Ordinary Images—Extraordinary Stories: Echo Challenges and Clinical Decisions

TRANSESOPHAGEAL echocardiography (TEE) is fast assuming the role of an essential monitor in cardiac operating rooms (ORs). Its role has evolved from an alternative to epicardial echocardiography during cardiac surgery to be classified as a category I indication during congenital and valve repair cardiac surgery.1, 2 The diagnostic and therapeutic uses of TEE cross medical disciplines, and the indications are determined by the circumstances of its use (eg, cardiologists commonly use it for the evaluation of intracardiac masses and the placement of percutaneous closure devices and anesthesiologists have traditionally used TEE for intraoperative monitoring during cardiac surgery). Gradually, the use of perioperative TEE is transitioning from being exclusively a monitoring modality during cardiac surgery to use during high-risk noncardiac surgery.3 Despite its widespread use by anesthesiologists (cardiac and noncardiac), the degree of therapeutic impact of TEE on perioperative decision-making is controversial. This perhaps could be caused by the difficulty in defining the nature and degree of therapeutic impact.4 Also, it is quite possible that because of the supportive nature of information gained from TEE, the therapeutic impact is significantly underestimated.5, 6

With increasing sophistication and utilization of TEE for perioperative decision-making by anesthesiologists, their role in the OR gradually is being redefined. They are no longer considered as mere “service providers” but rather an integral part of clinical decision-making, and, quite likely, in the future, they could be held liable for those decisions.5 The provision of information, which can change the course of surgery, does not automatically make us responsible for making that specific decision, but the accuracy of the data, which led to decision-making, is certainly our responsibility. Such a scenario is most commonly experienced when an unanticipated clinical situation is encountered in the OR or the pathophysiology diagnosed in the OR is of a different severity grade than reported. Common examples are mild-to-moderate aortic stenosis or moderate mitral regurgitation discovered during a routine coronary artery bypass graft operation. Immediate post-cardiopulmonary bypass assessment of repaired or prosthetic valves is another similar challenging scenario. The aforementioned situations may lead to decisions and procedures not originally planned, and regardless of who makes the decision or what the decision is, the information, which leads to this point, is our responsibility. It is likely that with anesthesiologists becoming more proficient with the use of TEE, our surgical colleagues will expect and demand a higher level of participation in this decision-making process.

As anesthesiologists, we have all come across situations in which we had to make an intraoperative decision based on an echocardiographic finding. The majority of these situations are clinically challenging and sometimes do not have an absolutely correct answer or such decisions do not always lead to a happy ending. The thought process for making a decision under these circumstances may be specific and unique to each patient and may not necessarily be applicable in a different context of the clinical circumstances. This was the main reason for us to come together and create a forum for the presentation of such cases in this Journal. We believed that there were no such forums specifically for the anesthesiologists to present these cases. Unlike similar sections in other journals, our section is more about the quality of the “story behind the image” rather than the quality of the “image.” Having considered all the subtleties involved, we have decided to name the new section “E (Echocardiographic)-Challenges and Clinical Decisions.” Hence, we would like to present cases in which an intraoperative echocardiographic finding led to a clinical decision. We would particularly highlight the context of the clinical decision and the rationale for proceeding in a specific direction. We would also like this section to be based primarily online with a small print section in the printed journal to direct the readers to the web site. Because the presented cases will revolve around echocardiographic images, we expect the authors to submit more video loops and images with notes for the readers. We understand that many of the decisions will be controversial, and readers may not agree with the management; this will surely lead to a discussion, which is precisely the point of this endeavor.

To increase the educational value, we would also encourage the potential authors to submit cases in which echocardiography was not particularly helpful. These cases will be presented in 2 parts. In the first part, a brief clinical summary and the associated clinical/echocardiographic dilemma will be presented. The case will be open for discussion and comments by the readers on our blog site, and the conclusion of the case will be presented in the print/online format in the following issue of the Journal; the section editors, Drs Mahmood and Swaminathan, will write the concluding remarks as editorial commentary. As we proceed to present more cases, we are sure that we will receive high-quality submissions consistent with the educational goals of the esteemed Journal. Because of the primarily online nature of the presentation, the Journal web site will be updated to highlight the acceptable video and presentation formats for optimal display. Because this is a novel and revolutionary idea, we are sure that it will be a “work in progress.” We will constantly update and modify our approach and presentation style in light of the feedback of our readers.

We are also extremely thankful to Dr Kaplan who has provided us with the opportunity to take this initiative and set up this section in the Journal. He has provided valuable guidance and directions, and this project could not have been possible without his input and advice. We are also thankful to Mr Nick DeAngelis at the journal publication office who has been instrumental in editing our presentations and commentaries to make them suitable for publication. We seriously believe this E-Challenges and Clinical Decisions section will have a unique educational value and will ultimately improve our understanding of echocardiography and its impact on clinical decision-making in the operating room.

With this background, we present in this issue a case of rheumatic aortic and mitral stenosis from the Beth Israel Deaconess Medical Center in Boston. The first part of the case is being presented in this issue. We welcome your comments and suggestions, and in the next issue we will disclose what our decisions were and why we made them. As readers will notice, these are ordinary images with an extraordinary story behind them. We request and encourage our readers to take the initiative and submit their extraordinary “stories” in the coming months and years.