41 Transesophageal Echocardiography

Training and Certification

The introduction of transesophageal echocardiography (TEE) into the perioperative arena in the mid-1980s heralded a new era in the care of surgical patients and offered a new dimension to the role of anesthesiologists.¹ Soon after its introduction, it became clear that perioperative TEE had the potential for significant impact on the care for both cardiac and noncardiac surgical patients.^2–4 Because of its minimally invasive nature and a high diagnostic potential, TEE has been used by practitioners from multiple specialties, for example, cardiologists, anesthesiologists, and critical care physicians. The therapeutic impact of TEE on preoperative surgical decision making soon was established, and it was recognized that it has the potential to offer improvements in patient care and, perhaps, eventual improvements in outcomes. However, there is the possibility for patient harm from misdiagnosis or from a poor understanding of the limitations of the technology and its application. The introduction of any new technology or technique into clinical practice, which can have such a dramatic impact on patient management, requires proper training and experience. The effectiveness of this expertise should be demonstrable by, among other things, significant training and experience, objective and validated measurement tools such as examinations, and demonstration of continued clinical activity. It was from these basic principles that the development of a certification process for perioperative TEE was born.

The debate surrounding the credentialing and certification for TEE is not unique to this technology. Often, the introduction and acceptance of technology into clinical practice outpace the efforts to legislate the credentialing requirements. Several other clinical techniques (e.g., laparoscopic surgical techniques and percutaneous angioplasty) were widely adopted clinically before credentialing and certification could be established.⁵ Perioperative TEE also has been rapidly accepted and deployed as an essential monitor in the cardiac operating rooms (ORs) before training and certification guidelines could be adequately developed. Despite being in clinical practice for more than two decades, a survey conducted among the membership of the Society of Cardiovascular Anesthesiologists (SCA) in 2001 showed that of the nearly 2000 members, less than 30% had any formalized training in TEE, and less than 50% reported having any specific credentialing requirements at their hospitals.⁶ Although there have been considerable improvements in perioperative TEE training programs, there is considerable room for improvement, and the majority of the clinical institutions, which include major academic centers, do not have specific credentialing requirements for anesthesiologists to use this monitoring modality.

The importance of collaboration between anesthesiologists and cardiologists was acknowledged in the 1996 American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists (ASA/SCA) guidelines for training and certification in TEE.^5,7 It was believed that because it was impractical for cardiologists to be present in the OR all the time, it was imperative for anesthesiologists to learn to perform and interpret intraoperative TEE examinations. To encourage more widespread use of TEE, the guidelines also stated that TEE should not be performed for making extremely focused examinations and narrow diagnoses, but broadly as a monitor to assist in cardiac surgical procedures. In addition to specifically describing the evidence of the therapeutic utility of TEE in clinical situations, the indications were analyzed in the context of the patient, the procedure, and the clinical setting⁷ (Boxes 41-1 and 41-2). The ASA/SCA guidelines recommended the following fundamental principles for optimal physician training in perioperative TEE^5,7:

Definitions

Because of the rapidly changing landscape of the training and certification requirements and because of multiple ambiguities, it often is confusing to follow the terminology used for echocardiography training and certification. This section provides the standard definitions of the most commonly used terms.

Perioperative Echocardiography

According to current guidelines, perioperative echocardiography is defined as TEE, epicardial, or epiaortic echocardiography performed on surgical patients immediately before, during, or after surgery.^7,8 Transthoracic echocardiography, although sometimes performed on surgical patients, is not considered a “perioperative” technique. Thus, the guidelines do not apply to transthoracic echocardiography–related procedures and image acquisition techniques.

Basic Training

At the basic level of training, the trainee should have knowledge of the principles of ultrasound and image acquisition, be able to place a TEE probe, operate the equipment, and conduct an examination. Although independent work is expected, all examinations performed by the basic-level trainee have to be supervised and interpreted under the guidance of an advanced-level echocardiographer together with the availability of a periodic assessment program. It also was recommended that anesthesiologists trained as basic echocardiographers should be able to use the TEE for establishing diagnoses within the customary practice of anesthesiology⁷ (Box 41-3).

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