Hand-held Echocardiography Research Articles

Prevalence of mitral valvar prolapse in young athletes

The prevalence of mitral valvar prolapse has been reported to be between 0.6 and 21%. The goal of our study was to evaluate its prevalence in young athletes who underwent hand-held echocardiography as a screening mostly in southern California. We retrospectively analyzed 1742 echocardiograms that were performed as a part of a cardiac screening of teenage athletes. The total prevalence of mitral valvar prolapse was calculated and stratified based on gender. We screened a total of 1172 male and 570 female high school athletes. The echocardiographic prevalence of mitral valvar prolapse was 0.9%. The prevalence was similar in both genders, at 1.2% in male and 0.7% in female athletes. The prevalence of mitral valvar prolapse in young athletes mostly in southern California was found to be less than 1%, and was similar in both genders.

Handheld echocardiography offers rapid assessment of clinical volume status

Assessment of volume status is vital for successful management of patients in heart failure (HF) programs. Bedside determination of elevated left-sided filling pressure (LFP) can be challenging and frequently inaccurate; therefore, incorporating technology such as handheld echocardiography, to aid in estimation of LFP, may improve patient care. In this study, we evaluated the feasibility and accuracy of handheld echocardiography by a nonexpert for potential use in the point of care evaluation of compensation. Subjects were recruited from the HF clinic or inpatient service at a single center. Each subject underwent a focused handheld transthoracic echocardiogram by a medical resident trained for 10 hours. Subjects were assigned to 1 of 4 filling patterns (1 = normal, 2 = abnormal relaxation, 3 = pseudonormal, 4 = restrictive) based on measurements by pulsed wave and tissue Doppler. A 3-step echocardiography test for congestion in HF (TEC-HF) was devised for estimation of LFP. The gold standard for determining elevated LFP was clinical evaluation by a HF specialist, who classified subjects as being euvolemic or hypervolemic. A total of 100 consecutive subjects (72% male) were recruited, with average age of 60 years and left ventricular ejection fraction of 27%. All subjects had evaluable echocardiographic data. Based on TEC-HF, filling patterns 3 and 4 predicted hypervolemia and patterns 1 and 2 predicted euvolemia, with sensitivity and specificity of 86% and 92%, respectively, and positive and negative predictive values of 86% and 92%, respectively. Applying TEC-HF with handheld echocardiography accurately reflects clinical LFP as assessed by HF specialists. This procedure was easily taught to nonexpert medical staff who obtained adequate images in all patients. Handheld echocardiography could be a useful tool for assessing volume status in nonspecialized community settings.

Handheld vs. Conventional Transesophageal Echocardiography in Non-Cardiac Surgical Intensive Care Unit Patients

We examined the feasibility of a newly developed handheld ultrasound device capable of transesophageal echocardiography (TEE). Prospective case series in a non-cardiac surgical intensive care unit including 18 deeply sedated and endotracheally intubated critically ill non-cardiac surgical patients. The imaging quality and findings of a newly developed handheld device were compared to those of a cart-based standard TEE system. All patients were examined with both systems in a randomized order by independent examiners performing a structured and complete TEE examination. The imaging quality of the standard cardiac cross sections and spectral Doppler studies of the cardiac valves was assessed on an analog scale from 1 (excellent) to 5 (insufficient). The time requirements for each study were documented. We did not detect significant differences in two-dimensional imaging. Continuous-wave Doppler imaging of the left ventricular outflow tract and pulsed-wave Doppler imaging of the transmitral flow were significantly better (p <0.001) with the standard system. Handheld TEE is a goal-oriented diagnostic tool, which may sufficiently replace a standard cart-based TEE system in unstable critically ill patients when an acute gross diagnosis is required.

Importance of transesophageal echocardiography in the critically ill and injured patient

Echocardiography, particularly transesophageal echocardiography (TEE), is a vital diagnostic and monitoring imaging modality for the intensivist. The field of echocardiography spans different venues and pathologies, ranging from surface transthoracic echocardiography and portable hand-held echocardiography, to contrast echocardiography, stress echocardiography, and TEE, among others. Numerous investigations have proven the worth of echocardiography, especially TEE, in the critically ill and injured patient, changing lives with the identification of obvious and subtle cardiothoracic diseases. Because this powerful imaging tool is immediately available and portable, crucial delays in diagnosis are not commonplace; rather than echocardiography, TEE, specifically, should be (and is in some institutions) the standard of care and management in assisting the intensivist in diagnosis of a variety of maladies. The effect of TEE technology is quite formidable, and numerous investigations have borne this out. The therapeutic effect of TEE ranges from 10% to 69%, with the majority of investigations falling into the 60% to 65% range. The diagnostic yield of TEE is far greater, approaching 78%. This article will detail the importance of echocardiography, its efficacy, and its high-yield imaging capability, particularly when compared with other imaging modalities, even transthoracic echocardiography.

Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit

We sought to evaluate the efficacy of a limited training dedicated to residents without knowledge in ultrasound for performing goal-oriented echocardiography in ICU patients. Prospective pilot observational study. Medical-surgical ICU of a teaching hospital. 61 consecutive adult ICU patients (SAPS II score: 38 +/- 17; 46 ventilated patients) requiring a transthoracic echocardiography were studied. After a curriculum including a 3-h training course and 5 h of hands-on training, one of four noncardiologist residents and an intensivist experienced in ultrasound subsequently performed hand-held echocardiography (HHE), independently and in random order. Assessable "rule in, rule out" clinical questions were purposely limited to easily identifiable conditions by the sole use of two-dimensional imaging. When compared with residents, the experienced intensivist performed shorter examinations (4 +/- 1 vs. 11 +/- 4 min: p < 0.0001) and had significantly less unsolved clinical questions [3 (0.8%) vs. 27 (7.4%) of 366 clinical questions: p < 0.0001]. When addressed, clinical questions were adequately appraised by residents: left ventricular systolic dysfunction [Kappa: 0.76 +/- 0.09 (95% CI: 0.59-0.93)], left ventricular dilatation [Kappa: 0.66 +/- 0.12 (95% CI: 0.43-0.90)], right ventricular dilatation [Kappa: 0.71 +/- 0.12 (95% CI: 0.46-0.95)], pericardial effusion [Kappa: 0.68 +/- 0.18 (95 CI: 0.33-1.03)], and pleural effusion [Kappa: 0.71 +/- 0.09 (95% CI: 0.53-0.88)]. The only case of tamponade was accurately diagnosed by the resident. Limited training of noncardiologist ICU residents without previous knowledge in ultrasound appears feasible and efficient to address simple clinical questions using point-of-care echography. Influence of the learning curve on diagnostic accuracy and potential therapeutic impact remain to be determined.

99 Supra-regional success of a structured training program for general practitioners enabling performance of handheld echocardiography and point-of-care BNP testing and use for heart failure diagnosis

99 Supra-regional success of a structured training program for general practitioners enabling performance of handheld echocardiography and point-of-care BNP testing and use for heart failure diagnosis

Correlates of aortic root size in a population-based screening by hand-held echocardiography: “The Heart in the City” Study

Our experience underscores the ability of hand-held echocardiography to identify the association between aortic root dilation and left ventricular mass in a population-based screening among normotensive and hypertensive participants of “The Heart in the City”, a project designed to detect pre-clinical echocardiographic markers of heart failure by hand-held echocardiography.

Use of natriuretic peptides in pre-participation screening of college athletes

Current screening methods have poor specificity and sensitivity for detecting cardiac abnormalities that predispose young athletes to sudden death. Natriuretic peptides (NPs) show promise in screening asymptomatic populations for structural heart disease, but little is known about their use in student athletes. This study sought to describe the distribution and characteristics of NP levels in a population of college athletes and determine the relationship between NPs and the pre-participation exam (PPE) and hand-held echocardiography (HHE). We evaluated 457 college varsity athletes with B-type NP (BNP) and N-terminal proBNP (NT-proBNP) levels and a standard PPE; 200 also underwent HHE. NT-proBNP and BNP levels were highly correlated ( r = 0.87, p < 0.001), with a median of 21 pg/ml and 8 pg/ml respectively. 95% of athletes had NT-proBNP < 84 pg/ml and 95% had BNP < 33 pg/ml. Levels were higher in athletes with a history of exertional dizziness/syncope but did not correlate with other elements of the PPE or with HHE, although no major cardiac structural abnormalities were identified in this population. In men, there were weak correlations between NP levels and number of days per week performing distance running, strenuous exercise, or sprinting. In conclusion, NPs are only weakly correlated with intensity of physical training, and most college athletes have low NP levels; further studies are needed to elucidate the significance of elevated NP levels in this population, as they may provide incremental information beyond that provided by the PPE and echocardiography.

PREVALENCE OF MITRAL VALVE PROLAPSE IN YOUNG ATHLETES

PURPOSE: The prevalence of mitral valve prolapse (MVP) has been reported to be between 0.6-21%. We studied unselected population of young athletes who underwent hand held echocardiography as a screening for the prevalence of MVP in the last 4 years in California.

Use of Handheld Echocardiography for Rapid Assessment of Clinical Volume Status

Use of Handheld Echocardiography for Rapid Assessment of Clinical Volume Status

Point of care ultrasound for basic haemodynamic assessment: novice compared with an expert operator

Miniaturization of ultrasound equipment has led to the development of hand-held echocardiography devices suitable for bedside evaluation of cardiac function. Basic assessment of the haemodynamic state can be performed using a limited transthoracic echocardiography examination. This study evaluated a third generation device (SonoSite Titan) used by novice and expert operators. Limited transthoracic examination was performed on 30 healthy volunteers by an expert and a novice operator. The novice had performed 10 studies prior to data accrual. Agreement analysis was performed using weighted least products regression and Bland-Altman analysis. Acceptable results for the novice were achieved following 20 studies (including practice sessions) for basic haemodynamic assessment and following 40 studies for all measured parameters. The SonoSite Titan is acceptable for basic transthoracic measurements to determine the basic haemodynamic state and cardiac output measurements. We recommend a minimum of 20 training studies for novice operators prior to clinical use.

Screening for ventricular remodeling

Current guidelines emphasize the importance of preventing heart failure (HF) by targeting people with preclinical forms of the disease. Accordingly, there is considerable interest in identifying left ventricular (LV) remodeling, the fundamental substrate for HF, in asymptomatic individuals in the community. Increased LV mass and asymptomatic LV systolic and LV diastolic dysfunction are the remodeling phenotypes that could be potentially considered for population-wide screening. Plasma levels of natriuretic peptides (NP) have been extensively investigated for such screening purposes. However, a majority of investigations suggest that their performance characteristics are suboptimal for identifying LV remodeling phenotypes unless high-risk individuals (eg, older men with hypertension) are targeted. In general, the prevalence of LV systolic dysfunction in women is too low to justify screening. In recent reports, sequential screening strategies combining urine and plasma NP or plasma NP and hand-held portable echocardiography have been advocated as potential approaches to identify asymptomatic LV systolic dysfunction in a cost-effective manner. Additional studies are warranted to confirm these findings.

What is the most useful and cost-effective strategy to screen for left ventricular systolic dysfunction in clinical practice?

We agree with many of the comments made by Yamada et al .,1 namely that the ECG and NTproBNP are fundamental tests used in the diagnosis of heart failure and that as tests become cheaper they become more cost-effective. We further agree that our data show that hand-held echocardiography gives the greatest sensitivity, ECGs give intermediate sensitivity, and NTproBNP normal range cuts off …

Echocardiography and the critically ill patient

Echocardiography provides valuable diagnostic information in the assessment and management of the critically ill patient on the intensive care unit (ICU). Transthoracic echocardiography (TTE), through the advent of portable hand-held echocardiography devices can provide the cardiologist, the intensivist or the sonographer with a rapid non-invasive and safe assessment of the cardiovascular status of the patient on ICU. Recent advances in technology such as harmonic imaging, digital image acquisition and contrast echocardiography have made for improvements in image quality. This has extended the use of bedside echocardiography from not only assessing the cardiac status, but also to diagnose or exclude complications of procedures and therapies commonly used in ICU. However, in common with other investigations, the information obtained from bedside echocardiography should be interpreted in the context of other relevant investigations and clinical findings. As more and more critical care physicians are getting trained in performing bedside echocardiography, they should be aware of different techniques that can be used while performing the study. Here, we review the application of echocardiography in various clinical diagnoses encountered in ICU and the interpretation of findings in echocardiography.

Échographie portable chez les patients en état critique

Echographic systems which are the size of a laptop computer are currently available. These hand-held ultrasound units have different technological characteristics: the first category includes low-cost simple portable systems and the second category includes miniaturized well-equipped units with most modern application tools. The first category of portable systems has only been tested in critically-ill patients. Validation studies conducted in intensive care units have pointed out the limitations of hand-held echocardiography and allowed to better define its field of application. The concept of “ultrasound stethoscope” uses hand-held echography as an extension of physical examination to rapidly answer simple questions (e.g. pump function, regional wall motion abnormalities, cavitary dilatation, pericardial, pleural or abdominal effusions). The efficacy of a limited training program to physicians without experience in ultrasound for goal-directed examination using portable systems is currently evaluated. Since this practice does not correspond to the state-of-the-art, portable echography is not an alternative to standard transthoracic echocardiography or conventional ultrasound when they are available. In addition, transesophageal echocardiography is still required to perform a comprehensive hemodynamic examination in ventilated critically-ill patients.

1136 The heart in the city: ability of hand-held echocardiography to detect independent association of left ventricular mass and aortic root size

1136 The heart in the city: ability of hand-held echocardiography to detect independent association of left ventricular mass and aortic root size

What is the most cost-effective strategy to screen for left ventricular systolic dysfunction: natriuretic peptides, the electrocardiogram, hand-held echocardiography, traditional echocardiography, or their combination?

To assess the screening characteristics and cost-effectiveness of screening for left ventricular systolic dysfunction (LVSD) in community subjects. A total of 1392 members of the general public and 928 higher risk subjects were randomly selected from seven community practices. Attending subjects underwent an ECG, N-terminal pro-brain natriuretic peptide (NTproBNP) serum levels, and traditional echocardiography (TE). A total of 533 consecutive subjects underwent hand-held echocardiography (HE). The screening characteristics and cost-effectiveness (cost per case of LVSD diagnosed) of eight strategies to predict LVSD (LVSD <45% on TE) were compared. A total of 1205 subjects attended. Ninety six per cent of subjects with LVSD in the general population had identifiable risk factors. All screening strategies gave excellent negative predictive value. Screening high-risk subjects was most cost-effective, screening low-risk subjects least cost-effective. TE screening was the least cost-effective strategy. NTproBNP screening gave similar cost savings to ECG screening; HE screening greater cost-savings, and HE screening following NTproBNP or ECG pre-screening the greatest cost-savings, costing approximately 650 Euros per case of LVSD diagnosed in high-risk subjects (63% cost-savings vs.TE). Thus several different modalities allow cost-effective community-based screening for LVSD, especially in high-risk subjects. Such programmes would be cost-effective and miss few cases of LVSD in the community.

The rate at which residents learn to use hand-held echocardiography at the bedside

Purpose Because there is little information about the training that general internists require to perform hand-carried cardiac ultrasonography (HCU), we studied the rate of learning of a group of medical residents performing HCU after minimal formal training. Methods Medical residents on the inpatient services at Johns Hopkins Bayview Medical Center received formal training in HCU consisting of 15-30 minutes of didactic instruction about the principles of echocardiography, followed by ongoing one-on-one instruction in performing HCU and subsequent ongoing one-on-one training from a certified echocardiography technician as they were doing scans. The residents were shown how to position the patient to obtain 2-dimensional echo images from the parasternal short and long axes and apical 4-chamber views, and how to obtain color-flow Doppler images across the mitral and aortic valves. Residents were asked to determine whether pericardial effusion was present and to assess left ventricular size, left ventricular function, and the mitral and aortic valves. The residents performed cardiac physical examination and HCU independently on patients who had a conventional transthoracic echocardiogram (CTTE) performed within 24 hours of the HCU. The residents’ HCU results were compared with the CTTE results by a cardiologist specializing in echocardiography. The rates at which residents gained technical proficiency and skills in interpreting their studies were measured by linear regression to fit various outcome variables against their experience at scanning as gauged by the number of scans performed. Results Thirty medical residents performed a total of 231 HCU studies. Linear regression models showed that the residents’ overall technical proficiency skills improved at the rate of 0.79 (95% confidence interval [CI] 0.53-1.04) points on an overall assessment index (0-3 scale) per 10 scans completed. Interpretation accuracy improved at a rate of 1.01 (95% CI 0.69-1.39) points per 10 scans as measured by an interpretation accuracy index (0-3 scale). Because scanning efforts and instruction in HCU occurred during residents’ usual rotation duties, some residents gathered experience in HCU slowly and sporadically. Conclusion This study, the first prospective, experimental effort of its kind, shows that residents as a group learned important aspects of HCU scanning and interpretation at a reasonably rapid rate.

Cost‐Effective Strategies to Screen for Left Ventricular Systolic Dysfunction in the Community—A Concept

Early detection of heart failure caused by left ventricular systolic dysfunction (LVSD) is important, since early treatment has been shown to retard the progression of heart failure. While traditional echocardiography remains the standard for the detection of LVSD, electrocardiography and serum brain natriuretic peptide have also been shown to predict LVSD. Recently, hand-held echocardiography systems have been shown to have high predictive accuracy for assessment of LVSD. With the availability of the above bedside and relatively less-costly techniques, compared with traditional echocardiography, the major question now is what is the most cost-effective strategy for screening subjects for LVSD. To date, no studies have systematically addressed this issue, but preliminary data are becoming available. This review article discusses the pros and cons of various investigative strategies and likely cost-effectiveness of each strategy to screen for LVSD.

Hand-held echocardiography: added value in clinical cardiological assessment

BackgroundThe ultrasonic industry has recently produced echocardiographic Hand Held Devices (miniaturized, compact and battery-equipped echocardiographic systems). Their potential usefulness has been successfully assessed in a wide range of clinical conditions. The aim of the study was to verify if the routine use of a basic model of echocardiographic Hand Held Device (HHD) could be an important diagnostic tool during outpatient cardiologic consulting or in non-cardiologic hospital sections.Methods87 consecutive patients were included in this study; they underwent routine physical examination, resting ECG and echocardiographic evaluation using a basic model of HHD performed by trained echocardiographists; the cardiologist, whenever possible, formulated a diagnosis. The percentage of subjects in whom the findings were judged reasonably adequate for final diagnostic and therapeutic conclusions was used to quantify the "conclusiveness" of HHD evaluation. Successively, all patients underwent a second echocardiographic evaluation, by an examiner with similar echocardiographic experience, performed using a Standard Echo Device (SED). The agreement between the first and the second echocardiographic exam was also assessed.ResultsMean examination time was 6.7 ± 1.5 min. using HHD vs. 13.6 ± 2.4 min. using SED. The echocardiographic examination performed using HHD was considered satisfactory in 74/87 patients (85.1% conclusiveness). Among the 74 patients for whom the examination was conclusive, the diagnosis was concordant with that obtained with the SED examination in 62 cases (83.8% agreement).ConclusionHHD may generally allow a reliable cardiologic basic evaluation of outpatient or subjects admitted to non-cardiologic sections, more specifically in particular subgroups of patients, with a gain in terms of time, shortening patient waiting lists and reducing healthy costs.