The ability to non-invasively assess left and right systolic and diastolic ventricular function, valvular disease and pulmonary hypertension makes transthoracic echocardiography (TTE) a commonly performed preoperative investigation. Exclusion of left ventricular failure or severe aortic stenosis may assist in clearance for surgery and, on the other hand, if diagnosed, then may prompt referral to a cardiologist for an opinion on perioperative risk, or to reduce risk with either medical or surgical treatment prior to surgery. The current British, European and American cardiology societal recommendations for TTE before elective non-cardiac surgery are listed in Table 4.2 [18–20]. Although TTE may identify structural evidence of ischaemic heart disease, such as regional wall motion abnormality and scar, it has a low sensitivity and specificity for ischaemic heart disease, for which exercise testing is recommended [8]. Guidelines also discourage repeat TTE with no intervening change in clinical status within 12 months [18].

Despite frequent use, the current evidence for the use of preoperative TTE for risk estimation is not strong (Table 4.2) and improvements in outcome after elective non-cardiac surgery has not yet been subjected to testing with an adequately powered randomised controlled trial. However, in a large retrospective cohort study of 264,823 patients aged over 40 years presenting for intermediate to high-risk non-cardiac surgery, preoperative echocardiography was not associated with improved survival or shorter hospital stay [21]. The only other report is a small retrospective cohort study that demonstrated a twofold 12-month survival advantage in elderly patients undergoing hip fracture surgery who received preoperative TTE compared with controls [22].

Access to TTE, traditionally performed by cardiology or radiology departments, is variable and the waiting times in many centres may be prolonged due to high demand and reduced availability [23], potentially interfering with surgical work flow [24]. The expansion in use of TTE coupled with persistent economic pressure has lead to a reduction in availability of TTE for preoperative testing in the USA.

Over the last 10 years there has been a rapid uptake in the clinical use of TTE by emergency and critical care physicians and anaesthetists to guide decision-making in real time, or at the ‘point-of-care’ [27]. This has occurred due to improved portability, availability and affordability of equipment as well as the realisation that accuracy of clinical assessment can be substantially improved with only limited training and views [28]. Haemodynamic state and cardiac pathology can be diagnosed very quickly, even during a cardiac arrest [29], guiding important decision-making during initial assessment, rather than waiting for a third party to perform the investigation, essentially representing ‘ultrasound assisted examination’ [2].

The use of focused TTE has been demonstrated to improve clinical assessment and alter important treatment decisions in the order of 50 % of patients either experiencing or at risk of persistent haemodynamic instability in intensive care [30], emergency department [31] and perioperative settings [17, 26], including the preoperative clinic [2] (Fig. 4.2). In 2012, ‘point-of-care’ physician-performed TTE was defined as focused cardiac ultrasound (FCU) and endorsed in a position statement from the American Society of Echocardiography [32] and in another position statement on preoperative assessment before non-cardiac surgery from the European Society of Cardiology and Anaesthesiology [20].

In a prospective observational study of 100 patients presenting for assessment by the anaesthetist in the preoperative clinic for non-minor elective noncardiac surgery, the treating anaesthetist’s plan was recorded before and after focused TTE was performed by an independent operator. The treating anaesthetists deemed 80 patients to have suspected cardiac disease (Table 4.3) and 20 patients who were not at increased cardiac risk, other than being aged over 65 years. Focused TTE identified at least moderately severe cardiac ventricular or valvular dysfunction in 36 % of the high-risk patients (where TTE was indicated as shown in Table 4.3) and 10 % of the low risk patients (overall 32 %), resulting in a change in management decisions in 54 % (Fig. 4.3). Not only did the TTE result in changes in decision to proceed or postpone surgery without subjecting the patient to postponement of surgery for a repeat appointment, but also altered the anaesthetic technique (regional and general anaesthetic), invasive haemodynamic monitoring and treatment and use of postoperative high dependency care. When a clinically important haemodynamic or valvular abnormality (or worsening of known abnormality) was detected on TTE (e.g. the 11 patients with aortic stenosis), the anaesthetist was alerted to increased cardiac risk, who stepped up their level of care (in 24 %). On the other hand, a clinically unimportant finding or normal TTE had the effect of reassuring the anaesthetist, leading to a reduced requirement for further investigation, invasive haemodynamic monitoring and high dependency postoperative care (step down in care in 30 %). Furthermore, the overall impact of the TTE findings was to improve hospital efficiency by reducing delays to surgery and referrals for further medical opinions, suggesting a resulting cost-savings to the hospital [33].

Another finding was that focused TTE led to a significant change in management in patients in whom the only identified risk factor was age greater than 65 years, raising the question whether focused TTE should be routine in this population. This was also found in a similar study performed in patients undergoing emergency non-cardiac surgery [17].

The findings from this study not only confirmed that routine anaesthetist-performed TTE was feasible and could be used to assist in decisions for suitability of patients for surgery, but it also influenced the anaesthesia and postoperative medical care in an attempt to reduce poor postoperative outcome, addressing the suggested criteria set by the American Heart Association in preoperative evaluation. However the study was not designed to assess the influence of TTE on postoperative outcome and this question remains unanswered. Another important limitation is lack of consensus and resultant variability in management of specific cardiac disorders and anaesthesia techniques. Despite this, the overall effect of routine focused TTE is earlier detection of patients at increased cardiac risk allowing time for appropriate management decisions. In this study, focused TTE identified clinically significant cardiac pathology in 36 % of patients with suspected cardiac disease (Table 4.3), a similar finding by Faris et al. [34] who reported 27.6 % of patients using comprehensive TTE when used as per published recommendations from the American Society of Echocardiography [35].