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Communications to the Editor |

Transthoracic Echocardiography Is Not Proven To Be the Principal Echocardiographic Test in the ICU FREE TO VIEW

William C. Culp, Jr, MD
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The Texas A&M University System Health Science Center College of Medicine, Temple, TX

Correspondence to: William C. Culp, Jr, MD, Department of Anesthesialogy, Scott & White Clinic and Memorial Hospital, The Texas A&M University System Health Science Center, College of Medicine, 2401 South 31st St, Temple, TX 76508



Chest. 2005;128(3):1887. doi:10.1378/chest.128.3.1887
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Published online

To the Editor:

Dr. Joseph and his group1recently reported data in CHEST (November 2004) on the role of transthoracic echocardiography (TTE) in identifying cardiac etiologies of shock in the ICU. I congratulate the authors on their high rate of “adequate” TTE images (99%), but I find that it is a rate far exceeding the more common 80% “adequate” rate that is seen in many clinical practices, even with tissue harmonic imaging. Of note, the authors do not strictly define their criteria for image “adequacy,” which is the crux of the study. Further, there is no mention of the role of echogenic contrast agents, which have been shown to consistently improve image quality in difficult-to-image patients.2 Cardiac index, certainly a key value in patients who are in shock, was only able to be measured by TTE in 46% of the patients, whereas transesophageal echocardiography (TEE) studies can routinely derive this value in at least 90% of patients.34 Post-cardiac surgery patients were excluded from this study, as the authors note, but this is a very important group of patients who are at high risk for cardiogenic shock in whom TEE has been well-validated. Further, this study does not directly compare TTE to TEE. All of these points make me a bit hesitant to agree with the authors’ concluding statement, “TTE should be considered not only the initial, but also the principal echocardiographic test in the critical care environment.” As TTE technologies improve, this indeed may become the case, but the data presented here do not yet support such a change in clinical practice.

Joseph, MX, Disney, PJ, De Costa, R, et al (2004) Transthoracic echocardiography to identify or exclude cardiac cause of shock.Chest126,1592-1597. [CrossRef] [PubMed]
 
Yu, EH, Sloggett, CE, Iwanochko, RM, et al Feasibility and accuracy of left ventricular volumes and ejection fraction determination by fundamental, tissue harmonic, and intravenous contrast imaging in difficult-to-image patients.J Am Soc Echocardiogr2000;13,216-224. [PubMed]
 
Feinberg, MS, Hopkins, WE, Davila-Roman, VG, et al Multiplane transesophageal echocardiographic Doppler imaging accurately determines cardiac output measurements in critically ill patients.Chest1995;107,769-773. [CrossRef] [PubMed]
 
Poelaert, J, Schmidt, C, Van Aken, H, et al A comparison of transoesophageal echocardiographic Doppler across the aortic valve and the thermodilution technique for estimating cardiac output.Anaesthesia1999;54,128-136. [CrossRef] [PubMed]
 

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References

Joseph, MX, Disney, PJ, De Costa, R, et al (2004) Transthoracic echocardiography to identify or exclude cardiac cause of shock.Chest126,1592-1597. [CrossRef] [PubMed]
 
Yu, EH, Sloggett, CE, Iwanochko, RM, et al Feasibility and accuracy of left ventricular volumes and ejection fraction determination by fundamental, tissue harmonic, and intravenous contrast imaging in difficult-to-image patients.J Am Soc Echocardiogr2000;13,216-224. [PubMed]
 
Feinberg, MS, Hopkins, WE, Davila-Roman, VG, et al Multiplane transesophageal echocardiographic Doppler imaging accurately determines cardiac output measurements in critically ill patients.Chest1995;107,769-773. [CrossRef] [PubMed]
 
Poelaert, J, Schmidt, C, Van Aken, H, et al A comparison of transoesophageal echocardiographic Doppler across the aortic valve and the thermodilution technique for estimating cardiac output.Anaesthesia1999;54,128-136. [CrossRef] [PubMed]
 
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