EDITORIAL Drawing Inferences From Tr ansesophageal Echocardiography
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RANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has become an essential component during cardiac surgery. Expertise in perioperative TEE has become a ubiquitous skill for cardiac anesthesiologists. TEE provides rapid diagnoses that often result in change in management; however, provision of exclusionary information is equally important to ensure quality and safety. Even though probe positions and scan plane rotations are standardized,1 patient-specific anatomic peculiarities sometimes can display more or less information than expected. More often than not, the information provided using TEE surpasses the expectations, leading to unanticipated clinical challenges.2 Even though TEE once was considered to be purely an anatomic monitor, Doppler-derived information has proven to be useful for physiologic and hemodynamic monitoring. At best, it displays dynamic anatomy with a physiologic perspective, offering a unique insight into myocardial structure and function. A review of literature regarding visualization of cardiac and noncardiac findings with TEE demonstrated the varied nature of derived information.3-5 Therapeutic impact is defined as a change in surgical management, anesthetic plan, or additional follow-up after an unanticipated intraoperative finding. In this context, aortic dissection, mitral valve repair, and congenital cardiac surgery are considered category-I indications for intraoperative TEE.6 Mostly, the therapeutic impact relates to the provision of positive information. However, exclusionary data and confirmatory evidence of provisional clinical diagnoses can be equally important. Because of its nature, therapeutic impact of exclusionary data is difficult to quantify. The case presented as an E-Challenge in this issue of the Journal signifies this clinical dilemma.7 The authors were managing a complex case requiring a very high level of clinical involvement. They were presented with an equivocal clinical situation. There was prolonged history of compression of the left circumflex artery (LCx), and the persistence of wall motion abnormalities (WMAs) after excision of a pseudoaneurysm and separation from cardiopulmonary bypass (CPB) suggested continued occlusion of the LCx artery. The obvious clinical course would have been to return to CPB and perform multiple aortocoronary vein grafts to bypass the occluded circumflex artery. This is when the information provided by TEE made the most difference. In the presented case, the authors were not able only to delineate the origin and course of the LCx artery, they also were able to demonstrate flow with color-flow Doppler.
The demonstration of normal flow excluded proximal compression and occlusion of the LCx artery, obviating the need for revascularization. As a result, a clinical decision was made to ignore the WMAs as a consequence of a potentially occluded LCx artery. At this stage, the patient underwent placement of an intra-aortic balloon pump. Thus an extended surgical procedure and prolonged CPB exposure were avoided. By any standards, this should be considered a major clinical impact. However, clinicians should be careful in overinterpreting this success because the authors used non-standard views and a non-standard approach to identify the LCx artery and to establish intraluminal flow. Fortunately, the patient’s anatomy was such that the authors were able to visualize the coronary artery in its entirety. It is important to appreciate that lack of visualization should not be inferred automatically as an occluded vessel. Similarly, unfavorable Doppler alignment can affect color-flow Doppler accuracy. Information provided using TEE should be interpreted in the clinical context and is just one piece of the puzzle. Even though this methodology cannot be recommended for every case, clinical improvisation was commendable and possibly prevented patient morbidity. Sir Arthur Conan Doyle’s character Dr. John Watson once complained that when faced with a clue he could see nothing. To this, Sherlock Holmes8 replied, “On the contrary, Watson, you can see everything. You fail, however, to reason from what you see. You are too timid in drawing your inferences.” The EChallenge case presented in this issue exemplifies the importance of recognizing, interpreting, and finally inferring an echocardiographic finding. The authors performed a comprehensive TEE examination that provided the most critical piece of information, with a major therapeutic impact with the inference they drew. Finally, as Holmes8 advised Watson, clinicians should not be timid when drawing inferences based on the information. It is more important to know exactly what is being seen and what is not. These inferences may change patient outcome dramatically. Jelliffe Jeganathan, MBBS Ziyad Knio, BS Feroze Mahmood, MD Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA
© 2016 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 http://dx.doi.org/10.1053/j.jvca.2015.08.029 Journal of Cardiothoracic and Vascular Anesthesia, Vol 30, No 1 (February), 2016: pp 261–262
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REFERENCES 1. Hahn RT, Abraham T, Adams MS, et al: Guidelines for performing a comprehensive transesophageal echocardiographic examination: Recommendations for the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 26:931-964, 2013 2. Mahmood F, Swaminathan M: Ordinary images—extraordinary stories: Echo challenges and clinical decisions. J Cardiothorac Vasc Anesth 24:5-6, 2010 3. Thunberg CA, Ramakrishna H: Echocardiographic detection of intimo-intimal intussusception in a patient with acute Stanford type A aortic dissection. Ann Card Anaesth 18:227-230, 2015 4. Datt VI, Diwakar A, Malik I, et al: Healed perivalvular abscess: Incidental finding on transesophageal echocardiography [corrected]. Ann Card Anaesth 17:141-144, 2014
5. Gurzun MM, Husain F, Zaidi A, et al: Accessory mitral valve—an unexpected intra-operative TEE finding causing left ventricular outflow tract obstruction in an adult. Echocardiography 31:E55-57, 2014 6. Practice guidelines for perioperative transesophageal echocardiography: A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 84:986-1006, 1996 7. Maxwell CD: Assessment of coronary blood flow by TEE. J Cardiothorac Vasc Anesth 30:258-260, 2016 8. Doyle AC: The Adventures of Sherlock Holmes. London, England, George Newnes Ltd, 1892.
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RANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has become an essential component during cardiac surgery. Expertise in perioperative TEE has become a ubiquitous skill for cardiac anesthesiologists. TEE provides rapid diagnoses that often result in change in management; however, provision of exclusionary information is equally important to ensure quality and safety. Even though probe positions and scan plane rotations are standardized,1 patient-specific anatomic peculiarities sometimes can display more or less information than expected. More often than not, the information provided using TEE surpasses the expectations, leading to unanticipated clinical challenges.2 Even though TEE once was considered to be purely an anatomic monitor, Doppler-derived information has proven to be useful for physiologic and hemodynamic monitoring. At best, it displays dynamic anatomy with a physiologic perspective, offering a unique insight into myocardial structure and function. A review of literature regarding visualization of cardiac and noncardiac findings with TEE demonstrated the varied nature of derived information.3-5 Therapeutic impact is defined as a change in surgical management, anesthetic plan, or additional follow-up after an unanticipated intraoperative finding. In this context, aortic dissection, mitral valve repair, and congenital cardiac surgery are considered category-I indications for intraoperative TEE.6 Mostly, the therapeutic impact relates to the provision of positive information. However, exclusionary data and confirmatory evidence of provisional clinical diagnoses can be equally important. Because of its nature, therapeutic impact of exclusionary data is difficult to quantify. The case presented as an E-Challenge in this issue of the Journal signifies this clinical dilemma.7 The authors were managing a complex case requiring a very high level of clinical involvement. They were presented with an equivocal clinical situation. There was prolonged history of compression of the left circumflex artery (LCx), and the persistence of wall motion abnormalities (WMAs) after excision of a pseudoaneurysm and separation from cardiopulmonary bypass (CPB) suggested continued occlusion of the LCx artery. The obvious clinical course would have been to return to CPB and perform multiple aortocoronary vein grafts to bypass the occluded circumflex artery. This is when the information provided by TEE made the most difference. In the presented case, the authors were not able only to delineate the origin and course of the LCx artery, they also were able to demonstrate flow with color-flow Doppler.
The demonstration of normal flow excluded proximal compression and occlusion of the LCx artery, obviating the need for revascularization. As a result, a clinical decision was made to ignore the WMAs as a consequence of a potentially occluded LCx artery. At this stage, the patient underwent placement of an intra-aortic balloon pump. Thus an extended surgical procedure and prolonged CPB exposure were avoided. By any standards, this should be considered a major clinical impact. However, clinicians should be careful in overinterpreting this success because the authors used non-standard views and a non-standard approach to identify the LCx artery and to establish intraluminal flow. Fortunately, the patient’s anatomy was such that the authors were able to visualize the coronary artery in its entirety. It is important to appreciate that lack of visualization should not be inferred automatically as an occluded vessel. Similarly, unfavorable Doppler alignment can affect color-flow Doppler accuracy. Information provided using TEE should be interpreted in the clinical context and is just one piece of the puzzle. Even though this methodology cannot be recommended for every case, clinical improvisation was commendable and possibly prevented patient morbidity. Sir Arthur Conan Doyle’s character Dr. John Watson once complained that when faced with a clue he could see nothing. To this, Sherlock Holmes8 replied, “On the contrary, Watson, you can see everything. You fail, however, to reason from what you see. You are too timid in drawing your inferences.” The EChallenge case presented in this issue exemplifies the importance of recognizing, interpreting, and finally inferring an echocardiographic finding. The authors performed a comprehensive TEE examination that provided the most critical piece of information, with a major therapeutic impact with the inference they drew. Finally, as Holmes8 advised Watson, clinicians should not be timid when drawing inferences based on the information. It is more important to know exactly what is being seen and what is not. These inferences may change patient outcome dramatically. Jelliffe Jeganathan, MBBS Ziyad Knio, BS Feroze Mahmood, MD Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA
© 2016 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 http://dx.doi.org/10.1053/j.jvca.2015.08.029 Journal of Cardiothoracic and Vascular Anesthesia, Vol 30, No 1 (February), 2016: pp 261–262
261
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JEGANATHAN ET AL
REFERENCES 1. Hahn RT, Abraham T, Adams MS, et al: Guidelines for performing a comprehensive transesophageal echocardiographic examination: Recommendations for the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 26:931-964, 2013 2. Mahmood F, Swaminathan M: Ordinary images—extraordinary stories: Echo challenges and clinical decisions. J Cardiothorac Vasc Anesth 24:5-6, 2010 3. Thunberg CA, Ramakrishna H: Echocardiographic detection of intimo-intimal intussusception in a patient with acute Stanford type A aortic dissection. Ann Card Anaesth 18:227-230, 2015 4. Datt VI, Diwakar A, Malik I, et al: Healed perivalvular abscess: Incidental finding on transesophageal echocardiography [corrected]. Ann Card Anaesth 17:141-144, 2014
5. Gurzun MM, Husain F, Zaidi A, et al: Accessory mitral valve—an unexpected intra-operative TEE finding causing left ventricular outflow tract obstruction in an adult. Echocardiography 31:E55-57, 2014 6. Practice guidelines for perioperative transesophageal echocardiography: A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 84:986-1006, 1996 7. Maxwell CD: Assessment of coronary blood flow by TEE. J Cardiothorac Vasc Anesth 30:258-260, 2016 8. Doyle AC: The Adventures of Sherlock Holmes. London, England, George Newnes Ltd, 1892.
