment of fluid status, and hemodynamics.

In the cardiac catheterization, electrophysiology laboratory or “hybrid suite” :

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  guidance of transseptal puncture, alcohol septal ablation, aortic and mitral balloon valvuloplasty, pericardiocentesis, myocardial biopsy, closure of atrial and ventricular septal defects and paravalvular leaks;

  
  
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  excluding thrombus in the left atrial appendage;

  
  
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  guidance and assessment during percutaneous valve implantation, and placement of atrial appendage occlusion devices.

In the intensive care unit and emergency department : provide bedside, non-invasive hemodynamic guidance in critically ill patients.

An excellent current example is the critical role of echocardiography in transaortic valve implantation (TAVI). Structural interventionalists, cardiac anesthesiologists, cardiovascular surgeons, sonographers, and clinical cardiologists collaborate and evaluate the details of aortic valve and root morphology and dimensions, calcification and adjacent structures. Selection of the appropriate valve size, identifying the correct implant location, and post implant valve function is really not feasible or as accurate and reproducible by any other imaging technique.

In the context of the foregoing, a number of important issues are raised.

First, since the echocardiogram provides such a comprehensive and critical analysis of the patient’s clinical problem, echocardiographers must take responsibility for appropriate and thorough evaluation before any procedures.

Second, the sub-subspecialty requires carefully trained, experienced, committed, high volume physicians and sonographers working as a team. There are no “cookbook” approaches possible for the pre and intraprocedural guidance of the type described. The collaboration during mitral valve repair in high volume centers of excellence is an example.

Third, we will need to address training requirements for both the physicians and sonographers. Some cross training or knowledge in the interventional techniques will help the echocardiographic imager to provide the greatest impact in the procedures.

Fourth, we must expect and accept differences between institutions and practice settings with respect to how these echocardiographic procedures will be performed. In some centers, the primary physician imager during the procedure will be a cardiologist, and in others an anesthesiologist. Expert sonographers are a necessary part of this team, but should not be expected to acquire images or provide independent interpretations without collaborative input at this time.

Finally, as these procedures occupy an increasing amount of time, the issue of reimbursement should be addressed. We need to decide whether the echocardiographic guidance during structural intervention is, indeed, a separate procedure or forms a part of the structural intervention itself.

The importance of these issues seems evident when one views the increasing number of publications, recommendations for practice, guidelines and symposia on topics related to echo-guided structural intervention . The ASE and its Intraoperative Council have had a leading role by establishing standards for quality, procedure volumes as well as appropriate credentialing. Of importance, in addition, is the local creation of a structural intervention team including the sonographer, physician echocardiographer, and structural interventionist.

As I view the current era of echocardiography, many new frontiers are opening before us. Each these is likely to challenge us as we learn new techniques, and to stimulate us with new capabilities that enhance patient care. We will accomplish all this while we are running from place to place in the new “echocardiography laboratory” that we call “home”.