Abstract
Left ventricular function can be evaluated by qualitative grading and by eyeball estimation of ejection fraction (EF). We sought to define the reproducibility of these techniques, and how they are affected by image quality, experience and accreditation. Twenty apical four-chamber echocardiographic cine loops (Online Resource 1–20) of varying image quality and left ventricular function were anonymized and presented to 35 operators. Operators were asked to provide (1) a one-phrase grading of global systolic function (2) an “eyeball” EF estimate and (3) an image quality rating on a 0–100 visual analogue scale. Each observer viewed every loop twice unknowingly, a total of 1400 viewings. When grading LV function into five categories, an operator’s chance of agreement with another operator was 50 % and with themself on blinded re-presentation was 68 %. Blinded eyeball LVEF re-estimates by the same operator had standard deviation (SD) of difference of 7.6 EF units, with the SD across operators averaging 8.3 EF units. Image quality, defined as the average of all operators’ assessments, correlated with EF estimate variability (r = −0.616, p < 0.01) and visual grading agreement (r = 0.58, p < 0.01). However, operators’ own single quality assessments were not a useful forewarning of their estimate being an outlier, partly because individual quality assessments had poor within-operator reproducibility (SD of difference 17.8). Reproducibility of visual grading of LV function and LVEF estimation is dependent on image quality, but individuals cannot themselves identify when poor image quality is disrupting their LV function estimate. Clinicians should not assume that patients changing in grade or in visually estimated EF have had a genuine clinical change.Electronic supplementary materialThe online version of this article (doi:10.1007/s10554-015-0659-1) contains supplementary material, which is available to authorized users.
Highlights
Clinicians are sometimes surprised that a patient moves between normal and impaired left ventricular function with just re-assessment of the same acquired images
There is growing availability of affordable portable cardiac ultrasound hardware [1, 2] which lacks a facility for Doppler, tissue Doppler, or area quantification
Visual grading and ‘‘eyeball’’ ejection fraction (EF) may appear to be a pragmatic choice for rapid assessment of LV function and charting progress
Summary
Clinicians are sometimes surprised that a patient moves between normal and impaired left ventricular function with just re-assessment of the same acquired images. Qualitative grading of ventricular function using portable hardware with limited functionality is common [1, 2]. An alternative is the speedy ‘‘eyeball’’ EF [3], in which the recommended formal Simpson’s calculation [4] is not carried out but a judgment is made from the images alone. It is apparent that this practice occurs in clinical practice and in recruitment for landmark randomized controlled trials. REVERSE [5] and MADIT-CRT [6], for example, have disclosed the histograms of EF values from recruitment centers, which suggest that the majority were eyeball estimates. Patients undergoing echocardiography for clinical reasons may have images that would not be of the quality typically displayed as published examples [7] of the
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
