Limited Transthoracic Echocardiography Research Articles

Do we still need intra-procedural TTE during Transcatheter aortic valve replacement? A high volume, single center experience

BackgroundTranscatheter aortic valve implantation (TAVI) has undergone significant advances in recent years, with the development of improved pre-planning tools and devices. These advances have led to a reduction in the rate of paravalvular leak (PVL), a complication that is associated with poor outcomes even when mild. As some centers around the world are moving to solely fluoroscopy-focused implantation, we aimed to describe the clinical impact of intra-procedural transthoracic echocardiography (TTE) during TAVI in a high volume hospital. MethodsObservational study during a 3-month period. A limited TTE examination was performed immediately after deployment to assess the existence of PVL and grade its severity. Complete TTE was performed a day after the procedure. In case of ≥mild PVL after valve deployment, a decision was made according to the severity of the PVL, patient anatomy and extent of annular calcification to preform balloon post-dilation. If done, an additional limited TTE was performed to assess possible complication and the degree of PVL post dilatation. Results115 patient were included in the study. Intra-procedural TTE identified 16 patients (14 %) with at least mild PVL, three of them with moderate (3 %). Post balloon dilatation was performed in 10 patients (9 % of the cohort) with significant improvement in the degree of PVL. ConclusionIntra-procedural TTE immediately after TAVI deployment can accurately identify PVL, allowing operators to perform post balloon dilatation with improvement in early echocardiographic results. Our findings support the routine use of TTE during procedures, without relying solely on fluoroscopy.

Unmasking a Silent Threat: Improving Pulmonary Hypertension Screening Methods for Interstitial Lung Disease Patients.

This article provides a comprehensive overview of the latest literature on the diagnostics and treatment of pulmonary hypertension (PH) associated with interstitial lung disease (ILD). Heightened suspicion for PH arises when the advancement of dyspnoea in ILD patients diverges from the expected pattern of decline in pulmonary function parameters. The complexity of PH associated with ILD (PH-ILD) diagnostics is emphasized by the limitations of transthoracic echocardiography in the ILD population, necessitating the exploration of alternative diagnostic approaches. Cardiac magnetic resonance imaging (MRI) emerges as a promising tool, offering insights into hemodynamic parameters and providing valuable prognostic information. The potential of biomarkers, alongside pulmonary function and cardiopulmonary exercise tests, is explored for enhanced diagnostic and prognostic precision. While specific treatments for PH-ILD remain limited, recent studies on inhaled treprostinil provide new hope for improved patient outcomes.

Inpatient cardiology consultation for COVID-19: What are cardiologists' diagnostic approaches?

Aim: Despite concerns about cardiovascular implications in coronavirus disease-2019 (COVID-19) patients, not all COVID-19 patients are visited by cardiologists and recommended to perform comprehensive cardiovascular assessments including measurement of biomarkers and echocardiography. We aimed to investigate the reasons for seeking cardiology care and to assess our cardiologists' diagnostic approaches to COVID-19 patients with potential cardiovascular involvement. Methods and Results: In this prospective, observational study, data of all consecutive COVID-19 patients admitted to six designated hospitals for COVID-19 in Iran in whom bedside cardiology consultation was requested were collected. A total of 148 patients including 105 (71%) males were included. The mean age was 57 ± 17 years. The most common reasons for cardiology consultation were dyspnea (56.7%), chest pain (12.8%), and suspected arrhythmias (10.8%). The most common comorbidities were hypertension (40.5%), diabetes mellitus (19.6%), and coronary heart disease (18.9%). A 12-lead electrocardiography (ECG) was obtained in all patients. Point-of-care ultrasonography or limited transthoracic echocardiography (TTE) was performed in 106 (71.6%) patients, and complete TTE was performed in 35 (23.4%) patients. Cardiac troponin was measured in 63 (42.6%) patients, and N-terminal pro B-type natriuretic peptide level was measured in 34 (23%) patients. Overall, 51 (34.5%) patients underwent invasive mechanical ventilation, inotropes were used in 29 (19.6%) patients, and 40 (27%) patients died. Conclusions: While preventing unnecessary investigations, the cardiologists should not overlook the lifesaving role of ubiquitous diagnostic modalities (such as ECG and TTE) in early detection and management of cardiac involvement in COVID-19.

Heart-lung interactions in COVID-19: prognostic impact and usefulness of bedside echocardiography for monitoring of the right ventricle involvement.

Due to the SARS-CoV-2 infection–related severe pulmonary tissue damages associated with a relative specific widespread thrombotic microangiopathy, the pathophysiologic role of heart–lung interactions becomes crucial for the development and progression of right ventricular (RV) dysfunction. The high resistance in the pulmonary circulation, as a result of small vessel thrombosis and hypoxemia, is the major cause of right heart failure associated with a particularly high mortality in severe COVID-19. Timely identification of patients at high risk for RV failure, optimization of mechanical ventilation to limit its adverse effects on RV preload and afterload, avoidance of medication-related increase in the pulmonary vascular resistance, and the use of extracorporeal membrane oxygenation in refractory respiratory failure with hemodynamic instability, before RV failure develops, can improve patient survival. Since it was confirmed that the right-sided heart is particularly involved in the clinical deterioration of patients with COVID-19 and pressure overload-induced RV dysfunction plays a key role for patient outcome, transthoracic echocardiography (TTE) received increasing attention. Limited TTE focused on the right heart appears highly useful in hospitalized COVID-19 patients and particularly beneficial for monitoring of critically ill patients. In addition to detection of right-sided heart dilation and RV dysfunction, it enables assessment of RV-pulmonary arterial coupling and evaluation of RV adaptability to pressure loading which facilitate useful prognostic statements to be made. The increased use of bedside TTE focused on the right heart could facilitate more personalized management and treatment of hospitalized patients and can contribute towards reducing the high mortality associated with SARS-CoV-2 infection.

Application of Point-of-care Cardiac Ultrasonography in COVID-19 Infection: Lessons Learned from the Early Experience.

The outbreak of the SARS-CoV-2 infection, also known as coronavirus disease 2019 (COVID-19), was formally defined a pandemic by the World Health Organization (WHO) in March 2020, and is still a global health issue. Since there is a high prevalence of acute cardiac injury in patients with COVID-19 infection, point-of-care cardiac ultrasound (PoCCUS) may be used for longitudinal monitoring of patients infected with COVID-19. However, there is still limited experience on the application of PoCCUS in the COVID-19 pandemic. Within the point of care setting in our system, focused cardiac US exams were performed with specific imaging protocols on the basis of suspicion of a specific disease, such as ruling out tamponade or thrombotic complications. Our preliminary experience shows that PoCCUS helps distinguish the causes of dyspnea in febrile patients. The COVID-19 infection may play a role in unmasking or exacerbating underlying chronic cardiovascular conditions, especially in patients with inadequate past history. In hospitalized patients with COVID-19, CURB-65 score for pneumonia severity and raised D-dimer were significantly associated with deep vein thrombosis (DVT). COVID-19 patients with DVT had worse prognosis, and patients with lower leg edema deserve further evaluation by using point-of-care ultrasound for the lower legs and heart. In COVID-19 patients with arrhythmia, PoCCUS used by experienced hands may reveal abnormal right ventricle (RV) functional parameters and lead to a more comprehensive cardiac US study. When there is suspicion of cardiac disease, PoCCUS can be done first, and if information is inadequate, limited transthoracic echocardiography (TTE), and critical care echocardiography (CCE) can be followed. Ultrasound practitioners should follow the standard precautions for COVID-19 as outlined by the Centers for Disease Control and Prevention to prevent transmission of infection, regardless of suspected or confirmed COVID-19.

Quantification of mitral regurgitation using transthoracic echocardiography and cardiac magnetic resonance imaging

Both Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) have well-established role in mitral regurgitation (MR) quantification for optimal management strategy. We assessed the correlation between TTE and CMR in the quantification of MR. Participants with isolated MR and echocardiographic mitral regurgitant volume (RVol) ≥ 30 mL/beat were included. A consecutive sample of 30 participants (Mean age 52.7 ± 19.3 years, 50% males) was selected and referred for indirect and direct CMR quantification of mitral RVol. There was a statistically significant strong positive correlation between the echocardiographic and indirect CMR quantification of the mitral RVol (r = 0.753, P < 0.001) and a statistically significant moderate positive correlation between the echocardiographic and direct CMR quantification of the mitral RVol (r = 0.530, P < 0.003). The inter-observer reliability of the MR grade between TTE and CMR showed a statistically significant moderate agreement (κ = 0.502, P = 0.0001) when the observers used the echocardiographic mitral RVol for grading of MR. On the other hand, the inter-observer reliability of the MR grade between TTE and CMR showed a statistically significant faint agreement (κ = 0.251, P = 0.024) when the observers used the echocardiographic regurgitant fraction (RF) for grading of MR. The positive reciprocal relationship between the CMR and the TTE highlights the potential role of the CMR as a concomitant imaging tool for quantification of the mitral RVol and grading of isolated MR, especially with limited or inconclusive TTE studies. This will enhance the management strategy and improve outcomes.

Feasibility of using a handheld ultrasound device to detect and characterize shunt and deep vein thrombosis in patients with COVID-19: an observational study

BackgroundCoronavirus disease 2019 (COVID-19) causes an atypical acute respiratory distress syndrome associated with thromboembolism and high shunt fraction. Shunt may be intrapulmonary, or extrapulmonary. Handheld devices are increasingly being used for point-of-care ultrasound, but their use to characterize shunt has not been reported.ObjectivesDetermine the feasibility of using handheld ultrasound to detect and characterize anatomical substrates of hypoxia and deep vein thrombosis (DVT) in patients with COVID-19 suspected to have severe shunt.MethodsA handheld ultrasound device (iQ, Butterfly, USA) was used to perform lung ultrasound, vascular assessment for DVT, and limited transthoracic echocardiography (TTE) with color Doppler and saline microbubble contrast in patients with COVID-19 suspected to have severe shunt. Images were reassessed by an independent reviewer.ResultsAfter screening 40 patients, six patients who fulfilled the inclusion criteria were identified. Two were excluded because palliation had been initiated. So, four patients were studied. Interpretable images were obtained in all cases. Interobserver agreement was good. All patients had abnormal lung ultrasound (lung ultrasound score range 17–22). Identified lung pathology included interstitial syndrome with light beams and small peripheral consolidation (4), lobar consolidation (1), and pleural effusion (1). Abnormal echocardiographic findings included interatrial shunt (2), intrapulmonary shunt (1), and dilated right ventricle with tricuspid valve regurgitation (1). Significant DVT was not detected.ConclusionUse of handheld ultrasound to perform combined lung ultrasound, DVT ultrasound, and limited TTE with color Doppler and saline microbubble contrast is feasible, and may be able to characterize shunt in critically hypoxic patients. Serial studies could be used to monitor changes in shunt. Further studies are required to determine whether this can guide treatment to improve the outcomes of patients with refractory hypoxia.

Abstract 15537: An Electronic Health Record Intervention to Optimize Utilization of Transthoracic Echocardiography: Opportunity for Cost Savings in the Era of Value Based-care

Introduction: In the current value-based era, targeting diagnostic resources and minimizing unnecessary testing is of paramount importance. Transthoracic echocardiography (TTE) is a common and costly test, and available Appropriate Use Criteria (AUC) guide optimal utilization. Limited TTE (L-TTE) shortens sonographer time, lowers cost and may be ideal for repeat TTEs (R-TTE) with a focused indication. However, many clinicians are unfamiliar with the AUC and opportunities for L-TTE. We prospectively tested an Electronic Health Record (EHR)-based intervention aimed at optimizing TTE utilization in a large academic medical center. Methods: TTE utilization at the University of Chicago Medicine was assessed over a 6-month period and complete TTE (C-TTE), L-TTE and R-TTE (TTE repeated within 6 months) were recorded. An EHR-based intervention was then implemented and TTE utilization was assessed over the ensuing 8 weeks. The intervention included presenting new descriptive L-TTE options (i.e. “Limited TTE: EF or Effusion Only”) when any “echo” was searched in the EHR order panel, an alert to prior TTEs (i.e. date &amp; LVEF) and a link to AUC-based guidance for TTE ordering. Educational materials were also distributed to frequent TTE ordering providers. Results: Among 9121 TTEs (53% inpatient) pre-intervention , 11% (n=1002) were L-TTEs and 25% (n=2320) were R-TTEs. There were more L-TTEs and R-TTEs in pre-intervention inpatients compared to outpatients (L-TTE 14% vs 7%, p&lt;0.0001, R-TTE 33% vs 17%, p&lt;0.0001). Post-intervention (2879 TTEs, 53% inpatient), R-TTEs significantly decreased (22.6% vs 25.4%, p=0.0019) and L-TTEs significantly increased (14% vs 11%, p&lt;0.0001) compared to pre-intervention, with inpatient TTEs most impacted (R-TTE 28% vs 33%, p=0.0016, L-TTE 19% vs 14%, p&lt;0.001). The intervention’s greatest impact was to markedly increase L-TTEs among inpatient R-TTEs (44% vs 35%, p=0.0002). Conclusions: Despite AUC discouraging frequent repeat TTEs, R-TTEs are common in an academic medical center and utilization of L-TTE is rare. An EHR-based intervention with prior TTE alerts and descriptive L-TTE options increases L-TTEs and reduces R-TTEs. Further study is warranted to describe the full clinical and financial impact of this intervention.

Mitral Annular Plane Systolic Excursion: An Early Marker of Mortality in Severe COVID-19

Mitral Annular Plane Systolic Excursion: An Early Marker of Mortality in Severe COVID-19

Utilization and Appropriateness of Transthoracic Echocardiography in Response to the COVID-19 Pandemic

Utilization and Appropriateness of Transthoracic Echocardiography in Response to the COVID-19 Pandemic

Bedside Focused Cardiac Ultrasound in COVID-19 from the Wuhan Epicenter: The Role of Cardiac Point-of-Care Ultrasound, Limited Transthoracic Echocardiography, and Critical Care Echocardiography

BackgroundThree cases of the application of focused cardiac ultrasound in patients with coronavirus disease 2019 are presented.MethodsCardiac point-of-care ultrasound, limited transthoracic echocardiography, and critical care echocardiography were applied in cases of heart failure, pulmonary embolism, and myocarditis with thrombus respectively.ResultsThe impact on patient management and the global context of each presentation are discussed. Conclusions: Focused cardiac point-of-care ultrasound played an important, front-line role in the bedside management of patients during the COVID-19 pandemic in Wuhan, China.

UTILIZATION OF COMPLETE VS. LIMITED TRANSTHORACIC ECHOCARDIOGRAPHY: AN OPPORTUNITY FOR COST SAVINGS IN THE ERA OF VALUE BASED CARE

Inpatient transthoracic echocardiography (TTE) is reimbursed as part of “bundled payments” in the current era of value-based healthcare. Thus, targeting TTE resources to impact optimal care is paramount. Limited TTE (L-TTE) shortens sonographer time and lower costs, and may be ideal for repeat

Addition of price transparency to an education and feedback intervention reduces utilization of inpatient echocardiography by resident physicians.

Previous studies have demonstrated the impact of appropriate use criteria (AUC) education and feedback interventions in reducing unnecessary ordering of transthoracic echocardiography (TTE) by trainees. To our knowledge, no study has evaluated the impact of the addition of price transparency to this education and feedback model on TTE utilization by resident physicians. We performed an education and feedback quality improvement initiative combining charge transparency data with information on AUC. We hypothesized that the initiative would reduce the number of complete TTE ordered and increase the number of limited TTE ordered, anticipating there would be substitution of limited for complete studies. Residents rotating on inpatient teaching cardiology ward teams received education on AUC for TTE, indications for limited TTE, and hospital charges for TTE. Feedback was provided on the quantity and charges for complete and limited TTE ordered by each team. We analyzed the effects of the intervention using a linear mixed effects regression model to adjust for potential confounders. The post-intervention weeks showed a reduction of 4.6 complete TTE orders per 100 patients from previous weekly baseline of 31.3 complete TTE orders per 100 patients (p value = 0.012). Charges for complete TTE decreased $122 from baseline of $980 per patient (p value = 0.040) on a per-week basis. Secondarily, there was no statistically significant change in limited TTE ordering during the intervention period. This initiative shows the feasibility of a house staff-driven charge transparency and education/feedback initiative that decreased medical residents' ordering of inpatient TTE.

The utility of limited trans-thoracic echocardiography in the stratification of pulse pressure variation: A feasibility study in major open abdominal surgery.

Background and Aim:Limitation in use of pulse pressure variation (PPV) in predicting fluid responsiveness (FR) in hypotensive patients is encountered when values are in the “gray zone” (8–13%). Dynamic arterial elastance (Eadyn= PPV/SVV) can be used in such situations to predict arterial pressure response to volume expansion (VE). In our study, we used respiratory variation of ascending aorta velocity time integral (AoVTI) calculated from suprasternal window as a surrogate of stroke volume variation (SVV). Fluids/vasopressors were administered to hypotensive patients intraoperatively based on value of Eadyn. Aim was to assess feasibility and utility of suprasternal echocardiography in the above-mentioned subset of patients.Materials and Methods:Hemodynamic data were monitored and respiratory variation in AoVTI was recorded using suprasternal echocardiography at all time points when patients developed hypotension (systolic blood pressure <90 mm Hg/<20% of baseline for 5 min) and at randomly selected time intervals when hemodynamic stability was maintained. VE with 250 ml of Ringer lactate (RL) was done in hypotensive patients with PPV value of 8–13% and Eadyn>0.9. Increase of >15% in AoVTI after VE defined “fluid responsiveness.”Results:Twenty-eight patients were enrolled, but three were excluded in view of left ventricular systolic dysfunction detected during preinduction echocardiography. Hemodynamic and echocardiographic data were recorded at 538 observation points in 25 adults. Hypotension occurred in 247 data sets, and in 168 data sets, value of PPV was 8–13%. VE was carried out in only those 131 data sets in which the value of Eadyn was >0.9. Area under the curve (AUC) for VE as an intervention in the indeterminate (PPV 8–13%) group was 0.574 (0.49–0.68, 95% CI, P < 0.049), and in the observation set with PPV >13, the AUC value was 0.7 (0.59–0.98, 95% CI, P < 0.01).Conclusions:Echocardiography using the suprasternal window in the operating room during abdominal surgery is feasible, but the utility of Eadyn in stratification of patients with PPV 8–13% is inconclusive.

The Feasibility and Impact of Routine Combined Limited Transthoracic Echocardiography and Lung Ultrasound on Diagnosis and Management of Patients Admitted to ICU: A Prospective Observational Study

Limited transthoracic echocardiography (TTE) and lung ultrasound increasingly is performed in the intensive care unit (ICU), though used in a goal-directed rather than routine manner. Prospective observational study. Tertiary ICU. Ninety-three critically ill participants within 24 hours of admission to ICU. A treating intensivist documented a clinical diagnosis and management plan before and after combined limited TTE and lung ultrasound. Ultrasound was performed by an independent intensivist and checked for accuracy offline by a second reviewer. Ultrasound images were interpretable in 99%, with good interobserver agreement. The hemodynamic diagnosis was altered in 66% of participants, including new (14%) or altered (25%) abnormal states or exclusion of clinically diagnosed abnormal state (27%). Valve pathology of at least moderate severity was diagnosed for mitral regurgitation (7%), aortic stenosis (1%), aortic stenosis and mitral regurgitation (1%), tricuspid regurgitation (3%), and 1 case of mitral regurgitation was excluded. Lung pathology diagnosis was changed in 58% of participants including consolidation (13%), interstitial syndrome (4%), and pleural effusion (23%), and exclusion of clinically diagnosed consolidation (6%), interstitial syndrome (3%), and pleural effusion (9%). Management changed in 65% of participants including increased (12%) or decreased (23%) fluid therapy, initiation (10%), changing (6%) or cessation (9%) of inotropic, vasoactive or diuretic drugs, non-invasive ventilation (3%), and pleural drainage (2%). Routine screening of patients with combined limited TTE and lung ultrasound on admission to ICU is feasible and frequently alters diagnosis and management.

The limitation of transthoracic echocardiography in diagnosing partial anomalous pulmonary venous drainage

Objective: To improve the diagnostic accuracy of transthoracic echocardiography (TTE) by analyzing its limitations in diagnosing partial anomalous pulmonary venous drainage (PAPVD). Method: This was a retrospective analysis of PAPVD patients seen at the Children's Hospital of Fudan University from October 1 2006 to October 1 2016. The echocardiographic data were compared to findings on multi-slice spiral CT (MSCT), cardiac catheterization or surgery. The echocardiography machines used were Philip IE33, GE Vivid 7 and Vivid i with frequency ranging from 5.0 MHz to 7.5 MHz. The cardiac structure was analyzed according to Van Praagh segments. Result: A total of 43 cases of PAPVD were enrolled, male∶ female ratio 20∶23 with average age (27.9±21.4) months. Among them, 3 cases were simple PAPVD and 40 cases had other associated congenital heart diseases. TTE was successful in diagnosing 29 cases (67%) while 14 cases were missed. The diagnostic rate for right pulmonary vein drainage into superior vena cava, right atrium, inferior vena cava were 5/10, 17/20, and 3/5 respectively while left pulmonary vein drainage into left innominate vein was only 1/4. Added TTE images to re-exam the 9 of the 14 missed cases, 5 cases of abnormal drainage from right superior pulmonary vein were diagnosed, while 4 cases of drainage from right lower or left pulmonary vein were only picked up by indirect signs. Conclusion: The distance of the pulmonary veins from the routine ultrasound view and the possibility of branch number variation may limit the accuracy of TTE in diagnosing PAPVD, especially for drainage from right lower and left pulmonary vein. But TTE is still the preferred diagnostic method. The diagnostic rate could be increased by paying special attention to non-routine views including the suprasternal fossa, the right parasternal and subcostal area.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery

The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery. Prospective observational study. Tertiary university hospital. The study comprised 51 patients aged 18 years or older presenting for cardiac surgery. Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points. Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01). Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.

Usefulness of limited echocardiography with A-F mnemonic in patients with suspected non‑ST-segment elevation acute coronary syndrome.

When diagnosing the causes of acute chest pain, both acute coronary syndromes (ACSs) and other serious conditions should be considered. The aim of the study was to assess the usefulness of limited transthoracic echocardiography (TTE) with an A-F mnemonic in patients with suspected non-ST-segement elevation ACS (NSTE-ACS) and the effect of TTE on therapeutic decisions. This retrospective study was conducted at an emergency department for 12 months. The study population consisted of consecutive patients with a preliminary diagnosis of NSTE-ACS. We analyzed demographic data, clinical condition, medical history, electrocardiography, TTE, and the levels of necrotic markers. TTE with the A-F mnemonic was performed within 15 minutes from admission. A total of 916 consecutive patients were enrolled to the study. The diagnosis of ACS was confirmed in 70.19% of the patients. TTE with the A-F mnemonic revealed regional wall motion abnormalities in 74.03% of the ACS group and significant echocardiographic abnormalities in 2.18% of the ACS group and 55.31% of patients without ACS. On the basis of those findings, 4.69% of the patients underwent invasive treatment other than myocardial revascularization. A comparative analysis revealed that patients with ACS were older, more likely to have ST-segment depression, higher levels of necrotic markers, and lower left ventricular ejection fraction, while patients without ACS had more echocardiographic abnormalities in points B-F according to the A-F scheme. Limited TTE with the A-F mnemonic should be performed in all patients with suspected NSTE-ACS. It allows to confirm ischemia and detect other life-threatening conditions. TTE with the A-F mnemonic covers a sufficient spectrum of cardiac abnormalities and has a significant effect on therapeutic decision making in patients with suspected NSTE-ACS.

Use of limited transthoracic echocardiography in patients with traumatic cardiac arrest decreases the rate of nontherapeutic thoracotomy and hospital costs.

Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest. Approval by the Institutional Review Board was obtained. All nonsurviving patients with traumatic cardiac arrest who reached the trauma bay were evaluated retrospectively for 1 year. Comparisons between groups of patients in whom LTTE was performed as part of the resuscitation effort and those in whom it was not performed were conducted. From January 2012 to January 2013, 37 patients did not survive traumatic cardiac arrest while in the trauma bay: 14 in the LTTE group and 23 in the non-LTTE group. When comparing the LTTE and non-LTTE groups, both were similar in sex distribution (LTTE, 86% male; non-LTTE, 74% male; P = .68), age (34.8 versus 24.1 years; P= .55), Injury Severity Score (41.0 versus 38.2; P= .48), and percentage of penetrating trauma (21.6% versus 21.7%; P = .29). Compared with the non-LTTE group, the LTTE group spent significantly less time in the trauma bay (13.7 versus 37.9 minutes; P = .01), received fewer blood products (7.1% versus 31.2%; P = .789), and were less likely to undergo nontherapeutic thoracotomy in the emergency department (7.14% versus 39.1%; P < .05). The non-LTTE group had a mean of $3040.50 in hospital costs, compared with the mean for the LTTE group of $1871.60 (P = .0054). In this study, image-guided resuscitation with LTTE decreased the time in the trauma bay and avoided nontherapeutic thoracotomy in nonsurviving trauma patients. Limited TTE could improve the use of health care resources in patients with traumatic cardiac arrest.

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Introduction: Bedside ultrasound is effective for accurate point of care assessment and rapid decision-making in the intensive care unit. Critical care medicine fellowship training programs have attendings, fellows and physician extenders from diverse training backgrounds with various levels of ultrasound training. Implementing bedside ultrasonography in the intensive care unit is limited by the training of the Intensivist. National organizations have advocated increasing the use of critical care ultrasonography in the intensive care unit. The purpose of this study was to investigate the feasibility and impact of incorporating focused training in critical care ultrasonography to critical care attendings, fellows and physician extenders. Methods: A four hour ultrasound course was held with focused didactic sessions followed by hands-on image acquisition with human models. Participants were critical care attendings, fellows and physician extenders from surgery, anesthesiology, neurology, internal medicine and emergency medicine backgrounds. Instructors were intensivists with formalized training in critical care ultrasonography. A pre and post course survey regarding current ultrasound experience and comfort was circulated amongst the participants. Results: The course was offered to thirty participants with focused training in the FAST exam (focused assessment with sonography for trauma), limited transthoracic echocardiography, and pulmonary ultrasound. All participants agreed that bedside ultrasound was a useful tool in clinical practice for the intensivist. Sixty-nine percent of participants reported that they were not formally trained in ultrasound during their previous training programs. Seventy-one percent of participants reported that they were uncomfortable with their current experience and knowledge of bedside ultrasound before the course. After the course, seventy-five percent of participants reported that they were comfortable with their current knowledge and experience with bedside ultrasound. Pre course evaluation showed that most participants were uncomfortable obtaining the following ultrasound studies: sixty-eight percent (FAST exam), seventy-five percent (limited transthoracic echocardiography) and sixty-one percent (pulmonary). Comparison of pre and post course surveys showed that comfort in image acquisition and interpretation increased from thirty-two percent to ninety-eight percent in the FAST exam, twenty-five percent to ninety-five percent in limited transthoracic echocardiography, and thirty-nine percent to ninety-five percent in pulmonary ultrasound. Conclusions: Post course evaluation showed that all participants were more comfortable with their knowledge of bedside ultrasound. Participants reported an increase in comfort with image acquisition and familiarity in the FAST exam, limited transthoracic echocardiography, and pulmonary ultrasound. A focused critical care ultrasound training curriculum can be successfully implemented into an existing critical care medicine fellowship training program. Our curriculum represents a useful training model for teaching critical care ultrasound to critical care attendings, fellows and physician extenders.