Newsletter

In the March 1999 issue of the Journal of the American Society of Echocardiography,¹  Stevenson reports on patient outcome in congenital cardiac surgery, during 5-month periods in 2 different years. During the first 5-month period, intraoperative TEE was performed by physicians (one pediatric cardiologist and two anesthesiologists) who met published guidelines for performance of TEE in children. Their only intraoperative duty was TEE. During the second 5-month period, TEE examinations were performed by pediatric cardiac anesthesiologists who did not meet the training guidelines; their duties involved both the administration of anesthesia and the performance of the TEE examinations. The reasons for this change in practice were not explained other than to state that it was based on an administrative decision. Although mortality was similar for both periods, differences were observed between the 2 study periods for adequacy of echocardiographic recordings, return to bypass for further surgery based on echocardiographic results, and prevalence and detection of significant residual problems by intraoperative echocardiography.

In the May 1999 issue of the Journal,²  Fyfe published an editorial on the same topic. The major points of the editorial were that: 1) "administrative decisions" can negatively affect outcome; 2) the conflicting responsibilities of providing anesthesia care and performing TEE may preclude doing either well; 3) the performance of TEE by untrained anesthesiologists is bound to adversely affect patient outcome; and 4) billing for both the anesthetic and the intraoperative TEE exam may represent a form of fraud and abuse.

Because intraoperative TEE is of great interest to SCA and cardiothoracic anesthesiologists, it might be useful to ponder on the implications of these 2 publications. My comments will focus on general issues, rather than on the specifics of the study, since I have no privileged knowledge of the clinical practice at the reporting institution.

First, the editors of the Journal of the American Society of Echocardiography should be congratulated for publishing Dr. Stevenson's study. Although one could enumerate a long list of scientific flaws in the design, methodology, results, and conclusions of the study, its publication stimulates discussion on a topic that is important for patient care. While peer review certainly has its virtues, one of its drawbacks is that it tends to perpetuate established, current thinking, while stifling new and controversial ideas. In this case, the editors decided to ignore scientific weaknesses in favor of challenge and dialogue.

Should anesthesiologists who are not adequately trained, perform pediatric TEE? The obvious answer is no. As is alluded to in the editorial, the impact of intraoperative TEE on patient outcome in congenital cardiac surgery is well-established. If outcome is better when intraoperative TEE is used, it should be utilized expertly because our patients deserve the best possible outcome. The question then evolves around what is adequate training and what is expert utilization. Both publications refer to training guidelines developed by the Society of Pediatric Echocardiography (SOPE) and published by the American Society of Echocardiography (ASE).³  Do these guidelines adequately reflect the reality of anesthesia training and can they be applied to the practice of cardiothoracic anesthesia? Although an anesthesiologist participated in the development of the guidelines, no formal input or review was elicited from anesthesia organizations. Clearly, this is less than optimal; SCA should be at the table when issues that concern the practice of cardiothoracic anesthesia are debated. How do we ensure this for the future? The Board of Directors of SCA has endorsed the establishment of a Joint SCA/ASE Task Force on Perioperative Echocardiography. The SCA members are Solomon Aronson, Michael Cahalan, Robert Savage, Jack Shanewise, and myself, as Chair of the Task Force. Its main purpose is to advise the Board of Directors of both societies on issues in Perioperative Echocardiography that are of common interest. Both societies are committed to excellence in echocardiography and patient care and there is, therefore, a lot of common ground. What needs to be achieved is greater awareness and better sharing of information between the two societies.

In his editorial, Dr. Fyfe mentions the credentialing of echocardiographic laboratories by the Intersociety Commission for the Accreditation of Echocardiographic Laboratories (ICAEL). As its name implies, ICAEL was sponsored by several societies with an interest in echocardiography. They include the American College of Cardiology, the American Society of Echocardiography, and the Society of Pediatric Echocardiography. ICAEL's main purpose is to develop standards for the practice of quality echocardiographic services and to recognize those facilities that meet the standards. At present, accreditation by ICAEL is voluntary and optional. As practitioners of echocardiography, cardiothoracic anesthesiologists should welcome standards for quality practice, particularly if they participate in the development of the standards. One of the Joint Task Force's first agenda items is to explore how SCA can become a meaningful contributor to ICAEL. While there are numerous unresolved issues, this dialogue must begin.

Whether a single physician should provide anesthesia and perform TEE in pediatric cardiac patients is another valid question. Anesthesiologists often fancy the comparison between their activities and those of airplane pilots. It is, therefore, useful to remember that the Federal Aviation Administration determines, based on pilot workloads, whether a certain type of airplane must be flown by one or two pilots. Scientific studies should be undertaken to examine workload and work distribution as pediatric cardiac patients are separated from cardiopulmonary bypass and echocardiographic information needs to be obtained. With the growing availability of anesthesia simulators, scientific data can be collected on this topic and conclusions, based on facts, could be derived. Until then, one must unfortunately rely on anecdotal reports. In some practices, a single individual may be able to accomplish both tasks successfully, while in others it may not be possible.

If you have comments or suggestions on these issues, please feel free to communicate them to me at sca@societyhq.com. After editorial review by the Newsletter Committee, they will be published. One of my hopes is that the SCA Newsletter will develop into a forum for active discussion on topics that interest us all.

Daniel M. Thys, M.D.

President, SCA

1. Stevenson JG. Adherence to Physician Training Guidelines for Pediatric Transesophageal Echocardiography affects the outcome of patients undergoing repair of congenital cardiac defects. J Am Soc Echocardiogr. 1999; 12: 165-72.

2. Fyfe D. Transesophageal echocardio-graphy guidelines: return to bypass or to bypass the guidelines? J Am Soc Echocardiogr. 1999; 12: 343-4

3. Fyfe DA, Ritter SB, Snider AR, et al. Guidelines for transesophageal echocardiography in children. J Am Soc Echocardiogr. 1992; 5: 640-4