Abstract
BackgroundRight ventricle (RV) size and function assessment by echocardiography (echo) is a standard tool in the ICU. Frequently subjective assessment is performed, and guidelines suggest its utility in adequately trained clinicians. We aimed to compare subjective (visual) assessment of RV size and function by ICU physicians, with advanced qualifications in echocardiography, vs objective measurements.MethodsICU specialists with a qualification in advanced echocardiography reviewed 2D echo clips from critically ill patients on mechanical ventilation with PaO2:FiO2 < 300. Subjective assessments of RV size and function were made independently using a three-class categorical scale. Agreement (B-score) and bias (p value) were analysed using objective echo measurements. RV size assessment included RV end-diastolic area (EDA) and diameters. RV function assessment included fractional area change, S′, TAPSE and RV free wall strain. Binary and ordinal analysis was performed.ResultsFifty-two clinicians reviewed 2D images from 80 patients. Fair agreement was seen with objective measures vs binary assessment of RV size (RV EDA 0.26 [p < 0.001], RV dimensions 0.29 [p = 0.06]) and function (RV free wall strain 0.27 [p < 0.001], TAPSE 0.27 [p < 0.001], S′ 0.29 [p < 0.001], FAC 0.31 [p = 0.16]). However, ordinal data analysis showed poor agreement with RV dimensions (0.11 [p = 0.06]) and RV free wall strain (0.14 [p = 0.16]). If one-step disagreement was allowed, agreement was good (RV dimensions 0.6 [p = 0.06], RV free wall strain 0.6 [p = 0.16]). Significant overestimation of severity of abnormalities was seen with subjective assessment vs RV EDA, TAPSE, S′ and fractional area change.ConclusionSubjective (visual) assessment of RV size and function, by ICU specialists trained in advanced echo, can be fairly reliable for the initial exclusion of significant RV pathology. It seems prudent to avoid subjective RV assessment in isolation.
Highlights
Right ventricle (RV) size and function assessment by echocardiography is a standard tool in the ICU
More patients were diagnosed with right ventricle (RV) dilation when RV diameters were measured vs end-diastolic area (41% vs 26% respectively [p < 0.001])
Subjective assessment of the RV size and function can be fairly reliably used in the critical care setting for initial exclusion of significant RV pathology, when performed by intensivists with advanced and expert critical care echo (CCE) level of training
Summary
Right ventricle (RV) size and function assessment by echocardiography (echo) is a standard tool in the ICU. Subjective assessment is performed, and guidelines suggest its utility in adequately trained clinicians. We aimed to compare subjective (visual) assessment of RV size and function by ICU physicians, with advanced qualifications in echocardiography, vs objective measurements. The importance of the right ventricle (RV) in the management of critically ill patients is increasingly recognised [1]. Echocardiography (echo) plays a crucial role in RV assessment for both diagnosis and monitoring and is an essential tool for the management of these patients in the ICU [1]. Leading national echocardiography society guidelines suggest to examine the heart from multiple acoustic windows with overall assessment to be based on subjective assessment in addition to quantitative parameters [9]. The accuracy, inter-observer and intra-observer concordance is not well described, for critical care physicians
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