In the realm of cardiac surgery, the use of intraoperative transesophageal echocardiography (TEE) has been a topic of considerable debate. The question at the heart of this matter revolves around whether strain imaging should become a routine part of the TEE exam during cardiac surgical procedures.
A recent article published in the *Journal of Cardiothoracic and Vascular Anesthesia* offers a dissenting view on the necessity of routine strain imaging. Authors Theodore J. Cios, S. Michael Roberts, and John C. Klick of the Department of Anesthesiology and Perioperative Medicine at Penn State Health Milton S. Hershey Medical Center express their concerns and provide justifications for their position.
DOI: 10.1053/j.jvca.2019.02.041
In their publication from November 2019, under the title “Con: Strain Imaging Should Not Be a Routine Part of the Intraoperative TEE Exam During Cardiac Surgery,” the authors argue against the widespread implementation of this sophisticated echocardiographic technique. This article, which is indexed with the PMID 31060945, provides a contrast to other literature that may advocate for the routine use of strain imaging.
The Role of Strain Imaging’
Strain imaging is an advanced echocardiographic technique that measures myocardial deformation. It provides insights into the contractile function of the heart muscle which can be missed by other standard echocardiographic measurements. The primary value of strain imaging lies in its ability to detect subtle myocardial dysfunctions that could have prognostic implications for the patient.
Arguments Against Routine Use
Cios, Roberts, and Klick present several arguments against the routine use of strain imaging during intraoperative TEE in their commentary. Here are their key points:
1. Complexity and Time Consumption: The technique requires sophisticated software and expertise in echocardiography. It is time-consuming to perform and interpret, which may not be practical in all intraoperative settings, especially when time is critical.
2. Limited Prognostic Value: While strain imaging can provide additional information about myocardial function, its prognostic value in the setting of intraoperative cardiac surgery is not firmly established.
3. Potential for Inconsistencies: There’s a concern with the variability of measurements across different ultrasound machines and software. This inconsistency can compromise the reliability of the data.
4. Lack of Adequate Training: Not all anesthesiologists and cardiologists are adequately trained in strain imaging, which may lead to misinterpretation of results and potential mismanagement of the surgical plan.
5. Cost-Effectiveness: The increased cost associated with the implementation of strain imagining technology may not justify its routine use in all cardiac surgical procedures, especially without clear evidence of improved patient outcomes.
The Debate Continues
Despite the arguments presented by Cios and colleagues, the debate continues in the cardiology and anesthesiology community. The proponents of routine strain imaging argue that this technique allows for earlier and more accurate detection of myocardial ischemia, potentially leading to better patient outcomes.
Keywords
1. Transesophageal echocardiography
2. Strain imaging
3. Cardiac surgery
4. Myocardial function
5. Intraoperative TEE
Future Directions
The future of strain imaging in the intraoperative setting depends on further research and evidence that could strengthen the arguments for or against its routine use. As technology advances and training programs evolve, the application of strain imaging could become more streamlined and its potential benefits more pronounced. The decision to embed strain imaging into routine TEE exams will likely remain contingent upon the balance of risks, costs, and benefits elucidated in future studies.
Conclusion
The recent publication by Cios, Roberts, and Klick has added valuable perspectives to the ongoing conversation around the application of strain imaging during intraoperative TEE in cardiac surgery. As healthcare professionals weigh the pros and cons of adopting this technology, patient-centric decisions should be guided by meticulous research, cost-benefit analysis, and consensus within the medical community.
References
1. Cios, T. J., Roberts, S. M., & Klick, J. C. (2019). Con: Strain Imaging Should Not Be a Routine Part of the Intraoperative TEE Exam During Cardiac Surgery. Journal of Cardiothoracic and Vascular Anesthesia, 33(11), 3201-3203. [Original Article](https://doi.org/10.1053/j.jvca.2019.02.041)
2. J Cardiothorac Vasc Anesth. (2019). [Related Article on Strain Imaging Advocacy](https://pubmed.ncbi.nlm.nih.gov/31171421)
3. Tamborini, G., Pellegrini, C., & Muratori, M., et al. (2020). Is there a role for 3D TEE in the perioperative evaluation of cardiac function? Anesth Analg.
4. Duncan, A. E., Alfirevic, A., Sessler, D. I., et al. (2018). Perioperative assessment of myocardial deformation. Anesth Analg.
5. Unsworth, B., Casula, R. P., & Kyriacou, A. A. (2016). The use of strain imaging in the assessment of myocardial function in perioperative and critical care. J Intensive Care Soc.
Given the diverse points of view and the complexity of this debate, further studies are anticipated within the medical community. As evidence accumulates, the place of strain imaging in routine intraoperative TEE will surely be revisited, with patient welfare remaining the foremost consideration.