**5. Training**

42 Echocardiography – In Specific Diseases

A B C

limited so as to preclude adequate imaging of the posterior aortic wall.

Fig. 5. Ultrasound images of aorta. A angles of ultrasound probe. B Zone 1, C Zone 2, D Zone 3, E Aortic arch, F Cerebral vessels. Other abbreviations as for Fig. 4.Ultrasound probe selection is important. A phased, linear array probe with a frequency in the rage 8-12 Mhz is preferred. Some attention to the physical size is also important as a large probe may not easily fit in the sternotomy wound, and a round probe is difficult to hold or to maintain orientation. If the frequency is too high, then the depth of penetration may be sufficiently

D E F

This ultrasound examination pertains almost exclusively to cardiac surgery. It could quite easily be applied to any other forms of surgery involving examination of large arteries or veins. At the current time intraoperative transoesophageal echocardiography is routine in many parts of the Western world, and becoming more common in the developing world. Therefore generally there is a good level of basic ultrasound experience and knowledge amongst surgical staff from the general observation of ultrasound being performed. However, at present few will be actively performing ultrasound examinations such as transthoracic echocardiography, ultrasound guided procedures or venous duplex studies all of which are becoming standard practice in advanced cardiac surgical centres. With this familiarity, the performance of epiaortic ultrasound examination is extremely simple to implement and to teach since there is significant underlying theoretical and practical experience. For those who have not performed ultrasound examinations before themselves;

Epiaortic Ultrasound Assessment of the Thoracic Aorta in Cardiac Surgery 45

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or have quite limited theoretical knowledge of ultrasound technologies, learning this examination is a little more difficult. The emphasis here is on the word "little", highlighting that this examination is quite straightforward and simple to perform and therefore to learn. Also, interpreting the images is equally very simple since it is obvious from first principles without any formal training, and the precise locality of atheroma is similarly very easy to appreciate since it is always directly beneath the ultrasound probe at the time. Surgeons do not require additional anatomy training; indeed the level of anatomy knowledge is the greatest of all specialties and even trainees have an extremely good understanding of anatomy. It would be expected that an advanced surgical trainee should be able to competently and confidently perform and epiaortic ultrasound examination after about 10- 20 supervised cases. With previous practical and theoretical experience in ultrasound or echocardiography, it may only be 5-10 cases.

Learning epiaortic ultrasound examination may be a sufficient enough stimulus to engage in a wider use of ultrasound technologies. In the current advanced cardiac surgical management, the use of ultrasound by cardiac surgeons should become a matter of routine daily practice. Performing transthoracic echocardiography in the pre-and post-operative settings, ultrasound guided procedures including pleural drainage and ultrasound lung examinations are quite straightforward and simple to learn. However, specific postgraduate training in addition to advanced surgical training should be undertaken; specifically it is not yet integrated as part of an advanced training program. A variety of postgraduate courses are available including university-based courses. These may cater for general (non-cardiac) clinical practice, or for an advanced diagnostic (cardiac) practice. Our program may be reviewed at www.heartweb.com
