 Greetings and welcome. My name is Annette Vegas. Welcome to this year's edition of the TGH-TE Symposium, which began in 2003. Today I have the pleasure of kicking off the meeting with a session on surgical decision making, guidelines, updates, and translation to practice. I was invited today to speak on the topic of guidelines and their integration into practice. Consider this a warm-up and an opportunity to reflect on definitions related to guidelines, standards, and policy. The rationale and development of guidelines. Spend a bit of time on the 2020 PTE guidelines. And finally, the challenges involved with knowledge translation. I have no specific conflict of interest, but I do receive book royalties. Just a warning as you gear up for the day. For the first talk, I will not show any video clips, as there will be plenty of echo images and diagnostic challenges over the day. So sit back and enjoy your coffee and breakfast. By definition, guideline is information intended to advise people on how something should be done. There are several terms that are used interchangeably, but do have slightly different definitions and intent. Policy is a document that outlines requirements or rules that must be met and answers the question, why do I need to do this? Standard is a set of requirements about a given area that must be adhered to by everyone and answers the question, what is required? Procedure defines the specific step-by-step process to meet the requirements for implementing a policy, standard, or guideline, or how do I do it? Guideline, like a standard, but it differs in that it's merely a recommendation to or suggestion that should be probably followed, but not necessarily required. Guidelines and standards are largely interchangeable in most cases. The American Society of Echocardiography has a rich legacy of producing guidelines since 1999. There are roughly 80 published guidelines covering a variety of imaging topics written for sonographers and clinicians. These can be accessed free online on their website and represent a valuable resource. While most of us are familiar with the ASC guidelines, there are also European guidelines published through the European Society of Cardiology. These are also available free online. There are approximately 20 guidelines of relevance to TEE and perioperative practice. These are some key guidelines related to imaging of which the most significant are the comprehensive TEE, basic TEE, 3D echo, epicardial, and the recent one on surgical decision making. There are guidelines that look at valves and ventricular size and function, different pathologies and procedures. There are a few guidelines devoted to congenital heart disease. All guidelines are worthy reads for those studying for exams and seeking information on these topics. This two-page commentary addresses the question of why ASC guidelines matter. The rationale and important reasons for guidelines include to support decision making in the use of echocardiography as an imaging modality. To reduce inappropriate variation in practice. To provide a focus for continuing education. To highlight limitations of existing literature. And provide direction for future research. So how are guidelines made? This involves a formal process based on the ASC guideline development manual. This is an orderly process which begins with a proposal, either a new idea or updated previous guidelines. And nomination of writing committee chairs who write and submit the proposal. The proposal is reviewed by the standards committee, modifications are made, and finally accepted. A key component of the process is the selection of the writing committee, which is based on very specific criteria to reflect a multidisciplinary, geographic, experiential and gender composition. Meetings occur, the committee members write drafts which are edited by the code chairs. A final draft is submitted for review by a single reviewer. After further iterations, the document is submitted to by review for the guideline committee and board of directors. The final document is reviewed, approved and submitted to the to JACE. A timeline for this type of project is roughly one to two years. So let's turn our attention to the surgical decision making guidelines published last year in 2020. The project began in 2016, took a hiatus and thanks to Dr. Alina Nakora from Duke got back on the rails and was finished. The project had a diverse 16 member writing committee of experts representing North America. The document comprises 43 pages, 22 tables and 15 figures. It was developed in collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons and endorsed by 18 ASC international alliance partners from around the world. The document outlines a systematic approach to apply existing guidelines to address questions of cardiac structure and function specific to the interoperative environment in open, minimally invasive or hybrid procedures. The document is divided into multiple sections, mostly related to cardiac structure and procedures as indicated here. I'm not going to go through each section, but I have selected a few to highlight some key points. While the document starts with mitral valve surgery, table one is about the assessment of right ventricular function. This may seem odd, but in fact reflects an increasing acceptance of the right ventricle often plays a significant role in patient outcome. Point number two is the increasing role of newer technology, such as 3D and deformation imaging along with more traditional assessment techniques such as Tapsi fractional area change and myocardial performance index. The mitral valve may be the focus of the procedure or casualty of pathology. There are many pre and post assessment points, mostly relating directly to the mitral valve, but also include surrounding structures. We perform these evaluations with each study. Assessing and determining the mechanism of mitral regurgitation becomes crucial to deciding on whether and what intervention may be warranted. A similar list of assessment points exists for aortic valve surgery. While there is pre assessment of the aortic valve, the actual surgical assessment and repair technique likely has a more profound effect on patient outcome. The emphasis here is on the post assessment and ensuring adequacy of repair with a good potential for durability. Imaging frequently occurs during common procedures such as cabbage surgery. Though this is less so here at our institution. The goal is to assess global and regional ventricular function, valvular function and aortic atheroma. This highlights a major limitation of echocardiography, which is the inability to easily and adequately assess regional perfusion and the presence of post graft ischemia. Occasionally there are procedures that are less common or we image less frequently. This represents an opportunity where the guidelines can provide important basic information to complete the assessment. But really at the end of the day, what does this all mean? Knowledge is of no value unless you put it into practice. Unless of course you are setting for an exam. This involves knowledge translation, which can be defined as the process of moving evidence into practice or alternatively using high quality knowledge in processes of decision making. Implementation is a complex process as shown in this graphic that involves adjusting knowledge to local content, assessing barriers to knowledge use. Tailoring tools, monitoring knowledge use, evaluating outcomes, sustaining knowledge use. The details are beyond the scope of the current talk. I will briefly mention the first few and leave the discussion of quality assurance to talks later in the meeting. Implementation begins with a simple question of what should constitute an appropriate TEE study? Should the views be standardized or non-standardized views? Should the approach be based on obtaining all the views targeted or structure based? And importantly, should the views be obtained in a standard or randomized order? There are a few papers suggesting a standardized approach, which may provide quality improvement by facilitating teaching and completeness. There are many potential barriers to obtaining an interoperative TEE exam, including technology factors such as the adequacy of equipment, maintaining hardware, updating software, and understanding machine workflow. Time factors such as pressures for pre- and post-assessment and providing off-hour services. Image quality may be affected by patient factors, the echocardiographer's skill, and the presence of coterie artifacts. But at the bedside, to apply these guidelines effectively, one must remember their content. This may be challenging as we age, try to recall cutoff values in diverse and sometimes uncommon situations. Cognitive aids help us get it right in challenging conditions. The ASC offers many cognitive aids in the form of posters, pocket guidelines, and apps, but none relates specifically to the topic of surgical decision-making. You can design your own as we have at TGH. While we currently do not mandate a standardized approach to image acquisition or study content, we have developed protocol for acquiring views and assessing lesions. This is a pocket version that enables the trainee and echocardiographer to have relevant information at their fingertips. Finally, the last part of implementation involves monitoring use, evaluating outcomes, and sustained knowledge use. These components fall under the umbrella of quality assurance in echocardiography. It is beyond the scope of this talk to discuss this topic in detail, but there will be a session later on in the day. So the take-home messages. Multiple echocardiographic guidelines exist. These guidelines support clinical decision-making. Guidelines provide expert opinion and an update for continuing education. Knowledge translation is challenging. Guidelines serve as a foundation for quality assurance and improvement. Thank you very much.