Perioperative Transthoracic Echocardiography—Thoughtful Design and Delivery of Standardized Imaging Protocols for Anesthesiology Teams

Abstract

The continued and ever-increasing incorporation of transthoracic echocardiography in perioperative practice has revolutionized point-of-care hemodynamic diagnosis and management.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar The applications of this diagnostic modality are a natural extension of current cardiac anesthesia practice and facilitate clinical triage throughout the perioperative setting including the preoperative clinic, the operating room, the postanesthesia care unit, and/or the intensive care unit.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar,2Flower L Dempsey M White A et al.Training and accreditation pathways in critical care and perioperative echocardiography.J Cardiothorac Vasc Anesth. 2021; 35: 235-247Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The importance of education, competence, and certification in this practice domain has been highlighted recently in the journal.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 2Flower L Dempsey M White A et al.Training and accreditation pathways in critical care and perioperative echocardiography.J Cardiothorac Vasc Anesth. 2021; 35: 235-247Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Kalagara H Manson W Townsley M. Point-of-care ultrasound (POCUS) training for anesthesiologists: Is is time to embrace and attain competency? [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Aug 14; https://doi.org/10.1053/j.jvca.2021.08.013Abstract Full Text Full Text PDF Scopus (1) Google Scholar In this issue, Subramaniam et al. present a framework for establishing a standardized transthoracic echocardiography exam for the perioperative physician.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar In their framework, they have proposed 3 levels of perioperative echocardiography: basic, advanced, and comprehensive. They have reviewed the indications, scope, and training requirements for these defined expertise levels in transthoracic echocardiography with a focus on the basic and advanced categories since these 2 are readily applicable in the perioperative environment.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar Furthermore, the authors also have outlined quality improvement initiatives to assist in the evaluation and continuous enhancement of these acquired skills.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar Their proposal represents an important step forward to address the required standards for this diagnostic modality in the perioperative period.5Kiefer JJ Raiten J Gutsche J. Point-of-care transthoracic echocardiography: A growing body of evidence, an educational need.J Cardiothorac Vasc Anesth. 2020; 34: 97-98Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Although multiple national and international specialty societies have established training and accreditation pathways in echocardiography, there could be more focus on defining standards and categories across the spectrum of perioperative transthoracic echocardiography.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 2Flower L Dempsey M White A et al.Training and accreditation pathways in critical care and perioperative echocardiography.J Cardiothorac Vasc Anesth. 2021; 35: 235-247Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Kalagara H Manson W Townsley M. Point-of-care ultrasound (POCUS) training for anesthesiologists: Is is time to embrace and attain competency? [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Aug 14; https://doi.org/10.1053/j.jvca.2021.08.013Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 5Kiefer JJ Raiten J Gutsche J. Point-of-care transthoracic echocardiography: A growing body of evidence, an educational need.J Cardiothorac Vasc Anesth. 2020; 34: 97-98Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 6Spencer KT Kimura BJ Korcarz CE et al.Focused cardiac ultrasound: Recommendations from the American Society of Echocardiography.J Am Soc Echocardiogr. 2013; 26: 567-581Abstract Full Text Full Text PDF PubMed Scopus (362) Google Scholar Subramaniam et al. have defined the category of basic echocardiography as relevant to all anesthesiologists owing to its primary indication, namely for clinical diagnosis and rescue for perioperative hemodynamic instability.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar,4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar In their construct, the basic transthoracic exam has 5 views and 3 imaging windows using both 2-dimensional and color Doppler imaging. The basic exam functions well as a rescue tool during perioperative emergencies by providing diagnostic qualitative echocardiography.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar This qualitative assessment can guide assessment of volume status, ventricular function, valvular function, pericardial tamponade, as well as lung and pleural function.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 2Flower L Dempsey M White A et al.Training and accreditation pathways in critical care and perioperative echocardiography.J Cardiothorac Vasc Anesth. 2021; 35: 235-247Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Kalagara H Manson W Townsley M. Point-of-care ultrasound (POCUS) training for anesthesiologists: Is is time to embrace and attain competency? [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Aug 14; https://doi.org/10.1053/j.jvca.2021.08.013Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 5Kiefer JJ Raiten J Gutsche J. Point-of-care transthoracic echocardiography: A growing body of evidence, an educational need.J Cardiothorac Vasc Anesth. 2020; 34: 97-98Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 6Spencer KT Kimura BJ Korcarz CE et al.Focused cardiac ultrasound: Recommendations from the American Society of Echocardiography.J Am Soc Echocardiogr. 2013; 26: 567-581Abstract Full Text Full Text PDF PubMed Scopus (362) Google Scholar Since the basic exam does not include quantitative echocardiography and requires a total of 25 proctored exams, it is likely a reasonable goal for all anesthesiologists to achieve competence for this entry level of transthoracic echocardiography.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar In contrast, Subramaniam et al. have defined advanced transthoracic echocardiography to include 13 imaging views and 3 imaging windows with utilization of 2-dimensional, color Doppler, and spectral Doppler imaging.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar The advanced examination in their tiered approach includes both qualitative and quantitative echocardiography. Given its additional complexity and a suggested exposure to at least 150 examinations, competency at this echocardiography level is likely a reasonable goal for experienced echocardiographers.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar The authors also note that practitioners with advanced certification in transesophageal echocardiography likely can achieve competence in advanced transthoracic echocardiography with less clinical exposure, given their extensive background in echocardiography.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar The comprehensive examination is the most advanced level of transthoracic echocardiography, as outlined by Subramaniam et al.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar This examination provides a detailed cardiac evaluation with 27 imaging views and 6 imaging windows with utilization of all imaging modalities, including 3-dimensional, strain, and contrast imaging.7Mitchell C Rahko PS Blauwet LA et al.Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: Recommendations from the American Society of Echocardiography.J Am Soc Echocardiogr. 2019; 32: 1-64Abstract Full Text Full Text PDF PubMed Scopus (506) Google Scholar The comprehensive examination provides both qualitative and quantitative assessments in fine detail. This very advanced cardiac imaging is reserved for very experienced echocardiographers with considerable formal training.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar,7Mitchell C Rahko PS Blauwet LA et al.Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: Recommendations from the American Society of Echocardiography.J Am Soc Echocardiogr. 2019; 32: 1-64Abstract Full Text Full Text PDF PubMed Scopus (506) Google Scholar This very advanced level of echocardiographic assessment recently has been described by the American Society of Echocardiography.7Mitchell C Rahko PS Blauwet LA et al.Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: Recommendations from the American Society of Echocardiography.J Am Soc Echocardiogr. 2019; 32: 1-64Abstract Full Text Full Text PDF PubMed Scopus (506) Google Scholar This classification of complexity levels for transthoracic echocardiography by Subramaniam et al. is pragmatic and facilitates an understanding of a structured application of this imaging modality in the perioperative setting. The value of basic transthoracic echocardiography for perioperative clinical rescue has been highlighted in the literature.8Markin NW Gmelch BS Griffee MJ et al.A review of 364 perioperative rescue echocardiograms: Findings of an anesthesiologist-staffed perioperative echocardiography service.J Cardiothorac Vasc Anesth. 2015; 29: 82-88Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,9Shillcutt SK Markin NW Montzingo C et al.Use of rapid ‘rescue’ perioperative echocardiography to improve outcomes after hemodynamic instability in noncardiac surgical patients.J Cardiothorac Vasc Anesth. 2012; 26: 362-370Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Although transesophageal echocardiography may be preferred in the intraoperative period, there are risks with this invasive procedure.10Hilberath JN Oakes DA Shernan SK et al.Safety of transesophageal echocardiography.J Am Soc Echocardiogr. 2010; 23: 1115-1127Abstract Full Text Full Text PDF PubMed Scopus (307) Google Scholar In contrast, transthoracic echocardiography can provide a noninvasive imaging option, provided that the acoustic windows are reasonable.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar In the perioperative setting, there are multiple indications for basic transthoracic imaging, as outlined by Subramaniam et al. in Table 2.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar Although the indications for basic transthoracic echocardiography are also applicable to advanced imaging, the advanced transthoracic protocol also has additional indications for preoperative evaluation, as outlined by Subramanian et al. in Table 4.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar Prompt cardiac imaging can provide high-quality cardiac assessment to guide perioperative management and streamline workflow to improve safety and minimize delays in noncardiac surgery, including in the setting of hip fractures.11Hoehmann CL Thompson J Long M et al.Unnecessary preoperative cardiology evaluation evaluation and transthoracic echocardiogram delays time to surgery for geriatric hip fractures.J Orthop Trauma. 2021; 35: 205-210Crossref PubMed Scopus (7) Google Scholar, 12Kaleem M Kocaoglu H Sahin E et al.Impact of echocardiography on one-month and one-year mortality of intertrochanteric fracture patients.Acta Orhop Traumatol Turc. 2018; 52: 97-100Crossref PubMed Scopus (5) Google Scholar, 13Subramaniam K Boisen ML Yehushua L et al.Perioperative transthoracic echocardiography practice by cardiac anesthesiologists – report of a ‘start-up’ experience.J Cardiothorac Vasc Anesth. 2021; 35: 222-232Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 14Canty DJ Royse CF Kilpatrick D et al.The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: A retrospective cohort study.Anaesthesia. 2012; 67: 1202-1209Crossref PubMed Scopus (79) Google Scholar In the preoperative domain, advanced transthoracic imaging can evaluate cardiac status in emergency settings, clinical presentations suggestive of cardiac disease, known cardiac disease with clinical deterioration, and known significant cardiac disease to assess baseline severity.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar,15Acan AE Gultac E Kilmc CY et al.Preoperative mild pericardial effusion is associated with perioperative complications in elderly patients following hip fracture surgery.J Invest Surg. 2020; 33: 453-458Crossref PubMed Scopus (2) Google Scholar An advanced transthoracic imaging protocol led by anesthesiologists could detect and stratify cardiac disease to condense the preoperative evaluation, promote perioperative efficiency, and improve outcomes both in the cardiac and noncardiac settings.14Canty DJ Royse CF Kilpatrick D et al.The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: A retrospective cohort study.Anaesthesia. 2012; 67: 1202-1209Crossref PubMed Scopus (79) Google Scholar, 15Acan AE Gultac E Kilmc CY et al.Preoperative mild pericardial effusion is associated with perioperative complications in elderly patients following hip fracture surgery.J Invest Surg. 2020; 33: 453-458Crossref PubMed Scopus (2) Google Scholar, 16Chen X Ma Y Deng Z et al.Prediction of early postoperative major cardiac events and in-hospital mortality in elderly hip fracture patients: The role of different types of preoperative cardiac abnormalities on echocardiography report.Clin Interv Aging. 2020; 15: 755-762Crossref PubMed Scopus (6) Google Scholar, 17Tanaka CY Hartman KM Patel PA et al.Anesthesiologists can add value in transcatheter aortic valve replacement by performing transthoracic echocardiography.J Cardiothorac Vasc Anesth. 2020; 34: 32-34Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 18Chang MG Bittner EA Dalia AA. Perioperative TTE service: Developing a roadmap for success.J Cardiothorac Vasc Anesth. 2021; 35: 233-234Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 19Lee LKK Tsai PNM Ip KY et al.Preoperative cardiac optimisation: A directed review.Anaesthesia. 2019; 74: 167-179Crossref PubMed Scopus (18) Google Scholar Subramaniam et al. have highlighted the growing importance and impact of appropriate transthoracic imaging across the perioperative spectrum.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar Current and future research likely will demonstrate important outcome improvements with directed and tiered transthoracic imaging.19Lee LKK Tsai PNM Ip KY et al.Preoperative cardiac optimisation: A directed review.Anaesthesia. 2019; 74: 167-179Crossref PubMed Scopus (18) Google Scholar,20Canty DJ Heiberg J Yang Y et al.Pilot multicentre randomised trial of the impact of preoperative focus cardiac ultrasound on mortality and morbidity in patients having surgery for femoral neck fractures (ECHONOF-2 pilot).Anaesthesia. 2018; 73: 428-437Crossref PubMed Scopus (27) Google Scholar As this important imaging technology is integrated into perioperative practice, it remains essential to promote standards, guidelines, and protocols for basic and advanced imaging to limit errors and enhance safety.5Kiefer JJ Raiten J Gutsche J. Point-of-care transthoracic echocardiography: A growing body of evidence, an educational need.J Cardiothorac Vasc Anesth. 2020; 34: 97-98Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,21Díaz-Gómez JL Frankel HL Hernandez A. National certification in critical care echocardiography: Its time has come.Crit Care Med. 2017; 45: 1801-1804Crossref PubMed Scopus (15) Google Scholar The authors also have reviewed the current guidelines for training and certification in transthoracic imaging, including recommendations from international critical care societies, the American Society of Echocardiography, the National Board of Echocardiography, the American College of Cardiology, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar These multiple recommendations likely will require further translation in their gradual implementation across the specialty of anesthesiology and critical care.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar This diffusion process offers leadership opportunities for cardiac anesthesiologists owing to their extensive experience in perioperative echocardiography.22MacKay EJ Salmon MK Fatuzzo MR et al.Validation of claims data for the identification of intraoperative transesophageal echocardiography during cardiac surgery.J Cardiothorac Vasc Anesth. 2021; 35: 3193-3198Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,23MacKay EJ Zhang B Heng S et al.Association between transesophageal echocardiography and clinical outcomes after coronary artery bypass graft surgery.J Am Soc Echocardiogr. 2021; 34: 571-581Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Furthermore, in a similar fashion, there is significant leadership potential in this domain for anesthesiologists with critical care training, given the advent of mature certification process for transthoracic imaging in critical care medicine.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 2Flower L Dempsey M White A et al.Training and accreditation pathways in critical care and perioperative echocardiography.J Cardiothorac Vasc Anesth. 2021; 35: 235-247Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Kalagara H Manson W Townsley M. Point-of-care ultrasound (POCUS) training for anesthesiologists: Is is time to embrace and attain competency? [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Aug 14; https://doi.org/10.1053/j.jvca.2021.08.013Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 5Kiefer JJ Raiten J Gutsche J. Point-of-care transthoracic echocardiography: A growing body of evidence, an educational need.J Cardiothorac Vasc Anesth. 2020; 34: 97-98Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,21Díaz-Gómez JL Frankel HL Hernandez A. National certification in critical care echocardiography: Its time has come.Crit Care Med. 2017; 45: 1801-1804Crossref PubMed Scopus (15) Google Scholar Cardiac anesthesiologists and critical care anesthesiologists with their existing comfort with perioperative echocardiography could provide expertise and leadership in establishing teams for structured and systematic training in tiered transthoracic imaging for all team members, including trainees.24Ramsingh D Rinehart J Kain Z et al.Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents.Anesthesiology. 2015; 123: 670-682Crossref PubMed Scopus (88) Google Scholar A standardized implementation of transthoracic echocardiography as part of the scope of practice of the anesthesiologist requires careful consideration of its indications, as well as the training and maintenance of competency required for impactful and optimal patient care. As more anesthesiology residency programs integrate this imaging modality into their curriculums, the quality of the experience should be assessed serially to optimize this new curriculum. The didactic approach could include balanced learning methods, including simulation, to enhance the educational delivery and impact.25Matyal R Mitchell JD Mahmood F et al.Faculty-focused perioperative ultrasound training program: A single-center experience.J Cardiothorac Vasc Anesth. 2019; 33: 1037-1043Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,26Mahboobi S Mahmood F Bortman J et al.Simulator-based training of workflow in echocardiography.J Cardiothorac Vasc Anesth. 2019; 33: 1533-1539Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The curriculum also could create comprehensive longitudinal training to ensure that residents acquire adequate training in transthoracic echocardiography with sufficient opportunities to practice and maintain skills.24Ramsingh D Rinehart J Kain Z et al.Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents.Anesthesiology. 2015; 123: 670-682Crossref PubMed Scopus (88) Google Scholar A smartly designed curriculum can have high effectiveness but may require extensive commitment from both the educators and the residents.24Ramsingh D Rinehart J Kain Z et al.Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents.Anesthesiology. 2015; 123: 670-682Crossref PubMed Scopus (88) Google Scholar, 25Matyal R Mitchell JD Mahmood F et al.Faculty-focused perioperative ultrasound training program: A single-center experience.J Cardiothorac Vasc Anesth. 2019; 33: 1037-1043Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 26Mahboobi S Mahmood F Bortman J et al.Simulator-based training of workflow in echocardiography.J Cardiothorac Vasc Anesth. 2019; 33: 1533-1539Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 27Fatima H Amador Y Walsh DP et al.Simplified algortihm for evaluation of perioperative hypoxia and hypotension (SALVATION): A practical echo-guided apporach proposal.J Cardiothorac Vasc Anesth. 2021; 35: 2273-2282Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar At the University of Pennsylvania, the authors’ home institution, the authors have included this type of curriculum as part of the rotations through critical care and the postanesthesia care unit, but still have capacity to incorporate these concepts further into the operating room setting.28Mok D Schwarz SKW ROndi K. Point-of -care ultrasonagraphy in Canadian anesthesiology residency education programs: A national survey of program directors.Can J Anaesth. 2017; 64: 1023-1036Crossref PubMed Scopus (16) Google Scholar Adapting transthoracic imaging in an agile fashion for perioperative applications including cardiac assessment will continue as the technology becomes ever more accessible, including cost and portability.29Baribeau Y Sharkey A Chaudhary O et al.Handheld point-of-care ultrasound probes: The new generation of POCUS.J Cardiothorac Vasc Anesth. 2020; : 3139-3145Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar This enhanced accessibility adds further emphasis to the clinical imperative for standardization with pragmatic imaging protocols to facilitate universal adoption and integration, as outlined by Subramaniam et al.4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar The basic imaging approach could be used for rescue echocardiography in the perioperative space since it offers diagnostic power and prompt solutions in this challenging clinical scenario.1Kalagara H Coker B Gerstein NS et al.Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist [epub ahead of print].J Cardiothorac Vasc Anesth. 2021 Jan 16; https://doi.org/10.1053/j.jvca.2021.01.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar,4Subramaniam K Subramaniam H Knight J et al.An approach to standard perioperative transthoracic echocardiography practice for anesthesiologists.J Cardiothorac Vasc Anesth. 2022; 36: 367-386Abstract Full Text Full Text PDF Scopus (3) Google Scholar The advanced imaging approach may be championed by specific interested stakeholders such as cardiac anesthesiologists and critical care anesthesiologists as part of a perioperative echocardiography service. Subramaniam et al. should be congratulated for highlighting a comprehensive framework for standardizing transthoracic echocardiography across the perioperative spectrum to improve uptake, quality, and, ultimately, patient care. None. An Approach to Standard Perioperative Transthoracic Echocardiography Practice for Anesthesiologists—Perioperative Transthoracic Echocardiography ProtocolsJournal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 2PreviewThe use of intraoperative transesophageal echocardiography (TEE) has become the standard of care for most cardiac surgical procedures. There are guidelines established for training, practice, and quality improvement in perioperative TEE by the joint efforts of the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists. Cardiac point-of-care ultrasound (POCUS) increasingly is being incorporated into anesthesiologists’ training and practice. While a special “certification in Critical Care Echocardiography” was created by the National Board of Echocardiography in 2019, there currently exist no guidelines for training, certification, and practice of perioperative TTE by anesthesiologists. Full-Text PDF