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Table of Contents
Year : 2014  |  Volume : 30  |  Issue : 3  |  Page : 313-315

Pre-operative echocardiography: Evidence or experience based utilization in non-cardiac surgery?

1 Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA
2 Deparment of Anaesthesiology, Dayanand Medical College, Ludhiana, Punjab, India

Date of Web Publication22-Jul-2014

Correspondence Address:
Sudhakar Subramani
Department of Anesthesiology, University of Iowa Hospitals & Clinics, 200 Hawkins Drive 6 JCP, Iowa City, IA 52242, USA

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9185.137258

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How to cite this article:
Subramani S, Tewari A. Pre-operative echocardiography: Evidence or experience based utilization in non-cardiac surgery?. J Anaesthesiol Clin Pharmacol 2014;30:313-5

How to cite this URL:
Subramani S, Tewari A. Pre-operative echocardiography: Evidence or experience based utilization in non-cardiac surgery?. J Anaesthesiol Clin Pharmacol [serial online] 2014 [cited 2021 Jun 19];30:313-5. Available from:

Pre-operative echocardiography has been utilized in perioperative period for decades in patients with active cardiac conditions scheduled for non-cardiac surgery to aid in risk stratification. Echocardiography enables direct visualization of the various chambers of the heart, valves, adjacent structures and major connecting vessels like pulmonary artery and aorta. In the majority of patients, trans-thoracic echocardiography (TTE) has been used for screening with few exceptional clinical conditions such as endocarditis, severe calcific aortic stenosis, suspected intra cardiac thrombus etc., where trans esophageal echocardiography has been performed pre-operatively. TTE as a cardiac imaging offers safety, portability and repeatability in addition to high quality imaging. The pertinent question raised is "Is pre-operative resting or stress TTE evidence based?" This editorial scrutinizes if the pre-operative echocardiography utilization is based on the guidelines or individualistic expert opinion.

Cardiac disease is a potential source of perioperative complications in any non-cardiac surgery. Perioperative physicians and anesthesiologists realize the importance of risk stratification by evaluation of the nature and severity of cardiac disease prior to anesthesia. Major non-cardiac surgeries with prolonged hemodynamic and cardiac stress are associated with major cardiac complications (between 2.0% and 3.5%) and mortality (between 0.5% and 1.5%). [1] This difference in the incidences is mainly explained by patient selection and the endpoints defined for myocardial infarction. The morbidity and mortality depends on various factors like the nature of the patient's pre-existing clinical condition (e.g., ischemic heart disease [IHD], left ventricular [LV] dysfunction and significant valvular heart disorders), its severity and the type of surgical procedure being performed.

Currently, British Society of Echocardiography (BSE) as well as American Society of Echocardiography (ASE) is establishing guidelines for Echocardiography in the pre-operative assessment with periodic revision. BSE recommends TTE in patients with documented IHD with reduced functional capacity (<4 metabolic equivalents [METS]), unexplained shortness of breath in the absence of clinical signs of heart failure, if electrocardiogram (ECG) and/or chest X-ray are abnormal, murmur in the presence of cardiac or respiratory symptoms, murmur in an asymptomatic individual in whom clinical features or other investigation suggest severe structural heart disease. TTE should not be used just to repeat the assessment of previous echocardiogram with no intervening change in clinical status within 12 months. [2] ASE has no clearly defined indication for resting echocardiogram, except for high-risk vascular procedures in patients with reduced functional capacity (<4 METS) where only stress echocardiography is recommended. [3]

Clinical evidence showing appropriate utilization of pre-operative echocardiography in non-cardiac surgery is scanty. The resting echocardiography has relatively weak evidence in predicting post-operative outcomes even in patients with active cardiac conditions and poor functional status. [4] American Heart Association (AHA) guidelines for perioperative cardiac risk stratification state that cardiac evaluation in any form should help the perioperative care providers by doing more than just giving medical clearance for the surgery. [5] It should rather fortify informed clinical judgment in terms of existing cardiac status, recommendations for managing of cardiac issues and collaborating with perioperative anesthesiology team for management that might affect short or long-term cardiac outcomes.

Few prospective and retrospective studies validate a positive correlation between LV dysfunction and post-operative morbidity or mortality. [6],[7] Any degree of LV dysfunction has been found to be associated with perioperative myocardial infarction or cardiogenic pulmonary edema (odds ratio [OR] 2.1, 95% of the confidence interval 1-4.5, P < 0.05). [8] This finding of predictive post-operative events had a very poor sensitivity (43%) and predictive value (13%) but at the same time had significant specificity (76%) and negative predictive value (94%). It was found that the overall greatest risk of complications was associated with ejection fraction <35%. [9] Hence it makes cardiac risk stratification pertinent pre-operatively. Flu et al. in their prospective trial on more than 1000 vascular surgical patients found 40% asymptomatic LV failure of which majority had isolated diastolic dysfunction and this doubled the 30 day cardiovascular morbidity and quadrupled the long-term mortality more in open than endovascular procedures. They suggested including TTE routinely for asymptomatic open vascular procedures in the pre-operative risk stratification. [10] Technology advancements with newer echocardiography features such as strain analysis and 3D echo helps to quantify diastolic function more precisely and thereby improve overall perioperative management. [11],[12]

A meta-analysis of 25 echocardiography and 50 nuclear scanning in non-cardiac surgical patients, found out superior likelihood ratio (true positive to false positive rate) with stress echocardiography compared with thallium scanning (4.09 vs. 1.83) in predicting post-operative outcomes. [13] In terms of cost effective analysis, Kertai et al. [14] demonstrated a positive trend for dobutamine stress echo (DSE) to have better diagnostic performance than ambulatory ECG, exercise ECG, radionuclide ventriculography, myocardial perfusion scintigraphy and dipyridamole stress echo, in their meta-analysis of 8119 vascular patients. Mantha et al. suggested DSE is not an ideal test in predicting post-operative outcomes as suggested by the Kertai et al. [14] by proposing two stage hierarchic model to combine information about likelihood ratio separately for positive and negative outcomes. [15]

It has been seen that pre-operative echocardiography used based on the international guidelines in the targeted population influences perioperative management including the anesthesia technique. This information is predominantly from expert opinion and retrospective review. [16] Unfortunately, till date there exists no objective evidence in terms of randomized control trial on utilization of pre-operative echocardiography on the perioperative outcome. In a large population based retrospective cohort review 2,64,823 patients were analyzed and echocardiography performed in 15.1% of these patients. They found the pre-operative echocardiography was not associated with improved outcomes or shorter hospital stay in major non-cardiac surgery, casting doubts on proper utilization of the very common pre-operative test. [17]

Is there a better way to analyze if pre-operative echocardiography improves post-operative outcome? May be yes, with a large number of prospective cohort studies or with randomized control trials, but these studies are not devoid of their own inherent limitations. Cohort studies would be subjected to selection and information bias along with many confounding factors like severity of illness. Blinding is a pertinent concern even with a randomized trial leading to the observer and performance bias. Is there a way to optimize the pre-operative condition such as altering medications, fluid therapy etc. based on the echocardiography to assess the outcome? One should realize the ethical issues for the control group in these interventional trials. Thus, study designs in various forms for assessing the relationship between pre-operative echocardiography and post-operative outcome may have major clinical and logistical concerns.

Since multiple issues may be encountered while performing clinical trial on the utilization of the pre-operative echocardiography, perhaps a web-based survey may answer these issues. In a web-based survey on the simulated patients, Vigoda et al. found out that only 40% of responders follow the recommendations for patients without active cardiac conditions but 82% of responders followed the guidelines when faced with simulated patients with active cardiac issues. [18] This observation casts doubt on the recommendations advised by AHA/American College of Cardiology including utilizing echocardiography. We (SS) are currently doing web based questionnaire study on the pre-operative utilization of TTE in non-cardiac and non-vascular simulated patients with varying cardiac conditions. Participants are asked to report in terms of anesthetic induction, invasive lines, cardiac output monitoring, planned post-operative care before and after reading the echocardiography. However, these types of surveys are handicapped due to a large selection prejudice.

Evolution of computer technology aids miniature of versatile echo probes such as Vscan thus facilitating bedside availability including pre-operative clinic. Authors are expecting significant progression in the usage of TTE for limited examination on ventricular function and assessment of the valves and major vessels as proposed by BSE and cardiac society of Australia and New Zealand, which has also suggested inclusion of hemodynamic assessment in addition to diagnostic screening. [19] Canty and Royse audited echocardiography as point of care in the pre-operative clinic. [20] Although there was no available data for change in the outcome, they realized major impact in these techniques in terms of newly diagnosed end stage cardiac disease, change in the anesthetic and hemodynamic management and avoiding postponement of the surgery.

In conclusion, appropriate utilization of the pre-operative echocardiography to improve over all perioperative outcomes is a challenging task, encountered by every perioperative physician during pre-operative assessment. With recent increase in echocardiography training amongst anesthesiologists, we envisage increased integration with conventional anesthetic assessment. Utilization of pre-operative echocardiography can be extended to intraoperative as well as post-operative period as a new standard in monitoring. Cardiologists, cardiac anesthesiologists and anesthesiologists need to formulate a new strategy for utilizing echocardiography in an assessment paradigm in peri-operative risk stratification of patients afflicted with cardiac pathology.

Adequate training for use is essential as these imaging technologies require both skills in acquisition of diagnostic quality images, as well as knowledge and experience in their interpretation. Every perioperative physician needs to understand that it might not affect outcomes directly though it influences perioperative anaesthetic and medical management, indirectly.

  References Top

1.Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery, European Society of Cardiology (ESC), Poldermans D, Bax JJ, Boersma E, De Hert S, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009;30:2769-812.  Back to cited text no. 1
2.British Society of Echocardiography. Clinical indications for echocardiography. Available from: [Last accessed on April 2013].  Back to cited text no. 2
3.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, et al. ACCF/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, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr 2011;24:229-67.  Back to cited text no. 3
4.Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007;116:1971-96.  Back to cited text no. 4
5.Fleisher LA, American College of Cardiology/American Heart Association. Cardiac risk stratification for noncardiac surgery: Update from the American College of Cardiology/American Heart Association 2007 guidelines. Cleve Clin J Med 2009;76 Suppl 4:S9-15.  Back to cited text no. 5
6.Pedersen T, Kelbaek H, Munck O. Cardiopulmonary complications in high-risk surgical patients: The value of preoperative radionuclide cardiography. Acta Anaesthesiol Scand 1990;34:183-9.  Back to cited text no. 6
7.Poldermans D, Fioretti PM, Forster T, Thomson IR, Boersma E, el-Said EM, et al. Dobutamine stress echocardiography for assessment of perioperative cardiac risk in patients undergoing major vascular surgery. Circulation 1993;87:1506-12.  Back to cited text no. 7
8.Rohde LE, Polanczyk CA, Goldman L, Cook EF, Lee RT, Lee TH. Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery. Am J Cardiol 2001;87:505-9.  Back to cited text no. 8
9.Halm EA, Browner WS, Tubau JF, Tateo IM, Mangano DT. Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Study of Perioperative Ischemia Research Group. Ann Intern Med 1996;125:433-41.  Back to cited text no. 9
10.Flu WJ, van Kuijk JP, Hoeks SE, Kuiper R, Schouten O, Goei D, et al. Prognostic implications of asymptomatic left ventricular dysfunction in patients undergoing vascular surgery. Anesthesiology 2010;112:1316-24.  Back to cited text no. 10
11.Hoffmann R, Altiok E, Nowak B, Kühl H, Kaiser HJ, Buell U, et al. Strain rate analysis allows detection of differences in diastolic function between viable and nonviable myocardial segments. J Am Soc Echocardiogr 2005;18:330-5.  Back to cited text no. 11
12.Monaghan MJ. Role of real time 3D echocardiography in evaluating the left ventricle. Heart 2006;92:131-6.  Back to cited text no. 12
13.Beattie WS, Abdelnaem E, Wijeysundera DN, Buckley DN. A meta-analytic comparison of preoperative stress echocardiography and nuclear scintigraphy imaging. Anesth Analg 2006;102:8-16.  Back to cited text no. 13
14.Kertai MD, Boersma E, Bax JJ, Heijenbrok-Kal MH, Hunink MG, L'talien GJ, et al. A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart 2003;89:1327-34.  Back to cited text no. 14
15.Mantha S, Mascha E, Foss JF, Ellis JE, Roizen MF. Meta-analysis of diagnositic tests: Two stage hierarchic model for combining likelihood ratios for positive and negative test results. Anesth Analg 2007;104:S99.  Back to cited text no. 15
16.O'Neill S, Danjoux G. Targeted pre-operative echocardiography using international guidelines may influence patients' management and outcome Anaesthesia 2007;62:426-7.  Back to cited text no. 16
17.Wijeysundera DN, Beattie WS, Karkouti K, Neuman MD, Austin PC, Laupacis A. Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: Population based cohort study. BMJ 2011;342:d3695.  Back to cited text no. 17
18.Vigoda MM, Behrens V, Miljkovic N, Arheart KL, Lubarsky DA, Dutton RP. Perioperative cardiac evaluation of simulated patients by practicing anesthesiologists is not consistent with 2007 ACC/AHA guidelines. J Clin Anesth 2012;24:446-55.  Back to cited text no. 18
19.Canty DJ, Royse CF, Kilpatrick D, Bowman L, Royse AG. The impact of focused transthoracic echocardiography in the pre-operative clinic. Anaesthesia 2012;67:618-25.  Back to cited text no. 19
20.Canty DJ, Royse CF. Audit of anaesthetist-performed echocardiography on perioperative management decisions for non-cardiac surgery. Br J Anaesth 2009;103:352-8.  Back to cited text no. 20

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