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• W2892028059 abstract "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) was introduced into clinical practice for cardiac surgery nearly 40 years ago,1Matsumoto M Oka Y Strom J et al.Application of transesophageal echocardiography to continuous intraoperative monitoring of left ventricular performance.Am J Cardiol. 1980; 46: 95-105Abstract Full Text PDF PubMed Scopus (159) Google Scholar, 2Schlüter M Langenstein BA Polster J et al.Transoesophageal cross-sectional echocardiography with a phased array transducer system. Technique and initial clinical results.Br Heart J. 1982; 48: 67-72Crossref PubMed Scopus (110) Google Scholar and guidelines pertaining to the anesthesiologist's use of TEE were first published more than 20 years ago.3Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography.Anesthesiology. 1996; 84: 986-1006Crossref PubMed Scopus (517) Google Scholar Formalized training programs and standardized evaluation and testing before perioperative TEE board certification exist for physicians seeking specialization in TEE. Cardiac valve surgery is a component of cardiac surgical practice that often relies on the perioperative TEE examination for optimal outcomes; multiple “stakeholder” society groups, such as the American College of Cardiology, American Heart Association, American Society of Echocardiography, American Society of Anesthesiologists, Society of Cardiovascular Anesthesiology, and Society of Thoracic Surgeons, all have endorsed TEE use during valvular cardiac surgery.4American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, et alACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians.J Am Coll Cardiol. 2011; 57: 1126-1166Crossref PubMed Scopus (511) Google Scholar, 5Nishimura RA Otto CM Bonow RO et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Thorac Cardiovasc Surg. 2014; 148: e1-e132Abstract Full Text Full Text PDF PubMed Scopus (803) Google Scholar, 6Cheitlin MD Armstrong WF Aurigemma GP et al.ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography).J Am Soc Echocardiogr. 2003; 16: 1091-1110PubMed Scopus (0) Google Scholar, 7American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal EchocardiographyPractice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography.Anesthesiology. 2010; 112: 1084-1096Crossref PubMed Scopus (387) Google Scholar, 8Svensson LG Adams DH Bonow RO et al.Aortic valve and ascending aorta guidelines for management and quality measures.Ann Thorac Surg. 2013; 95: S1-66Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar Recommended TEE use via guidelines, however, does not equate to pervasive, guaranteed TEE use in practice. In this edition of the Journal of Cardiothoracic and Vascular Anesthesia, MacKay et al. assessed the heterogeneity of intraoperative TEE use for open cardiac valve surgery in the United States between 2010 and 2015.9MacKay E Groeneveld P Fleisher L et al.Practice pattern variation in the use of transesophageal echocardiography for open valve cardiac surgery.J Cardiothorac Vasc Anesth. 2019; 33: 132-134Google Scholar The authors used a large proprietary database to identify nearly 20,000 insurance discharge claims that include both International Classification of Disease-9-Clinical Modification and Current Procedural Terminology codes for open mitral valve (MV) repair, open MV replacement, open aortic valve (AV) replacement, and combined open MV and AV surgeries. These discharge claims then were cross-examined for the presence or absence of an intraoperative TEE physician service claim. Interestingly, the authors found that only 82% of the open cardiac valve surgeries had a corresponding intraoperative TEE service claim. There was a small, albeit statistically significant, difference between the occurrence of intraoperative TEE claims for AV surgeries compared with MV or MV-AV surgeries (80% v 85%, respectively). The occurrence of intraoperative TEE claims did not improve over the prespecified time period regardless of the type of cardiac valve surgery. The authors also found geographic differences of intraoperative TEE claims for cardiac valve surgeries, with the lowest in Alabama and Louisiana (both 61%) and highest in North Carolina (92%). With Minnesota as reference in univariable analyses, a significant variation of practice patterns across states continued to exist, with the odds ratio (OR) of intraoperative TEE claims ranging from 0.27 to 2.00. Logistic regression analysis, adjusting for patient demographics, surgical factors, and medical comorbidities, showed lower odds of intraoperative TEE claims for patients of Hispanic ethnicity. Subgroup analyses demonstrated that the ethnicity-related disparity was significant in those who underwent MV surgeries (OR 0.54; 95% confidence interval 0.30-0.95; p = 0.03) but not those who underwent AV surgeries (OR 0.72; 95% confidence interval 0.47-1.10; p = 0.13). Prior attempts to describe TEE use in cardiac valve surgery centered around 2 survey studies. Poterack reported that approximately 75% of academic centers with anesthesiology training programs routinely used intraoperative TEE (>50% of the time) for cardiac valve surgeries in 1995.10Poterack KA Who uses transesophageal echocardiography in the operating room?.Anesth Analg. 1995; 80: 454-458PubMed Google Scholar Nearly 20 years later, Dobbs et al. showed an increase in the practice commensurate with the published guidelines: intraoperative TEE at that time was used routinely (>50% of the time) during 95% and 97% of cardiac valve surgeries at academic and nonacademic centers, respectively.11Dobbs HA Bennett-Guerrero E White W et al.Multinational institutional survey on patterns of intraoperative transesophageal echocardiography use in adult cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 54-63Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Direct comparison of the discrete data of the surveys and the continuous MacKay data is not possible and these respondent data likely were inflated owing to selection bias and response bias. However, the survey results from Dobbs et al. represented a similar time period as that of the MaKay et al. report and give important context to the study presented here.10Poterack KA Who uses transesophageal echocardiography in the operating room?.Anesth Analg. 1995; 80: 454-458PubMed Google Scholar, 11Dobbs HA Bennett-Guerrero E White W et al.Multinational institutional survey on patterns of intraoperative transesophageal echocardiography use in adult cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 54-63Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The major limitation of the study by MacKay et al. is the use of TEE insurance claims as surrogates for TEE performed. Although this assumption may hold true for selected institutions, the reality is far more complex than it appears. Various studies have shown that this relationship does not necessarily hold true in all cases. In 1995, 43% of anesthesiologists billed for intraoperative TEE that they performed.10Poterack KA Who uses transesophageal echocardiography in the operating room?.Anesth Analg. 1995; 80: 454-458PubMed Google Scholar Sadly, this billing frequency only marginally improved over the years. Dobbs et al. continued to report that merely 57% of institutions billed for their TEE examinations in 2012.11Dobbs HA Bennett-Guerrero E White W et al.Multinational institutional survey on patterns of intraoperative transesophageal echocardiography use in adult cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 54-63Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Even though the institutions that responded to the Dobb et al. inquiries included international centers, it is not difficult to understand the flawed association between TEE insurance claims and the number of TEE examinations performed. There are several potential reasons for the absence of intraoperative TEE billing. Many community hospitals grant TEE privileges to clinicians who have passed the advanced perioperative TEE examination administered by the National Board of Echocardiography. These “testamur” echocardiographers hence are allowed to perform intraoperative TEE at their respective institutions despite not being “board certified” owing to the lack of formal TEE training. However, certain insurance carriers refute and discourage billing claims from non–board-certified echocardiographers, including those with testamur status. Personal correspondence with private practice non–fellowship-trained cardiac anesthesiologists confirms that TEE often is performed intraoperatively but the procedure is not submitted for reimbursement to avoid the scrutiny of an audit. Morewood et al. have shown frequent TEE usage for cardiac valve surgeries by anesthesiologists regardless of the local insurance carrier policies, suggesting that a sizable proportion of providers never had the intention to bill for performing TEE.12Morewood GH Gallagher ME Gaughan JP Does the reimbursement of anesthesiologists for intraoperative transesophageal echocardiography promote increased utilization?.J Cardiothorac Vasc Anesth. 2002; 16: 300-303Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar This most likely explains the low intraoperative TEE insurance claim finding across the United States, as opposed to the actual lack of TEE performance for cardiac valve surgery as Mackay et al. suggest. Even though these factors cast some doubt on their study's exact characterization of perioperative TEE guideline compliance, MacKay et al. should be applauded for pointing out that sluggish widespread adoption of sound, evidence-based clinical guidelines has been and continues to be a major threat to the delivery of high-quality medical care. Specifically, previous investigation of an American Heart Association and American College of Cardiology echocardiography surveillance recommendation revealed compliance of only 59% and unfortunately also highlighted health care disparities in historically disenfranchised patient populations.13Chan RH Shaw JL Hauser TH et al.Guideline adherence for echocardiographic follow-up in outpatients with at least moderate valvular disease.J Am Soc Echocardiogr. 2015; 28: 795-801Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Suppose intraoperative TEE performance is indeed reflected 100% by insurance claims, it then becomes undeniably shocking, especially to the current generation of cardiac anesthesiologists, that many institutions do not fully use TEE for cardiac valve surgeries. Unsurprisingly, the most commonly reported barriers to ubiquitous TEE usage are a lack of resources or infrastructure, although a lack of knowledge about the guidelines by qualified personnel also seemed to play a significant role.11Dobbs HA Bennett-Guerrero E White W et al.Multinational institutional survey on patterns of intraoperative transesophageal echocardiography use in adult cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 54-63Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Even when accounting for resource scarcity, it is possible that many cardiac surgical programs are rooted to their established practice patterns that have been honed over many years to yield favorable outcomes. Surely, there are surgeons who prefer to evaluate the cardiac valves by visual inspection or digital palpation directly in the field and place little emphasis on whether intraoperative TEE is performed. Many methods to examine valvular competency have been described and validated with good results in the surgical literature. The mitral apparatus can be tested by pressurizing the left ventricle via a left ventricular vent, intentional creation of aortic insufficiency, or direct infusion of saline with a bulb syringe.14Ferguson Jr, TB AS Wechsler Testing of mitral valve competence following combined mitral valve repair and aortic valve replacement.Ann Thorac Surg. 1985; 40: 631-633Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 15Watanabe T Arai H Leakage test during mitral valve repair.Gen Thorac Cardiovasc Surg. 2014; 62: 645-650Crossref PubMed Scopus (7) Google Scholar Mitral coaptation surface can be assessed by staining the closure line with a surgical marker as described by Anyanwu and Adams.16Anyanwu AC Adams DH The intraoperative “ink test”: A novel assessment tool in mitral valve repair.J Thorac Cardiovasc Surg. 2007; 133: 1635-1636Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar These provocative tests performed by surgeons are critical in that, unlike TEE, a significant positive result does not require reapplication of an aortic cross-clamp or reinitiation of cardiopulmonary bypass.15Watanabe T Arai H Leakage test during mitral valve repair.Gen Thorac Cardiovasc Surg. 2014; 62: 645-650Crossref PubMed Scopus (7) Google Scholar However, because of the annular conformational differences in the arrested and beating heart, discrepancies between direct surgical and intraoperative TEE assessment of valve competency can occur.17Nonaka M Marui A Fukuoka M et al.Differences in mitral valve-left ventricle dimensions between a beating heart and during saline injection test.Eur J Cardiothorac Surg. 2008; 34: 755-759Google Scholar Surgical resistance to relinquish the immense responsibility of testing valve integrity over to another provider is understandable, particularly considering that in one survey, only 63% of cardiac anesthesiologists had passed the National Board of Echocardiography advanced examination.11Dobbs HA Bennett-Guerrero E White W et al.Multinational institutional survey on patterns of intraoperative transesophageal echocardiography use in adult cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 54-63Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Of considerable controversy in the MacKay et al. study is the trend toward less perioperative TEE use in patients undergoing cardiac valve surgery who were identified as Hispanic. Any report that describes health care disparities in minorities is both dismaying and unsurprising. Epidemiologic literature is saturated with reports of lack of access to health care, less-frequently delivered “appropriate” care, and variations in morbidity and mortality when comparing minorities with Caucasians.18Smedley BD Stith AY Nelson AR Unequal treatment: Confronting racial and ethnic disparities in health care. National Academies Press, Washington, DC2003Google Scholar Although the use of retrospective administrative insurance data to describe clinical practice is fraught with severe limitations that may confound the interpretation of its findings, the noted trend in less TEE use in Hispanic patients warrants pause for consideration and further investigation. Perhaps the observed disparity is less about individual biases and more about systemic inequalities in health care delivery and access to care for marginalized populations. In an era of health care that increasingly is driven by guideline-directed medical therapy, race or ethnicity as a possible factor in the variation of recommended TEE use is a sobering thought. The current study by MacKay et al. is notable for what it adds to the literature regarding use (and perhaps the lack of use) of TEE for cardiac valve surgeries. As is noted, the methods used to collect data on TEE use in this study may not describe actual practice patterns; the lack of billing for TEE does not mean lack of TEE use. However, the findings do open questions—some of which may be uncomfortable—as to why we, as health care providers, do not use intraoperative TEE in each and every appropriate case. Additional investigation into TEE practice patterns would help clarify the results in the MacKay et al. study and may help identify areas in which anesthesiologists can strive to improve adherence to current guidelines, with the goal of enhancing patient outcomes. Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 1PreviewThe authors sought to assess for the presence of practice variation in the use of intraoperative transesophageal echocardiography (TEE) for open cardiac valve surgery. Full-Text PDF" @default.
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• W2892028059 title "Practice Patterns for the Use of Perioperative Transesophageal Echocardiography: A Practice not yet Made Perfect" @default.
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