Progress through cooperation: Securing a sound training pathway for perioperative transesophageal echocardiography

B rry A. Fin g n MB FFARCS FRCPC - Tageal echocardiography in this issue of the HE publication of the Canadian guidelines for training in adult perioperative transesophJournal represents a major achievement for the Canadian Perioperative Echocardiography Group and for the subspecialty of cardiac anesthesiology in Canada.1 The document is an honest effort, by those involved, to provide guidance on a practical training program for anesthesiologists wishing to use transesophageal echocardiography (TEE) in routine clinical practice, and given the diversity of training of those currently performing intraoperative TEE in Canada, is more than timely.2 The authors sought and received input from the Canadian Society of Echocardiography and the wider membership of the Cardiovascular and Thoracic Section of the Canadian Anesthesiologists Society, thereby ensuring diversity of opinion, an essential requirement in guideline development.3 Intraoperative TEE is an integral component of surgical cardiac care and has wide application perioperatively.46 The performance of the examination is operator-dependent and demands technical skill as well as the ability to instantaneously interpret information obtained and pursue additional images as indicated by the findings observed. Interpretation of TEE acquired images and placing them in the appropriate context is crucial to assure a correct diagnosis and subsequent management plan. This involves not simply offering a diagnosis to our surgical colleagues, but also providing an opinion as to the appropriate intervention to take, or perhaps more importantly, not to take, in a specific situation. This consultative role can only be exercised with confidence and competence if those offering it are appropriately trained. In 1987, the American Society of Echocardiography published training guidelines directed at cardiologists outlining the components of a comprehensive echocardiographic clinical examination, the core knowledge base, the suggested duration of training duration leading to each level of expertise in the modality, and the experience and training required of those supervising trainees.7 Subsequently, patterned on the latter document, specific recommendations were developed for TEE.8 In cooperation with the Society of Cardiovascular Anesthesiologists, training guidelines were developed specifically addressing perioperative TEE.9 The Canadian guidelines extend the expected proficiency of an individual trained at a basic level to include limited diagnostic abilities, specifically, recognition of valvular heart lesions, intra-cardiac masses and pericardial effusions of significance. This is a sensible recognition of the expertise one would realistically expect of a specialist physician who undertakes three months of dedicated training in TEE and is supported by research aimed at assessing how rapidly physicians can master basic echocardiographic skills. In a prospective, observational, educational study, emergency medicine (ER) residents (PGY 13) completed a written and practical examination assessing their knowledge on how to complete and interpret a goal-directed transthoracic echocardiogram (TTE) immediately prior and subsequent to a five-hour didactic session and one-hour proctored practical echocardiographic training session developed by an ER ultrasound director and a cardiologist.10 Significant improvements in correct written test scores (from 54% pre to 94% post) and capacity to perform an appropriate goaldirected TTE (from 56% pre to 94% post) were observed. A prospective study assessing the ability of medical residents to learn how to effectively perform and interpret TTE at the bedside following a brief didactic and practical instruction session demonstrated that such skills could be acquired rapidly.11 Hand-carried cardiac ultrasonography used as a supplement to routine physical examination, even in the hands of relatively inexperienced individuals, can add significantly to diagnostic accuracy.12 Ultrasound imaging equipment is now relatively inexpensive, widely available and portable. Anesthesiologists not involved in cardiovascular anesthesia routinely use ultrasonography to facilitate localization of nerve bundles during regional anesthesia and catheter placement. Consequently, exposure to ultrasound imaging occurs throughout residency training. Canadian residents seem eager to obtain further training in echocardiography, with 40% expressing a desire to take such training as an alternative to engaging in research related activity.13 Although not addressed by Bque et al.,1 there is clearly a need for inclusion of structured echocardiographic training within our residency programs and a mechanism for acknowledgement of such training subsequent to successful completion of residency. The proposed continuing medical education (CME) and maintenance of competence guidelines are reasonable and achievable by most practitioners in academic centres. In the absence of a critical mass, physicians in smaller non-academic centres will be challenged to meet peer review expectations. Echocardiographyrelated CME relevant to anesthesiologists is not widely available in Canada and one is hopeful that the publication of the guidelines will act as stimulus to the provision of such CME opportunities for Canadian anesthesiologists in an easily accessible manner. The guidelines address the issue of TEE training and encourage training in TTE. If anesthesiologists are to contribute meaningfully to the development of echocardiography, then comprehensive training, particularly of those in educational leadership roles, in all aspects of the modality, including TTE, is distinctly advantageous. One of the most exciting recent developments in the field, three dimensional (3D) echocardiography, is by and large, confined to TTE acquired images.14 With time, 3D imaging will be routinely available from the esophageal window and will form a very useful adjunct to our current menu of images, particularly in the assessment of mitral valve pathology.15 Optimally, anesthesiologists intending to supervise those training in echocardiography should be exposed to such novel applications of the technology and be the leaders in introducing relevant advances into perioperative practice. This requires that time be spent in a cardiology-directed echocardiography laboratory. Training in the latter environment offers particular advantages, including exposure to a high volume and varied TTE practice and insight into the decision-making process which directs a patient toward a surgical intervention rather than continued observation. Furthermore, collegial relationships between cardiologists and anesthesiologists are fostered by this approach, which are of great value in the ongoing development of a perioperative TEE service. The blurring of the borders of specific disciplines in medicine and the requirement of physicians to continually adapt and engage in skill development (...truncated)