British Society Of Echocardiography Research Articles

Role and application of three-dimensional transthoracic echocardiography in the assessment of left and right ventricular volumes and ejection fraction: a UK nationwide survey

Three-dimensional echocardiography (3DE) imaging has permitted advancements in the quantification of left ventricular (LV) and right ventricular (RV) volumes and ejection fraction. We evaluated the availability of 3DE equipment / analysis software, the integration of 3DE assessment of the LV and RV in routine clinical practice, current training provisions in 3DE, and aimed to ascertain barriers preventing the routine use of 3DE for volumetric analysis. Through the British Society of Echocardiography (BSE) regional representatives’ network, echocardiographers were invited to participate in an open online survey. A total of 181 participants from echocardiography departments in the United Kingdom (UK), the majority from tertiary centres (61%), completed the 28-question survey. For 3DE quantification, 3DE-LV was adopted more frequently than 3DE-RV (48% vs 11%, respectively). Imaging feasibility was a recognised factor in 3DE RV and LV adoption. Many respondents had access to 3D probes (93%). The largest observed barriers to 3DE routine use were training deficiencies, with 83% reporting they would benefit from additional training opportunities and the duration of time permitted for the scan, with 68% of responders reporting allowances of less than the BSE standard of 45–60 min per patient (8% < 30-min). Furthermore, of those respondents who had undertaken professional accreditation, competence in 3DE was not formally assessed in 89%. This UK survey also reported good accessibility to magnetic resonance imaging (72%), which was related to overall 3DE adoption. In summary, although 3DE is now readily available, it remains underutilised. Further training opportunities, integrated formal assessment, improved adoption of BSE minimum recommended scanning times, alongside industry and societal support, may increase 3DE utilisation in routine practice.

Performance of handheld ultrasound devices in diagnosis of pulmonary hypertension and right heart dysfunction in ICU patients.

The use of handheld ultrasonography devices (HHUD) has increased recently but there are limited data about their performance in the evaluation of right heart dysfunction (RHD) and pulmonary hypertension (PHT). The aim of the study is to compare the performance of a HHUD with a conventional ultrasound device (CUD) in assessing PHT and RHD. This single-center prospective study was performed in a seven-bed teaching hospital intensive care unit (ICU). PHT and RHD criteria were compared by HHUD and CUD. Additional PHT criteria and right ventricle (RV) systolic and diastolic dysfunction criteria were also measured. Forty-six patients were included in the study. There was no significant difference between the imaging rates and mean values of the parameters measured by both devices. When the positivity rates for additional PHT parameters and RHD criteria were compared, there were no significant differences between the devices. In Bland-Altman's analysis, there was good agreement and there was no bias between the measurements of the two devices but left ventricular end-systolic eccentricity index (LVSEI), right atrium area (RAA), and pulmonary artery diameter (PAD). Ninety percent of the patients had PHT probability, of whom 43% had a low, 37% had intermediate and 10% had a high probability of PHT. Ninety-two percent of the patients had RHD and there was no significant difference between the devices in the diagnosis of RHD (p=.212). When RV systolic and diastolic dysfunction evaluations of the devices were compared according to the British Society of Echocardiography (BSE) criteria there was no significant difference between the devices' measurements in the evaluation of systolic and diastolic function. The imaging and measurement capabilities of the HHUDs for PHT and RHD parameters were similar to CUDs, and considering the inconsistent parameters, the HHUD can be useful in diagnosing these problems.

The aortic root in young adults

Abstract Background Aortic size varies between individuals and is influenced by age, gender, body size and blood pressure. There are numerous studies aimed at defining normative aortic root measurements, but the vast majority of these are in older adults, or limited by a small sample size. Purpose To screen a large number of young individuals (≤35 years) to understand the rate of aortic growth, validate current guideline cut-offs for aortic root measurements in this age group and compare findings in males versus females. Methods Individuals ≥ 16 years old who attended a voluntary, nationwide cardiac screening programme for young individuals (aged 14-35) were offered and consented for an additional focused transthoracic echocardiogram of the aorta. Individuals with a known cardiac abnormality or genetic syndrome (for example Marfan’s) were excluded. Images were obtained in the parasternal long axis view with measurements of the sinus of Valsalva (SOV), sinotubular junction (STJ) and ascending aorta (AA) at end-diastole from inner-edge to inner-edge in line with British Society of Echocardiography (BSE) guidance[1]. Measurements were indexed to height (in metres). Mean SOV, STJ and AA measurements were plotted against age and comparisons were made between males and females. Results 1153 patients were recruited. 11 were excluded to a bicuspid aortic valve (BAV), leaving 1142 subjects in the final analysis. 88% (1004) were Caucasian. The aortic measurements are shown in table 1. Males had a significantly larger SOV, STJ and AA than females (p&amp;lt;0.001). However, when indexed to height, only the SOV was significantly larger. All mean aortic root measurements fell within the normative range for each gender as specified by current BSE guidance[1]. Mean aortic root measurements at each year of age are shown in figure 1. There was a weakly positive correlation coefficient between age and aortic diameter (r=0.33 at SOV, r=0.31 at STJ, r=0.39 at AA) which, coupled with the lines of best-fit in figure 1, suggest there is slow but continual aortic growth from the age of 16. Conclusion Despite adult height being reached by the age of 16 in most individuals, the aorta continues to grow beyond this age. This study further highlights the importance of indexing aortic measurements to height, and validates that the current BSE guideline cut-offs for aortic root measurements can be applied to young individuals.

The 'scan and treat' clinic; early evaluation of an advanced clinical practitioner (ACP) led combined echocardiography and outpatient cardiology clinic

Abstract Funding Acknowledgements Type of funding sources: None. Background There is increasing recognition that traditional models of hospital-based outpatient care in England are inefficient, unsustainable and do meet patient’s needs and preferences (RCP 2018). The National Health Service (NHS) ‘getting it right fist time’ (GIRFT) report for cardiology makes a number of recommendations including; increasing the utilisation non-medical roles such as Advanced Clinical Practitioners (ACPs), reducing face to face appointments, and triaging referrals with tests performed ahead of clinic appointments (NHS, 2021). We developed a novel clinic combining formal echocardiography with clinical assessment by a single British Society of Echocardiography (BSE) accredited ACP at medium sized district general hospital (DGH) in the west Midlands, England. No clinics of this type were identified in the literature, although there are studies demonstrating the efficacy of physiologist led valve clinics (Wasing et al., 2009) and cardiologist led ‘one stop’ clinics (Falces et al., 2008) Purpose To evaluate the case mix and early outcomes of the first 6 months of the scan and treat clinic. Methods Patient demographics, reason for referral and clinic actions were collected prospectively on an excel spreadsheet. A single un-blinded cardiologist reviewed the electronic patient records and echo images of 10 randomly selected patients from the first 3 months to assess the accuracy and appropriateness of documented diagnoses and treatment plans. Results 72 patients were seen over 11 clinics between July and December 2022. There was a low (6%) non-attendance rate, although a further 5 patients (7%) did not require an echo, due to booking errors. The most common reason for referral was suspected heart failure (33%) (table 1). Combined Heart Failure (HFrEF, HFmrEF, HFpEF) was also the most common primary diagnosis in the clinic (32%) (figure 1). There was a low rate of non-cardiac diagnoses (19%) and normal echocardiograms (33%) (figure 1). Clinic actions included prescribing (54%), cardiac monitors (24%), further imaging (15%) and blood tests (11%). The Cardiologist reviewer reported appropriate diagnosis and treatment of 10 radomly selected cases. Of 7 patients followed up in a cardiologist clinic before 10/01/2023, 5 had no significant changes in treatment or diagnosis, 1 patient had a pacemaker for asymptomatic 2nd degree AV block and another had Bisoprolol stopped due to side effects. Conclusion These preliminary results suggest the ‘scan and treat’ clinic is a viable alternative to traditional general cardiology clinic for patients who also require echocardiography. This review has a number of limitations including limited short term follow up, un-blinded cardiologist review and is not generalizable. This kind of initiative may help modernise and improve cardiology outpatient services. Further research is required to assess the efficacy of similar non-cardiologist led ‘one-stop’ clinic designs.Table 1Figure 1

IMproving PULmonary hypertension Screening by Echocardiography: IMPULSE

BackgroundThe world symposium on pulmonary hypertension (PH) has proposed that PH be defined as a mean pulmonary artery pressure (mPAP) > 20 mmHg as assessed by right heart catheterisation (RHC). Transthoracic echocardiography (TTE) is an established screening tool used for suspected PH. International guidelines recommend a multi-parameter assessment of the TTE PH probability although effectiveness has not been established using real world data.Study aimsTo determine accuracy of the European Society of Cardiology (ESC) and British Society of Echocardiography (BSE) TTE probability algorithm in detecting PH in patients attending a UK PH centre. To identify echocardiographic markers and revised algorithms to improve the detection of PH in those with low/intermediate BSE/ESC TTE PH probability.MethodsTTE followed by RHC (within 4 months after) was undertaken in patients for suspected but previously unconfirmed PH. BSE/ESC PH TTE probabilities were calculated alongside additional markers of right ventricular (RV) longitudinal and radial function, and RV diastolic function. A refined IMPULSE algorithm was devised and evaluated in patients with low and/or intermediate ESC/BSE TTE PH probability.ResultsOf 310 patients assessed, 236 (76%) had RHC-confirmed PH (average mPAP 42.8 ± 11.7). Sensitivity and specificity for detecting PH using the BSE/ESC recommendations was 89% and 68%, respectively. 36% of those with low BSE/ESC TTE probability had RHC-confirmed PH and BSE/ESC PH probability parameters did not differ amongst those with and without PH in the low probability group. Conversely, RV free wall longitudinal strain (RVFWLS) was lower in patients with vs. without PH in low BSE/ESC probability group (− 20.6 ± 4.1% vs − 23.8 ± 3.9%) (P < 0.02). Incorporating RVFWLS and TTE features of RV radial and diastolic function (RVFAC and IVRT) within the IMPULSE algorithm reduced false negatives in patients with low BSE/ESC PH probability by 29%. The IMPULSE algorithm had excellent specificity and positive predictive value in those with low (93%/80%, respectively) or intermediate (82%/86%, respectively) PH probability.ConclusionExisting TTE PH probability guidelines lack sensitivity to detect patients with milder haemodynamic forms of PH. Combining additional TTE makers assessing RV radial, longitudinal and diastolic function enhance identification of milder forms of PH, particularly in those who have a low BSE/ESC TTE PH probability.

AB0596 AORTIC MANIFESTATIONS IN GIANT CELL ARTERITIS: SINGLE CENTRE 10-YEAR EXPERIENCE

BackgroundDisease stratification in GCA is an urgent need, with patients categorised into cranial and large-vessel GCA (LV-GCA) subgroups. LV-GCA may have worse outcomes with regards relapsing disease, poor response to glucocorticoids (GC) and aortic involvement.ObjectivesWe report a single centre experience using clinical, imaging and treatment outcomes from a specialist clinic.Methods134 patients with LV-GCA were identified over a 10-year period at Southend University Hospital (2012-2022). Medical records were reviewed retrospectively for baseline demographics, clinical presentation, inflammatory markers, imaging (vascular ultrasound, PET-CT, echocardiography), vascular damage and treatment.ResultsThere was a female predominance (female n=91). Age at presentation ranged from 46 to 86 years (median 70 years). Co-morbidities implicated in aortic disease included hypertension (n=60), hypercholestrolaemia (n=29), diabetes (n=14), aortic valvular disease (n=5) and atherosclerotic disease including coronary and carotid artery disease (n=19). Constitutional disturbance was most frequently observed presentation (70%, n=94), and the only feature for 11 patients. This was followed by cranial symptoms (62%, n=83), polymyalgia (53%, n=71), ischaemic symptoms i.e., visual disturbance or tongue/jaw claudication (24%, n=32) and cardiovascular presentations (7%, n=9). The latter included limb claudication, stroke, and aortic aneurysm. Although LV-GCA refers to extra-cranial disease, 12 patients (9%) had isolated cranial and/or ischaemic symptoms at initial presentation.Inflammatory markers were typically elevated at presentation, C-reactive protein ranged from 1-425mg/L and ESR 1-130mm. Vascular ultrasound was used at diagnosis in 93 patients, with positive temporal artery findings in 50% (n=38) and positive axillary findings in 75% (n=57). PET-CT data was available for 125 patients, of which 113 were positive for LV-GCA. Thoracic aorta FDG-uptake was seen in 77%, with 7 ascending and 1 abdominal aortic aneurysm observed. Transthoracic echocardiogram was available for 46% (n=62). Four (6.5%) patients had a dilated aortic root when indexed to height as per British Society of Echocardiography (BSE) guidelines1 (SOV (mm/m) &gt; 21.8mm in males and &gt; 20.7mm in females). Values for our patients were 22.6 and 21.2 mm/m for the female patients and 29.2 and 25.2 mm/m for the male patients. Furthermore, 32 patients showed some extent of diastolic dysfunction as per BSE criteria (52%).All patients received GC as part of their treatment, 60% (n=82) needing one or more DMARDs and 17% (n=23) Tocilizumab for relapsing disease. DMARDs used included Leflunomide (n=63), Methotrexate (n=18), Mycophenolate mofetil (n=3) and Azathioprine (n=1). One patient received cyclophosphamide.ConclusionBy combined imaging modalities, 11 patients (8%) had evidence of ascending aortic damage. Grade 1 diastolic dysfunction can be age related, so this may be association rather than causation2,3. Over half of patients had not undergone echocardiogram evaluation, so there may be a hidden burden of disease. Many patients required GC-sparing therapy, showing GC alone are often not enough to halt disease progression, and vascular damage was relatively reduced compared to historical reports. The authors feel GCA services should include standardised protocols for early DMARDs, continuing thorough assessment for LV-GCA and vascular damage, including echocardiography, progressing to cross-sectional imaging if indicated.

Critical COVID-19 rarely associated with left ventricular systolic impairment

IntroductionFor some individuals infection with SARS-CoV-2 leading to COVID-19 can result in a life-threatening multi-system disease. Multiple potential pathophysiological mechanisms for the development of cardiovascular complications have been postulated [1]. Early reports suggested that more than a third of hospitalised patients undergoing TTE had evidence of LV impairment [2].PurposeTo ascertain the incidence of ventricular impairment among critically ill adults with COVID-19 admitted to the intensive care unit (ICU).MethodsRetrospective analysis of transthoracic echocardiograms (TTE) performed on patients admitted to ICU with COVID-19 between 10th March and 10th May 2020. Archived studies were reviewed by accredited professionals. Studies were performed according to a modified British Society of Echocardiography (BSE) Level 1 protocol [3], with the addition of right ventricle (RV) focused apical 4 chamber, as well as apical 2 and 3 chamber views, and without ECG synchronisation as per infection control protocols. In the majority of patients the left ventricular ejection fraction (LVEF) was estimated from biplane Simpson's method. The RV function was assessed using the TAPSE in most patients. In the remaining patients the LV or RV function was visually assessed.ResultsOf 179 patients admitted to ICU, 85 (47.5%) had at least one TTE of diagnostic quality. Studies were performed a median of 7 days after ICU admission (IQR 3–17 days). Baseline and clinical characteristics and key echocardiographic measurements are summarised in table 1. The majority of patients were undergoing mechanical ventilation at the time of the scan (94.1%). One hundred and fifty-nine patients (89%) had elevated Troponin T (≥14ng/L) on the day of the study. LV systolic impairment (LVSD) was present in 5 patients (6.0%). This was known to be chronic in 3 patients (1 with coronary artery disease, 1 with chemotherapy induced cardiomyopathy and 1 with dilated cardiomyopathy of unknown aetiology), whilst pre-morbid cardiac function was unknown in the other 2 patients. No patient had severe LVSD (LVEF ≤35%). RV systolic dysfunction (RVSD) was found in 25 patients (31.3%). Amongst patients receiving mechanical ventilation there was no significant difference in Positive End Expiratory Pressure (PEEP) between patients with and without RVSD (9.4cmH2O vs. 9.8cmH2O, p=0.64), however there was a non-significant trend towards lower PaO2/FiO2 (P/F ratio) amongst patients with RVSD (18.9kPa vs 25.7kPa, p=0.07).ConclusionsIn contrast to other studies which have reported high frequency of LV impairment amongst hospitalised patients with COVID-19 [3], de novo LVSD was rarely found in this study, occurring in just 2 patients (2.4%), and being severe in neither. RV dilatation and systolic impairment were commonly found. A trend towards lower P/F ratios in patients with RVSD suggests severity of lung injury may be a factor in developing RV impairment.Funding AcknowledgementType of funding sources: None.

Comparison between the British and the American/European guidelines for the assessment of left ventricular diastolic function with invasive validation of left ventricular filling pressure

Abstract Background Left ventricle diastolic function and filling pressures assessment is still a major challenge to echocardiographer. There are two echo guidelines regarding this issue: the British Society of Echocardiography (BSE 2013) and the American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI 2016). The 2016 guidelines, which is an expert consensus and simplified update of 2009 guidelines, needs an invasive validation according to its authors. Recent studies raised questions about the diagnostic accuracy as sensitivity results varied very widely (34% to 87%) and also that of 2009 (43% to 79%). This study validated the diastolic pressure invasively in the cath lab and compared the results with the echo guidline algorithms were done immediately before the catheterization. When possible, it included additional assessment of S/D and Ar-A duration. Purpose Validation of the diagnostic accuracy of the 2009, the updated 2016 ASE/EACVI and 2013 BSE echocardiographic LV filling pressure predicting algorithms, as well as pulmonary veins flow (S/D) and (Ar-A) durations with invasively measured LV-pre-A wave. Methods 124 patients (58.06% males) underwent transthoracic echocardiography immediately before left heart catheterization. A trained echocardiographer obtained E/A mitral flow, E/e', left atrial volume index, TR, EDT, lateral and septal e' to estimate LV filling pressure as normal, elevated or indeterminate using the 2009, 2016 ASE/EACVI algorithms and 2013 BSE algorithm. He also obtained Secondary parameters as (S/D) and (Ar-A) duration. Invasive LV pre-A pressure was the reference of this study, with &amp;gt;12 mm Hg defined as elevated. Results Invasive LV pre-A pressure was elevated in 60 (48.38%) patients. When they could determine LV filling pressure, 2016 sensitivity was 0.36 and specificity 0.94, 2009 had 0.56 sensitivity and 0.90 specificity and 2013 resulted in 0.63 sensitivity and 0.80 specificity. Results of diagnostic accuracy of each algorithm as well as (S/D) and (Ar-A) summarized in tables associated in (picture 1: Tables of results). EDT≥150 msec raised NPV in normal, grade one diastolic dysfunction and indeterminate pressure. Conclusion 2016 was the most specific but the least sensitive with modest NPV and PPV between the 2013 and 2009. 2013 was the most sensitive with the highest indeterminate pressure rate to execlude. Adding S/D or Ar-A duration markedly improved the sensitivity and reduced class indeterminate among all algorithms with more benefit when both combined. EDT had a rule out role in normal, grade one diastolic dysfunction and indeterminate pressure patients. We kindly propose a modification of 2016 algorithm by adding S/D, Ar-A and EDT as optional parameters to increase sensitivity and reduce indeterminate class without affecting simplicity or specificity (picture 2: Proposed algorithms A+B). We recommend future studies to validate the diagnostic accuracy of the proposed algorithms. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Al mouwasat University Hospital and University Heart Surgery Center at Damascus, Syrian Arab Republic. Tables of resultsProposed Algorithms A+B

An overview of the guideline from the British Society of Echocardiography 2020: what’s new?

Quantitative assessment of cavities and heart function is the most common task of echocardiography (EchoCG). It is difficult to overestimate the importance of standardizing EchoCG measurements, because their results influence clinical decisions. In January 2015, the American Society of Echocardiography and the European Association of Cardiovascular Imaging, published an update Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults. Since then, the results of new research using obtained prospective data, on the basis of which in February 2020 the British Society of Echocardiography (BSE) released a new guide. The authors of the recommendations set the goal of creating a simple, practical reference document and guide for everyday use that encourage the holistic interpretation of measurements (no single number should define normality or pathology). Based on these data, we considered the rational component of the updated recommendations, focused on important conceptual changes in the assessment of heart structure and function, provided new terminology for left ventricular function and left atrial size, and a new approach in assessing aortic root, right heart and left atrium. The BSE recommends obtain left ventricular dimensions from the parasternal long-axis window preferentially using 2D imaging. Aortic dimensions should be obtained using the “inner-edge to inner-edge” technique in end-diastole. The BSE suggests that for those Echocg labs that currently use the “leading-edge to leading-edge” technique, it is reasonable to continue doing so for continuity and consistency.

The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for valve surgery in Europe and despite the decline of rheumatic fever in Western societies, mitral stenosis of any aetiology is a regular finding in all echo departments. Mitral valve disease is, therefore, one of the most common pathologies encountered by echocardiographers, as both a primary indication for echocardiography and a secondary finding when investigating other cardiovascular disease processes. Transthoracic, transoesophageal and exercise stress echocardiography play a crucial role in the assessment of mitral valve disease and are essential to identifying the aetiology, mechanism and severity of disease, and for helping to determine the appropriate timing and method of intervention. This guideline from the British Society of Echocardiography (BSE) describes the assessment of mitral regurgitation and mitral stenosis, and replaces previous BSE guidelines that describe the echocardiographic assessment of mitral anatomy prior to mitral valve repair surgery and percutaneous mitral valvuloplasty. It provides a comprehensive description of the imaging techniques (and their limitations) employed in the assessment of mitral valve disease. It describes a step-wise approach to identifying: aetiology and mechanism, disease severity, reparability and secondary effects on chamber geometry, function and pressures. Advanced echocardiographic techniques are described for both transthoracic and transoesophageal modalities, including TOE and exercise testing.

Transthoracic echocardiography of hypertrophic cardiomyopathy in adults: a practical guideline from the British Society of Echocardiography

Hypertrophic cardiomyopathy (HCM) is common, inherited and characterised by unexplained thickening of the myocardium. The British Society of Echocardiography (BSE) has recently published a minimum dataset for transthoracic echocardiography detailing the core views needed for a standard echocardiogram. For patients with confirmed or suspected HCM, additional views and measurements are necessary. This guideline, therefore, supplements the minimum dataset and describes a tailored, stepwise approach to the echocardiographic examination, and echocardiography’s position in the diagnostic pathway, before advising on the imaging of disease complications and invasive treatments.

Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography

The guideline provides a practical step-by-step guide in order to facilitate high-quality echocardiographic studies of patients with aortic stenosis. In addition, it addresses commonly encountered yet challenging clinical scenarios and covers the use of advanced echocardiographic techniques, including TOE and Dobutamine stress echocardiography in the assessment of aortic stenosis.

British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab

The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

'How to do': digital-interactive-interpretation course for stress echocardiography.

To improve stress echocardiography interpretation standards, we introduced a structured 5-day interpretation course in 2017. In order to deliver the course during the world-wide pandemic, we transformed the existing boardroom style, workstation-based, interactive course into a cloud-based digital entity maintaining the same features. On completion of 6 lectures via live webinars, 15 participants performed, fully GDPR compliant, 80 recorded case analysis using a web-based reporting system over the course of 5 days. After self-reporting and generating preliminary reports the joint case review with the faculty, resulted in finalization of the reports and provided individual feedback for the participants. By the 5th day, participants had collected 80 reports for their e-logbook and were ready to sit the digital interpretation exam. Eighty-eight percent of participants passed the e-exam and received a certificate of completion with 15 re-accreditation and 30 CPD points by the British Society of Echocardiography and Federation of the Royal Colleges of Physicians, UK, respectively. The feedback by the participants was praising the pre-course provision of lectures and digital aids, the conduct of the course by the faculty and the technical support with an average score of 4.7 for each, on a scale from 1 to 5. Our experience proved that interactive, multi-day; hands-on reporting course can be delivered using the digital platform. Online interpretation courses have great potential to improve the competency of imaging specialists. This digital teaching model could be suitable in other imaging-based training courses like cardiac CT and MRI.

Piloting structured focused TTE in outpatients during the COVID-19 pandemic: 'old habits die hard'.

Transthoracic echocardiography presents a risk of COVID-19 transmission between an echocardiographer and the patient. Reducing the scanning time is likely to mitigate this risk for them both. British Society of Echocardiography (BSE) level 1 echocardiography offers a potential framework for focused scanning in an outpatient setting. There were 116 outpatients scheduled for a level 1 scan supplemented with additional predefined views, if required. Unexpectedly, a fifth of the scans were performed as an unintended full scan for a variety of reasons. Our results showed that focused scans were performed more quickly than full scans and below the NHS Test and Trace exposure cut-off of 15 minutes. However, if more than three sets of additional measurements were required then a full scan could be performed more quickly. Seniority of the echocardiographer and scan time had an inverse relationship. By examining the patients' clinical records we were confident that all of the scans, whether focused or full, had answered the requestor's clinical question. Although the COVID-19 vaccination programme should reduce the necessity of minimising exposure time during a scan there could still be a role for level 1 scanning during the COVID-19 recovery programme to tackle the vast lists of patients waiting for an echocardiogram.

Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography

Transthoracic echocardiography is the first-line imaging modality in the assessment of right-sided valve disease. The principle objectives of the echocardiographic study are to determine the aetiology, mechanism and severity of valvular dysfunction, as well as consequences on right heart remodelling and estimations of pulmonary artery pressure. Echocardiographic data must be integrated with symptoms, to inform optimal timing and technique of interventions. The most common tricuspid valve abnormality is regurgitation secondary to annular dilatation in the context of atrial fibrillation or left-sided heart disease. Significant pulmonary valve disease is most commonly seen in congenital heart abnormalities. The aetiology and mechanism of tricuspid and pulmonary valve disease can usually be identified by 2D assessment of leaflet morphology and motion. Colour flow and spectral Doppler are required for assessment of severity, which must integrate data from multiple imaging planes and modalities. Transoesophageal echo is used when transthoracic data is incomplete, although the anterior position of the right heart means that transthoracic imaging is often superior. Three-dimensional echocardiography is a pivotal tool for accurate quantification of right ventricular volumes and regurgitant lesion severity, anatomical characterisation of valve morphology and remodelling pattern, and procedural guidance for catheter-based interventions. Exercise echocardiography may be used to elucidate symptom status and demonstrate functional reserve. Cardiac magnetic resonance and CT should be considered for complimentary data including right ventricular volume quantification, and precise cardiac and extracardiac anatomy. This British Society of Echocardiography guideline aims to give practical advice on the standardised acquisition and interpretation of echocardiographic data relating to the pulmonary and tricuspid valves.

Report from the Annual Conference of the British Society of Echocardiography, October 2018, ACC Liverpool, Liverpool

Report from the Annual Conference of the British Society of Echocardiography, October 2018, ACC Liverpool, Liverpool

Clinical Practice Guidelines on Ordering Echocardiography Before Hip Fracture Repair Perform Differently from One Another

BackgroundOsteoporotic hip fractures typically occur in frail elderly patients with multiple comorbidities, and repair of the fracture within 48 h is recommended. Pre-operative evaluation sometimes involves transthoracic echocardiography (TTE) to screen for heart disease that would alter peri-operative management, yet TTE can delay surgery and is resource intensive. Evidence suggests that the use of clinical practice guidelines (CPGs) can improve care. It is unclear which guidelines are most useful in hip fracture patients.Questions/PurposesWe sought to evaluate the performance of the five commonly used CPGs in determining which patients with acute fragility hip fracture require TTE and to identify common features among high-performing CPGs that could be incorporated into care pathways.Patients and MethodsWe performed a retrospective study of medical records taken from an institutional database of osteoporotic hip fracture patients to identify those who underwent pre-operative TTE. History and physical examination findings were recorded; listed indications for TTE were compared against those given in five commonly used CPGs: those from the American College of Cardiology/American Heart Association (ACC/AHA), the British Society of Echocardiography (BSE), the European Society of Cardiology and the European Society of Anaesthesiology(ESC/ESA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Scottish Intercollegiate Guidelines Network (SIGN). We then calculated the performance (sensitivity and specificity) of the CPGs in identifying patients with TTE results that had the potential to change peri-operative management.ResultsWe identified 100 patients who underwent pre-operative TTE. Among those, the patients met criteria for TTE 32 to 66% of the time, depending on the CPG used. In 14% of those receiving TTE, the test revealed new information with the potential to change management. The sensitivity of the CPGs ranged from 71% (ESC/ESA and AAGBI) to 100% (ACC/AHA and SIGN). The CPGs’ specificity ranged from 37% (BSE) to 74% (ESC/ESA). The more sensitive guidelines focused on a change in clinical status in patients with known disease or clinical concern regarding new-onset disease.ConclusionsIn patients requiring fixation of osteoporotic hip fractures, TTE can be useful for identifying pathologies that could directly change peri-operative management. Our data suggest that established CPGs can be safely used to identify which patients should undergo pre-operative TTE with low risk of missed pathology.

A minimum dataset for a Level 1 echocardiogram: a guideline protocol from the British Society of Echocardiography

The British Society of Echocardiography has previously outlined a minimum dataset for a standard transthoracic echocardiogram, and this remains the basis on which an echocardiographic study should be performed. The importance of ultrasound in excluding critical conditions that may require urgent treatment is well known. Several point-of-care echo protocols have been developed for use by non-echocardiography specialists. However, these protocols are often only used in specific circumstances and are usually limited to 2D echocardiography. Furthermore, although the uptake in training for these protocols has been reasonable, there is little in the way of structured support available from accredited sonographers in the ongoing training and re-accreditation of those undertaking these point-of-care scans. In addition, it is well recognised that the provision of echocardiography on a 24/7 basis is extremely challenging, particularly outside of tertiary cardiac centres. Consequently, following discussions with NHS England, the British Society of Echocardiography has developed the Level 1 echocardiogram in order to support the rapid identification of critical cardiac pathology that may require emergency treatment. It is intended that these scans will be performed by non-specialists in echocardiography and crucially are not designed to replace a full standard transthoracic echocardiogram. Indeed, it is expected that a significant number of patients, in whom a Level 1 echocardiogram is required, will need to have a full echocardiogram performed as soon as is practically possible. This document outlines the minimum dataset for a Level 1 echocardiogram. The accreditation process for Level 1 echo is described separately.

POCUS in Acute Medicine

POCUS in Acute Medicine