Perioperative Transthoracic Echocardiography by the Cardiac Anesthesiologist: Need of the Hour

One of the primary responsibilities of a cardiac anesthesiologist is to maintain hemodynamic stability, which translates into the maintenance of tissue oxygenation. Several invasive hemodynamic monitoring and necessary interventions are performed by the anesthesiologist to accomplish this goal. At times, conventional therapy, including fluid administration, inotropes, and vasodilators, does not work, necessitating the use of echocardiography for further insight. Transesophageal echocardiography (TEE) was introduced in 1976 and has since become the standard of care for most cardiac surgical procedures.[1-3] The cardiac anesthesiologist has acquired proficiency in the TEE, and this has contributed to overall improved hemodynamic as well as surgical management. In addition, several reports have shown that a change in surgical plan may be necessary with the use of TEE.[4,5] TEE is generally performed during intraoperative period when the patient is sedated and being mechanically ventilated. However, there can be several instances of hemodynamic instability in the pre- and postoperative period when the patient is not being mechanically ventilated that may require an echocardiographic examination. TEE may not be the best option for evaluation during such periods. A quick screening transthoracic echocardiographic (TTE) examination is an attractive and viable option in such a scenario. This is especially so, due to ready availability of number of portable devices nowadays. This will aid in the diagnosis of hypovolemia, left ventricular (LV) function, wall motion abnormalities, systolic anterior motion, pericardial effusion/tamponade, pleural effusion, and any other surprise finding. Such needs are also felt in the critical care units, and emergency rooms. A focus-assessed transthoracic echocardiography (FATE) was described in 2004 by Jensen, et al.[6] A rapid and systematic protocol was described with the aim to contribute to cardiopulmonary optimization. Later, other terminology, such as focused cardiac ultrasound (FOCUS or FCU), was used. In 2019, the American College of Cardiology approved this concept of limited TTE being performed by the non-cardiologists with the rider that amount of information as well as the expertise behind image acquisition and interpretation is limited.[7] Despite these developments, most cardiac anesthesiologists are still not well versed with the TTE and still depend on cardiologists who may not be readily available on short notice and round the clock in most intensive care units (ICUs). The situation is no different in India, although few centers have started taking an initiative in this direction. The dynamic nature of physiology of postoperative cardiac surgical patients requires serial examinations to assess the response to interventions. The cardiac anesthesiologists are distinctly positioned to integrate the information obtained from bedside echocardiographic examination with the pathophysiology of their patient’s condition. The guidelines regarding training, practice, and quality improvement in the perioperative TEE have been established by the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists.[8] Likewise, Indian Association of Cardiovascular Thoracic Anesthesiologists (IACTA) has also formulated guidelines regarding the perioperative use of TEE.[9,10] In recent times, FOCUS is increasingly being incorporated into anesthesiologists’ training and practice.[11-13] There is a distinct need to promote the practice of perioperative TTE to be applied in all the cardiac centers. The American Society of Anesthesiologists has recently announced a certification pathway for point-of-care ultrasound, which included cardiac assessment.[14] Other specialities have defined the levels of training and practice requirements for their patient care.[15,16] Kathirvel et al.[17] have recently suggested guidelines for training, certification, and practice of perioperative TTE by anesthesiologists. They suggest two categories of perioperative TTE training program: the basic TTE examination (only qualitative examination) meant for situations of perioperative hypotension and hypoxemia, providing diagnostic information to guide therapeutic actions in a timely manner, for example, pericardial effusion/tamponade; and advanced TTE which includes quantitative evaluation along with Doppler examination. The basic TTE can be learnt by any anesthesiologist/physician, whereas the cardiac anesthesiologist should master the advanced TTE. The advanced TTE will require extensive training, which can be easy for the cardiac anesthesiologists, as they already possess image interpretation and diagnostic echocardiographic skills by virtue of their expertise in TEE. With this background, it seems that the time is ripe for the IACTA to take the lead and incorporate the perioperative TTE in the curriculum of the fellowship program (FTEE/FIACTA), and also, formulate the guidelines related to training and certification of perioperative TTE on the lines of TEE program that they are conducting. What is required is a clear pathway for training or fellowships that will allow accreditation specific to cardiac anesthesiologist’s needs.