Guidelines for physician training in transesophageal echocardiography: recommendations of the American Society of Echocardiography Committee for Physician Training in Echocardiography

Intraoperative Echocardiography: Support for Decision Making in Cardiac Surgery

Intraoperative echocardiography (including transesophageal echocardiography, epiaortic ultrasound and epicardial echocardiography) is commonly performed in North American hospitals during cardiac anesthesia. Several authors have reported on the positive impact of intraoperative echocardiography on patients’ outcomes. Transesophageal echocardiography is useful in identifying anatomic and functional abnormalities either before or after cardiopulmonary bypass and helps to make decisions in the care of high-risk and unstable patients. In minimally invasive and robotically assisted surgery, transesophageal echocardiography is essential in order to guide cannulation of venous and arterial vessels for cardiopulmonary bypass and in providing immediate assessment of the quality of the performed repair. Intraoperative echocardiography can also detect complications associated with the performed procedure and can be an excellent hemodynamic monitor in unstable patients. In this paper different scenarios where intraoperative echocardiography is useful are reviewed, some clinical cases are shown to illustrate, and a review of related literature is reported.

Normative MDCT cross-sectional data estimation of superior vena cava and innominate vein in growing children using age as a predictor

This retrospective study aimed to determine the superior vena cava (SVC) and left innominate vein (INV) normative cross-sectional area in children noninvasively using age as a predictor and also to compare the correlation of the area measured with the diameter on multidetector computed tomography (MDCT). Analysis of the SVC-INV cross-sectional area was performed for 73 consecutive patients. The cross-sectional area of the SVC-INV was manually estimated. A regression analysis was performed for the cross-sectional area and age separately, and regression equations were compared. One-way analysis of variance (ANOVA) was performed to evaluate significant differences in the area means according to age groups. Regression analysis showed that age can be a predictor for the area of the SVC (50.6 mm(2) + 1.01 × age), te INV (48.3 mm(2) + 0.93 × age), and the left SVC-INV junction (47.2 mm(2) + 0.92 × age), with respective R(2) values of 93, 88 and 94%. The comparative evaluation of the cross-sectional area and the diameter measurement of SVC showed that the cross-sectional area was more closely associated with the increasing age of the cohort (R(2) of 68 vs. 61%) than the measured diameter. For a cohort of patients without congenital or acquired heart disease, MDCT can be used as a complementary test for a normative cross-sectional normogram area database of SVC-INV using age as a predictor.

Real-time three-dimensional transoesophageal echocardiography: a new intraoperative feasible and useful technology in cardiac surgery

A new generation of transoesophageal echocardiographic probes with a novel matrix array technique has been recently introduced, allowing three-dimensional (3D) presentation of cardiac structures in real-time. This new tool may potentially provide fast and complete 3D information about cardiac structures improving spatial orientation and overcoming limitations of offline 3D technologies. The aim of this study was to demonstrate the feasibility and usefulness of real-time 3D transoesophageal echocardiography (TOE) for the intraoperative evaluation of cardiac surgery procedures. One-hundred patients underwent transoesophageal echocardiographic examination during cardiac surgery as a part of their routine clinical practice. In the intraoperative pre- and post-cardiopulmonary bypass periods complete 2D and 3D transoesophageal examinations were performed. Feasibility and duration of examinations, and immediate additional anatomical value of 3D versus 2D-TOE were annotated intraoperatively. Image quality, additional clinical value of 3D- compared to standard 2D-TOE and the accuracy in the description of mitral valve pathology by a surgeon and an echocardiographer were evaluated off-line. No complications related to transoesophageal examination occurred and successful intubation was achieved in all 100 patients. Therefore, 200 examinations were performed and analysed considering the pre- and post-cardiopulmonary bypass periods. The mean number of acquisitions per patient was 16 +/- 14, including 3D real-time, zoom, full-volume and colour full volume modalities. The duration of the 3D examination was 16 +/- 10 min and the mean image quality score 2.8 +/- 0.7 (in a scale 1-4). In 36 out of 100 cases (36%) 3D-TOE provided additional anatomical information. The surgeon evaluated 3D images easier and more accurately than 2D images (88% vs. 76% in the evaluation of mitral valve scallop). Real-time 3D TOE may be used routinely for the intraoperative evaluation of cardiac surgery. Imaging with this new probe facilitates intraoperative evaluation of several surgical procedures with an additional clinical value in selected cases.

Is a 4 days transoesophageal training course sufficient to diagnose shock related pathologies?

INTRODUCTION

Echocardiography is a useful tool in patients suffering from shock of unknown origin to evaluate cardiac function and volume status in order to decide on further treatment. The aim of the study was to evaluate how well participants could identify function, preload and regional wall motion abnormalities after attending a 4-day transoesophageal echocardiography (TOE) seminar.

METHODS

In this prospective educational trial, participants of six TOE seminars from 2005 to 2006 were evaluated. On the basis of seven echocardiographic studies, evaluations by participants concerning cardiac function, preload and regional wall motion were analyzed. Moreover, specific causes of undifferentiated hypotension were to be judged in three cases by the participants.

RESULTS

A total of 115 participants of the TOE seminars from 2005 to 2006 were evaluated. Correct sectional plane was recognized by more than 76% of the participants. Left ventricular function, preload, and regional wall abnormalities were assessed correctly by the participants in 98%, 96%, and 84%, respectively. Moreover, more than 70% of the participants recognized the correct cause of hemodynamic instability.

CONCLUSION

The results of the investigation show that participants of a 4-day TOE seminar can interpret left ventricular function, preload and regional wall motion abnormalities correctly at a very high rate. TOE seminars seem to be effective in teaching basic theoretical knowledge of TOE.

Novel intubation technique for transesophageal echocardiographic examination

Pharyngeal intubation is a challenging problem during transesophageal procedures. The rate of unsuccessful intubation varies from 1.5 to 1.9%. In this article, we described a novel technique, which we utilize in our hospital for the difficult intubations without any technical failure for the insertion of the transesophageal probe.

Real-time three-dimensional transesophageal echocardiography in valve disease: comparison with surgical findings and evaluation of prosthetic valves

BACKGROUND

Recently, a novel real-time 3-dimensional (3D) matrix-array transesophageal echocardiographic (3D-MTEE) probe was found to be highly effective in the evaluation of native mitral valves (MVs) and other intracardiac structures, including the interatrial septum and left atrial appendage. However, the ability to visualize prosthetic valves using this transducer has not been evaluated. Moreover, the diagnostic accuracy of this new technology has never been validated against surgical findings. This study was designed to (1) assess the quality of 3D-MTEE images of prosthetic valves and (2) determine the potential value of 3D-MTEE imaging in the preoperative assessment of valvular pathology by comparing images with surgical findings.

METHODS

Eighty-seven patients undergoing clinically indicated transesophageal echocardiography were studied. In 40 patients, 3D-MTEE images of prosthetic MVs, aortic valves (AVs), and tricuspid valves (TVs) were scored for the quality of visualization. For both MVs and AVs, mechanical and bioprosthetic valves, the rings and leaflets were scored individually. In 47 additional patients, intraoperative 3D-MTEE diagnoses of MV pathology obtained before initiating cardiopulmonary bypass were compared with surgical findings.

RESULTS

For the visualization of prosthetic MVs and annuloplasty rings, quality was superior compared with AV and TV prostheses. In addition, 3D-MTEE imaging had 96% agreement with surgical findings.

CONCLUSIONS

Three-dimensional matrix-array transesophageal echocardiographic imaging provides superb imaging and accurate presurgical evaluation of native MV pathology and prostheses. However, the current technology is less accurate for the clinical assessment of AVs and TVs. Fast acquisition and immediate online display will make this the modality of choice for MV surgical planning and postsurgical follow-up.

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways - either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level--obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.

Safety, feasibility, and hemodynamic and blood flow effects of active compression-decompression of thorax and abdomen in patients with cardiac arrest

OBJECTIVE

During closed chest compression for cardiac arrest, any increase in coronary perfusion pressure accounts for a proportional increase in myocardial blood flow and therefore the resuscitability of the patient. The objectives of this study were to evaluate the safety, feasibility, and hemodynamic effects of phased chest and abdominal compression-decompression and to compare it with mechanical chest compression during cardiopulmonary resuscitation.

DESIGN

In this prospective, single-center, phase II study, we compared patients treated with the Datascope Lifestick Resuscitator with patients who had been treated with mechanical precordial compression.

SETTING

Emergency department of a tertiary care university hospital.

PATIENTS

We included 31 patients with cardiac arrest who had received cardiopulmonary resuscitation in the emergency department.

INTERVENTIONS

The Lifestick device was used in 20 patients. In 11 patients, mechanical chest compression with the Thumper device was used as a control intervention.

MEASUREMENTS AND MAIN RESULTS

We evaluated the safety, feasibility, and hemodynamic effects of both interventions and observed, with the help of echocardiography, the mechanisms through which blood flow was generated. We found no significant difference between the use of the Lifestick device and standard chest compression with the Thumper device in resuscitations. Most operators regarded the Lifestick as a feasible alternative to the Thumper. We could observe a mean increase in coronary perfusion pressure of 9.33 mm Hg (interquartile range, 1.96-14.36; p = .08) and an increase of end-tidal CO2 of 10 mm Hg (interquartile range, 5-16; p = .003) (1333Pa [interquartile range, 665-2133]) during resuscitation with the Lifestick compared with using the Thumper.

CONCLUSION

In this preliminary study, resuscitation with the Lifestick was found to be safe and feasible. The design of the study and small number of patients included in it limit the conclusions about the hemodynamic effects of the Lifestick.

Imaging studies in patients with heart failure: current and evolving technologies

Technological advances continue to expand the clinical role of echocardiography in the intensive care unit, particularly in patients with heart failure. It has many advantages over tomographic techniques such as echo cardiac magnetic resonance imaging and cardiac computed tomography, can provide rapid bedside cardiac assessment, and facilitate emergent decision-making for critically ill patients. Image quality problems in the intensive care setting have largely been overcome by the use of harmonic imaging, contrast opacification, and when indicated, transesophageal echocardiography. Newer techniques promise to advance the scope and prognostic power of echocardiography, and to expand the portability and availability of this tool.

Treating the right patient at the right time: Access to echocardiography in Canada

The Canadian Cardiovascular Society is the national professional society for cardiovascular specialists and researchers in Canada. In the spring of 2004, the Canadian Cardiovascular Society Council formed the Access to Care Working Group ('Working Group') to use the best science and information available to establish reasonable triage categories and safe wait times for access to common cardiovascular procedures. The Working Group decided to publish a series of commentaries to initiate a structured national discussion on this important issue, and the present commentary proposes recommended wait times for access to echocardiography. 'Emergent' echocardiograms should be performed within 24 h, 'urgent' within seven days and 'scheduled' (elective) within 30 days. A framework for a solution-oriented approach to improve access is presented.

Canadian guidelines for training in adult perioperative transesophageal echocardiography. Recommendations of the Cardiovascular Section of the Canadian Anesthesiologists' Society and the Canadian Society of Echocardiography

PURPOSE

To establish Canadian guidelines for training in adult perioperative transesophageal echocardiography (TEE).

METHODS

Guidelines were established by the Canadian Perioperative Echocardiography Group with the support of the cardiovascular section of the Canadian Anesthesiologists' Society in conjunction with the Canadian Society of Echocardiography. Guidelines for training in echocardiography by the American Society of Echocardiography, the American College of Cardiology and the Society of Cardiovascular Anesthesiologists were reviewed, modified and expanded to produce the 2003 Quebec expert consensus for training in perioperative echocardiography. The Quebec expert consensus and the 2005 guidelines for the provision of echocardiography in Canada formed the basis of the Canadian training guidelines in adult perioperative TEE.

RESULTS

Basic, advanced and director levels of expertise were identified. The total number of echocardiographic examinations to achieve each level of expertise remains unchanged from the 2002 American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists guidelines. The increased proportion of examinations personally performed at basic and advanced levels, as well as the level of autonomy at the basic level suggested by the Quebec expert consensus are retained. These examinations may be performed in a perioperative setting and are not limited to intraoperative TEE. Training 'on-the-job', the role of the perioperative TEE examination, the requirements for maintenance of competence and the duration of training are also discussed for each level of training. The components of a TEE report and comprehensive TEE examination are also outlined.

CONCLUSION

The Canadian guidelines for training in adult perioperative TEE reflect the unique Canadian practice profile in perioperative TEE and address the training requirements to obtain expertise in this field.

Canadian guidelines for training in adult perioperative transesophageal echocardiographyRecommendations of the Cardiovascular Section of the Canadian Anesthesiologists’ Society and the Canadian Society of Echocardiography

PURPOSE

To establish Canadian guidelines for training in adult perioperative transesophageal echocardiography (TEE).

METHODS

Guidelines were established by the Canadian Perioperative Echocardiography Group with the support of the cardiovascular section of the Canadian Anesthesiologists' Society (CAS) in conjunction with the Canadian Society of Echocardiography. Guidelines for training in echocardiography by the American Society of Echocardiography, the American College of Cardiology and the Society of Cardiovascular Anesthesiologists were reviewed, modified and expanded to produce the 2003 Quebec expert consensus for training in perioperative echocardiography. The Quebec expert consensus and the 2005 Guidelines for the provision of echocardiography in Canada formed the basis of the Canadian training guidelines in adult perioperative TEE.

RESULTS

Basic, advanced and director levels of expertise were identified. The total number of echocardiographic examinations to achieve each level of expertise remains unchanged from the 2002 American Society of Echocardiography-Society of Cardiovascular Anesthesiologists guidelines. The increased proportion of examinations personally performed at basic and advanced levels, and the level of autonomy at the basic level suggested by the Quebec expert consensus are retained. These examinations can be performed in a perioperative setting and are not limited to intraoperative TEE. Training "on the job", the role of the perioperative transesophageal echocardiography examination, requirements for maintenance of competence, and duration of training are also discussed for each level of training. The components of a TEE report and comprehensive TEE examination are also outlined.

CONCLUSION

The Canadian guidelines for training in adult perioperative TEE reflect the unique Canadian practice profile in perioperative TEE and address the training requirements to obtain expertise in this field.

Transoesophageal echocardiography (TOE) in the operating room

Perioperative transoesophageal echocardiography (TOE) was introduced from cardiology into cardiac anaesthesia in the 1980s. Initially TOE was used mainly as a monitor of left ventricular ischaemia, but now provides real-time dynamic information about the anatomy and physiology of the whole heart. TOE is of value in the management of patients undergoing procedures including cardiac valvular repair, surgery for endocarditis, surgery of the thoracic aorta, and may contribute useful information in a wide range of cardiac pathology. It is also useful in guiding therapy in haemodynamically unstable patients in the operating room and the intensive care unit. TOE is relatively cheap and non-invasive, but it should not be used as a stand alone device but as a tool which provides data in addition to the data acquired from other forms of monitoring. The use of TOE carries not only the benefits of a rapid and effective investigation, but also risks associated with the procedure itself and the burden of providing training and experience for practitioners. The establishment of TOE in perioperative cardiac anaesthetic care has resulted in a significant change in the role of the anaesthetist who, using TOE, can provide new information which may change the course and the outcome of surgical procedures.

Differential regulation of diacylglycerol kinase isozymes in cardiac hypertrophy

To examine the involvement of diacylglycerol kinase (DGK) and phosphatidic acid phosphatase (PAP) in pressure overloaded cardiac hypertrophy, rats were subjected to either ascending aortic banding for 3, 7, and 28 days or sham operation. In comparison with sham-operated rats, the left ventricular (LV) weight of the aortic-banded rats increased progressively. At 28 days after surgery, the expression of DGKepsilon mRNA but not DGKzeta or PAP2b mRNA in the LV myocardium significantly decreased in the aortic-banded rats compared with the sham-operated rats. DGKzeta protein in the LV myocardium translocated from the particulate to the cytosolic compartment in the aortic-banded rats. Furthermore, the myocardial content of 1,2-diacylglycerol and PKCdelta protein expression in the particulate fraction of the LV myocardium significantly increased in aortic-banded rats compared with sham-operated rats. These results suggest that DGKepsilon and DGKzeta play distinct roles in the development of pressure overloaded cardiac hypertrophy and that the two isozymes are differentially regulated.

Bringing MRI to the cardiologist: can we learn from echocardiography?

Cardiac MRI (CMR) is a low-risk, comprehensive diagnostic tool that has many similarities with echocardiography. It is noninvasive, lacks ionizing radiation, and the contrast material used to enhance various images does not have any renal toxicity. Although extremely valuable in the diagnosis of neurologic and musculoskeletal diseases for more than two decades, CMR has only recently become relevant for diagnosing the rapidly beating and constantly mobile heart. Through advances in cardiac gating and high-speed acquisition software, CMR is positioning itself as a critical utensil at the cardiovascular disease banquet. However, like echocardiography, currently celebrating its 50th birthday, CMR is likely to suffer occasional growing pains, along with its share of accomplishments. Therefore, those practicing CMR should learn from the past errors and achievements of echocardiography in an effort to deliver the most rewarding diagnostic instrument imaginable, without having to wait 50 years.

Transesophageal pulsed Doppler echocardiography of pulmonary venous flow to assess left ventricular filling pressure in ventilated patients with acute respiratory distress syndrome

OBJECTIVE

To determine whether the systolic fraction (SF) of the pulmonary venous flow (PVF), measured by transesophageal echocardiography (TEE) could be used to estimate the pulmonary artery occlusion pressure (PAOP).

DESIGN

Prospective clinical investigation.

PATIENTS

Nineteen intubated patients with ARDS.

INTERVENTIONS

Doppler examinations with measurement of the SF of the PVF (ie, the systolic velocity-time integral expressed as a fraction of the sum of systolic and early diastolic velocity-time integrals) were performed simultaneously with measurements of PAOP via a right heart catheter at 0 cmH2O PEEP (ZEEP), at PEEP = 8 cmH20 and at PEEP = 16 cmH2O.

MEASUREMENTS AND MAIN RESULTS

At ZEEP, PAOP was inversely correlated with the SF of the PVF (r = -.89). The difference of SF between the group with PAOP <18 mm Hg and the group with PAOP > or = 18 mm Hg was statistically significant (P < .05). A SF > or = 55% predicted a PAOP < 15 mm Hg with a positive predictive value of 100% (95% CI = 63-100%). A SF < or = 40% predicted a PAOP > or =18 mm Hg with a positive predictive value of 100% (95% CI = 52-100%). At PEEP = 8 cm H20 (12 patients studied) and at PEEP = 16 cmH2O (10 patients studied), PAOP was inversely correlated with the SF of the PVF: r = -.84, and r = -.85, respectively.

CONCLUSION

The SF of the PVF measured by Pulsed Doppler TEE seems to be a valuable index to estimate the left ventricular filling pressure in mechanically ventilated patients with ARDS.

Hypopharyngeal Perforation Near-Miss During Transesophageal Echocardiography

OBJECTIVES/HYPOTHESIS

The traditional blind passage of a transesophageal echocardiography probe transorally through the hypopharynx is considered safe. Yet, severe hypopharyngeal complications during transesophageal echocardiography at several institutions led the authors to investigate whether traditional probe passage results in a greater incidence of hypopharyngeal injuries when compared with probe passage under direct visualization.

STUDY DESIGN

Randomized, prospective clinical study.

METHODS

In 159 consciously sedated adults referred for transesophageal echocardiography, the authors performed transesophageal echocardiography with concomitant transnasal videoendoscopic monitoring of the hypopharynx. Subjects were randomly assigned to receive traditional (blind) or experimental (optical) transesophageal echocardiography. The primary outcome measure was frequency of hypopharyngeal injuries (hypopharyngeal lacerations or hematomas), and the secondary outcome measure was number of hypopharyngeal contacts.

RESULTS

No perforation occurred with either technique. However, hypopharyngeal lacerations or hematomas occurred in 19 of 80 (23.8%) patients with the traditional technique (11 superficial lacerations of pyriform sinus, 1 laceration of pharynx, 12 arytenoid hematomas, 2 vocal fold hematomas, and 1 pyriform hematoma) and in 1 of 79 patients (1.3%) with the optical technique (superficial pyriform laceration) (P =.001). All traumatized patients underwent flexible laryngoscopy, but none required additional intervention. Respectively, hypopharyngeal contacts were more frequent with the traditional than with the optical technique at the pyriform sinus (70.0% vs. 10.1% [P =.001]), arytenoid (55.0% vs. 3.8% [P =.001]), and vocal fold (15.0% vs. 3.86% [P =.016]).

CONCLUSION

Optically guided trans-esophageal echocardiography results in significantly fewer hypopharyngeal injuries and fewer contacts than traditional, blind transesophageal echocardiography. The optically guided technique may result in decreased frequency of potentially significant complications and therefore in improved patient safety.

Survey of observer variation in transesophageal echocardiography: comparison of anesthesiology and cardiology literature

OBJECTIVE

Transesophageal echocardiographic examination tends to be somewhat observer and experience dependent, and observer bias can arise easily when data are calculated and interpreted by unskilled, nonblinded, or single observers. The study plan was to see whether authors have adequately described how observer bias is minimized in their studies. Thus, a study was conducted systematically reviewing methods reported in transesophageal echocardio graphy articles in peer-reviewed anesthesiology journals versus those reported in peer-reviewed cardiology journals.

INTERVENTIONS

After MEDLINE searches of the literature published from 1997 through 1999, the authors investigated 56 anesthesiology reports and 56 randomly selected, year-matched cardiology reports. An 8-item questionnaire was developed that examined several factors: the number of observers and their experience levels, whether observers were blind to clinical data, whether low-quality images were excluded, the use of on-line or off-line analysis, and observer variability.

MAIN RESULTS

The analysis revealed inadequacies in reporting of important information that relates to bias and quality in 91.1% of anesthesiology and 98.2% of cardiology articles. Observer variability was not reported in 50.0% of the anesthesiology reports and 67.9% of the cardiology reports; however, difference between the 2 bodies of literature was not significant. The journal impact factor was significantly higher for the cardiology literature than for the anesthesiology literature (2.42 [0.386-10.893] v 1.07 [0.664-3.439]; median [range], p < 0.001).

CONCLUSION

Articles reviewed had at least some inadequacies in reporting the methods to minimize observer bias in both the anesthesiology and cardiology literature. Reporting methodology standards in TEE examinations remain to be established.

Expert consensus for training in perioperative echocardiography in the province of Quebec

PURPOSE

Establish an expert consensus for training in perioperative echocardiography in the province of Quebec.

METHODS

Cardiac anesthesiologists practicing in the province of Quebec with expertise in echocardiography were involved in the development of a multicentre expert consensus on training in perioperative echocardiography. Guidelines for training in adult echocardiography, transesophageal echocardiography and perioperative echocardiography by the American Society of Echocardiography (ASE), the American College of Cardiology (ACC) and/or the Society of Cardiovascular Anesthesiologists (SCA) were reviewed.

RESULTS

A basic, advanced and director level of expertise were identified for training in perioperative echocardiography. The total number of echocardiographic examinations to achieve each of these levels of expertise remains unchanged from the 2002 ASE-SCA guidelines. However, the recommended proportion of examinations performed personally is increased in the Quebec expert consensus for both the basic and the advanced level of training to ensure proficiency in echocardiography while providing anesthesia care to the patient. A level of autonomy in perioperative echocardiography is also identified in the basic level of training as defined in the Quebec expert consensus. Maintenance of competence, certification in the perioperative transesophageal echocardiography (PTE) examination and duration of training are outlined for each of the three levels of training in the Quebec expert consensus but are not part of the recent 2002 ASE-SCA guidelines.

CONCLUSION

Adequate perioperative echocardiographic training is an important aspect of cardiovascular anesthesia. The ACC, ASE and SCA guidelines for training in echocardiography were modified to reflect the expert consensus of anesthesiologists in the province of Quebec.

Does the reimbursement of anesthesiologists for intraoperative transesophageal echocardiography promote increased utilization?

OBJECTIVE

To determine whether access to reimbursement increases anesthesiologists' use of intraoperative transesophageal echocardiography (TEE).

DESIGN

Survey.

SETTING

United States.

PARTICIPANTS

Members of the Society of Cardiovascular Anesthesiologists, local Medicare carriers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In year 2000, local Medicare carrier policies specifically allowed some form of reimbursement to the attending anesthesiologist for intraoperative TEE in 15 states, but barred all forms of reimbursement in 16 states and Puerto Rico. Data regarding utilization and billing were available for 702 members of the Society of Cardiovascular Anesthesiologists from these jurisdictions who used TEE in their anesthetic practice. Billing patterns were found to vary significantly according to the local Medicare policy in effect (p = 0.004). Use of intraoperative TEE was found to be unrelated, however, to the reimbursement available from Medicare (p = 0.2 to 0.7).

CONCLUSION

The use of intraoperative TEE by anesthesiologists does not seem to be related to the availability of reimbursement from Medicare.

Right atrial thrombus treated successfully with abciximab and heparin

We report here a case of right atrial thrombus diagnosed by echocardiography in a 25-year-old female patient with Hodgkin's disease receiving chemotherapy and heparin. After 24 hours therapy with the glycoprotein IIb/IIIa receptor antagonist (abciximab) with concomitant heparin the complete dissolution of the thrombus could be demonstrated by transesophageal echocardiography. To our knowledge this case represents the first use of abciximab in right atrial thrombosis.

Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation

Electrical cardioversion of patients with atrial fibrillation (AF) is frequently performed to relieve symptoms and improve cardiac performance. Patients undergoing cardioversion are treated conventionally with therapeutic anticoagulation for three weeks before and four weeks after cardioversion to decrease the risk of thromboembolism. A transesophageal echocardiography (TEE)-guided strategy has been proposed as an alternative that may lower stroke and bleeding events. Patients without atrial cavity thrombus or atrial appendage thrombus by TEE are cardioverted on achievement of therapeutic anticoagulation, whereas cardioversion is delayed in higher risk patients with thrombus. The aim of this review is to discuss the issues and controversies associated with the management of patients with AF undergoing cardioversion. We provide an overview of the TEE-guided and conventional anticoagulation strategies in light of the recently completed Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) clinical trial. The two management strategies comparably lower the patient's embolic risk when the guidelines are properly followed. The TEE-guided strategy with shorter term anticoagulation may lower the incidence of bleeding complications and safely expedite early cardioversion. The inherent advantages and disadvantages of both strategies are presented. The TEE-guided approach with short-term anticoagulation is considered to be a safe and clinically effective alternative to the conventional approach, and it is advocated in patients in whom earlier cardioversion would be clinically beneficial.