Anesth Analg 2000;90:1248-1249
© 2000 International Anesthesia Research Society
LETTERS TO THE EDITOR
Five-grade Scoring System Is Still Confusing: Does ASE/SCA Set Up a Double Standard?
Toshiya Shiga, and
Ryo Ogawa, MD
Department of Anesthesiology Nippon Medical School Bunkyo-ku, Tokyo, Japan
We are gratified that the new ASE/SCA (the American Society of Echocardiography/Society of Cardiovascular Anesthesiologists) guidelines for intraoperative multiplane transesophageal echocardiography (TEE) have been introduced by Shanewise et al. (1). This presents an important step in building consensus between anesthesiologists and cardiologists.
As a result of these guidelines, a problem is emerging. In their "Left Ventricle (LV)" section, a method of LV segmental function analysis is described. The recommended grading scale for assessing segmental wall motion is as follows: 1 = normal, 2 = mildly hypokinetic, 3 = severely hypokinetic, 4 = akinetic, 5 = dyskinetic. The scale contrasts with that published in 1989 as the recommendation of the ASE Standards Committee (2): 1 = normal (or hyperkinesis), 2 = hypokinesis, 3 = akinesis, 4 = dyskinesis, 5 = aneurysmal. Couture et al. (3) recently addressed the differences between the scales, noting that, whereas anesthesiologists have conventionally used the former scale in the intraoperative echocardiography, cardiologists have preferred the latter scale. The fact that both scales originate from ASE recommendations means that ASE needs to clarify the usage of each. We do not understand the need for both scales and hope that the two different scoring systems will be standardized to one scale.
References
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Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999;89:870–84.[Free Full Text]
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Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography: American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989;2:358–67.[Medline]
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Couture P, Denault AY, Carignan S, et al. Intraoperative detection of segmental wall motion abnormalities with transesophageal echocardiography. Can J Anaesth 1999;46:827–31.[Web of Science][Medline]
Response
Jack Shanewise, MD
Division of Cardiothoracic Anesthesiology Emory University School of Medicine Atlanta, GA 30322
I appreciate Drs. Shiga’s and Ogawa’s kind words regarding the ASE/SCA recommended guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography (TEE) examination (1). They are correct in pointing out that the number scale recommended for scoring regional wall motion is different from the one previously recommended in 1989 by the Standards and Nomenclature Committee of the American Society of Echocardiography (ASE) (2).
The writing group for the guidelines decided to adopt the scale used most commonly in the intraoperative echocardiographic literature as documented by the references provided in the article (1). This scale also has the advantage of validation that a change of two or more grades is reproducibly detected between different observers and at different times by the same observer and should be considered significant. We felt that these factors outweighed the obvious disadvantage and confusion of not using the scale previously published by the ASE. This decision was endorsed by the approval of the guidelines by the Standards and Nomenclature Committee and the Board of the ASE as well as the Task Force for Certification in Perioperative TEE and the Board of the Society of Cardiovascular Anesthesiologists. This scale as published is recommended for use with intraoperative transesophageal echocardiography.
It is important to keep in mind that, in clinical practice, echocardiographic assessment of regional wall motion is based on a qualitative, "eyeball" assessment of ventricular motion and thickening. The existence of the two different scales points out the imprecise nature of the information they are intended to describe. Assignment of numbers to the qualitative descriptions (mild and severe hypokinesis, akinesis, and dyskinesis) should not be taken to mean that these data are on an interval scale, which would imply that akinesis (Grade 4) is twice as bad as mild hypokinesis (Grade 2). Regional wall motion score data may not even belong on an ordinal scale. Is dyskinesis (Grade 5), often associated with acutely ischemic but normal myocardium, always worse than akinesis (Grade 4), often due to scar? Another problem with regional wall motion analysis is that a similar echocardiographic feature, such as hypokinesis, may represent any number of very different conditions, such as acute ischemia, chronic ischemia (hibernation), stunning, acute infarction, completed infarction, or healed infarction. I certainly believe that, for scientific purposes, these data need to be analyzed with nonparametric tools and that it is not appropriate to compare numerical derivatives of regional wall motion scores, such as means and standard deviations.
Perhaps the only good reason to assign numbers to regional wall motion is to facilitate entry and storage in databases. I think it is always preferable to use the descriptive terms rather than numbers when communicating wall motion findings to colleagues. This will help avoid confusing the two scales and more accurately reflect the qualitative nature of echocardiographic wall motion assessment.
Other inconsistencies exist and have been pointed out between the intraoperative TEE guidelines and previously published recommendations. The intent and hope of the writing group was maximizing the usefulness of the document for the echocardiographer practicing TEE in the operating room. Inconsistencies do cause me pain, but seem inevitable when trying to apply any conceptual construct to a system of nature. Working on the intraoperative TEE guidelines has made me more understanding of inconsistency and better appreciate Aldous Huxley’s remark that, "The only completely consistent people are the dead."
References
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Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999;89:870–84.
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Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography: American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989;2:358–67.
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