IJTCVS Krishnan et al 32006; 22: 3–4 Editorial

The view within

Successful Cardiac Surgery requires complete andcomprehensive diagnosis. As residents in Cardio-thoracic surgery we were obliged to train for a periodof time in the Cathlab and attend regular cardiologypresentations. Weekly pathology conferenceshighlighted missed and incomplete diagnoses.

When Echocardiography was first introduced, it wasby present standards, crude and solely operatordependent for interpretation. It was just M (motion)mode Echocardiography, yet it was exciting becausenow one could get chamber dimensions, valve areas andvalve morphology in addition to other observations likepericardial thickening/collection etc. non-invasively.Though we could not see these structures as they were,this development excited cardiologists and surgeonsalike. It could be done at the bedside anytime of day ornight and gave sufficient information for a decision.

The introduction of 2-D Echo (Transthoraic Echo –TTE) made the surgeons sigh in relief. Now they couldsee themselves real-time images independent ofinterpretation. The addition of Doppler and color flowto 2-D examination provided vital additionalinformation. The equipments were bulky and requiredtraining in use. The surgeons with their ever present ‘ Iam busy’ attitude refused to learn but preferred todepend on cardiologists to show them everything.

As a natural consequence the echo entered theoperating rooms, now you could see before and aftersurgery. This introduced epicardial imaging whichinevitably was a joint effort between surgeon andcardiologist. The introduction of trans esophageal (TEE)echocardiography brought with it another revolutionarydiagnostic tool. This could show what TTE failed toshow, the pictures were extremely clear and crisp.Surgeons loved it, but once again depended on thecardiologist to perform the examination in the operatingroom. Inevitably they were made to wait sometimes insheer desperation for some useful hint on what wascausing the acute surgical emergency. The next step wasobvious. The passive standby teammate, yes, theanesthesiologists took over and learnt more by defaultthe performance and interpretation of TEE. Manysurgeons specially those domineering/enterprisingones decided to learn it themselves and use it ad lib fortheir own education and freedom.

This single step forward by many surgeons was, tobe expected. The equipment was user friendly. Theendoscopic probe was easy to position without need

for any additional skill. Suddenly a transesophagealexamination become fascinating and extremelyliberating. The surgeon could see the entire heart, thevalves, the ventricles, the defects, the tumors, theatheroseterotic plaques, calcification and what not. Theycould see pericardial collection; paravalvular leaksresidual shunts and failed repairs. They could seeventricular dysfunction and with a deft finger obtainejection fractions, valve areas, gradients and evencardiac output. There was more. Now they could seeair inside the heart and in many centers it is now routinepractice to use TEE for deairing the heart. Almost bymagic the surgeon had become a diagnostician parexcellence and totally independent. He became morepowerful, because now he could pickup what thecardiologist missed on TTE. He could see the proximalcoronaries, the RV outflow and pulmonary valve, theentire ventricular septum in profile, the missed, AtrialSeptal Defect (ASD), apical Ventricular Septal Defect(VSD), the left superior Vena Cava and valvularabnormalities like clefts, overriding chordae etc.

The cascading effect was phenomenal. Every moderncardiac surgical suite now has an Echo machine andprobes. At the head end the anaesthesiologist and evensurgeons begin by examining the heart. There was anexcellent opportunity to teach. Consequently TEEbecame an integral part of a surgeon’s (andanesthesiologists) armamentarium and remained insidethe operating room.

There are several extraordinary advantages for thesurgeon. Primarily he can see for himself and show toothers as well the intracardiac pathology andpathophysiology. It extended the surgeons vision of theworking heart in the intact person. It gave him vitalinformation required for decision-making. It allowedhim to choose better options especially in valve surgery.It provided him an opportunity to assess immediatelyafter surgery the functioning of the heart, valves, andventricles. It allowed him to ensure complete de airingand avoid the cerebral complications. In addition thisgave him freedom from being dependent on acardiologist.

A more recent but less used addition is the 3D Echowhere one can virtually hold the heart in his hand andperform virtual operations and immediately assess theresults. However this requires training, it is expensiveand has not become routine. Yet it is a tool available forthose interested in creative pursuits.

4 Krishnan et al IJTCVSEditorial 2006; 22: 3–4

If there is a reason to be disappointed, it is that notmany surgeons have taken to TEE. Few have learnt theskills and prefer even now to depend on someone else.For me it is invaluable and I am totally dependent on it.I cannot function satisfactory without it. And with it Iam fully liberated. It is high time that cardiac surgeonsbegan to use this simple tool for their own as well astheir patient’s benefit. As surgeons we have surrenderedto cardiologists for diagnosis, cardiac catheterizationand angiography, interventions etc. We are in dangerto surrendering even this simple, quick and efficient toolas well. Personally I would urge every surgical team toacquire the machine, go through a short training andbegin to liberate themselves.

A Cardiologist’s perspective

Adequate training in performing and interpreting theresults of TEE is mandatory. It is really not importantwho does TEE, but he/she must be well versed withthe technique and pit falls. Findings on TEE are likelyto be affected by hemodynamics, loading conditions andsystemic pressure. If the cardiac surgeon is theechocardiographer, he/she must make sure that theelement of bias is not introduced in interpreting theresults of surgery.

It is necessary to understand the full implication ofreturn to cardiopulmonary bypass, once a residualdefect, unsatisfactory repair is diagnosed. In a relativelystable patient, the decision is difficult, as going back onbypass has its associated morbidity and mortality. Andwhen in doubt it is best to consult the expert.

Anita SaxenaA. Sampath Kumar