Transoesophageal echocardiography in routine cardiac surgery

In reply: Stokes raises a number of relevant issues, but we would like to make the following points.

The case we reported occurred in a teaching hospital and neither of us undertakes routine transoesophageal echocardiography (TOE) in a private capacity.

While a Medicare rebate is not directly relevant to the clinical usefulness of a medical procedure, the Medicare Benefits Schedule functions as a surrogate marker for clinical legitimacy.

Stokes quotes anecdotes of occasional misuse or overuse of TOE. We agree that single cases neither justify nor give cause to reject a particular kind of monitoring. However, case reports, although lacking a denominator, are a start.

The main point of our letter was, in fact, to report the complication of surgery and the vital role played by TOE in achieving a good outcome.

Nevertheless, many of us who routinely use TOE consider that its advantages over other kinds of monitoring regularly benefit patients. We agree there is little “hard” evidence to support this, but detailed risk–benefit analysis for many of our routine monitoring devices is similarly non-existent. The Swan–Ganz catheter is a classic example.