Pediatric Echocardiography Laboratory Research Articles

News from the European Journal of Therapeutics: A new issue and a new editorial board

News from the European Journal of Therapeutics: A new issue and a new editorial board

The Role of the Pediatric Echocardiography Laboratory in Supporting Point-Of-Care Ultrasound (POCUS) Initiatives: A Survey from the American Society of Echocardiography Task Force on Cardiac POCUS in Children

The Role of the Pediatric Echocardiography Laboratory in Supporting Point-Of-Care Ultrasound (POCUS) Initiatives: A Survey from the American Society of Echocardiography Task Force on Cardiac POCUS in Children

Quality Improvement in a Pediatric Echocardiography Laboratory: A Collaborative Process.

Transthoracic echocardiography (TTE) is an essential tool for diagnosis and management of congenital heart disease. Pediatric echocardiography presents unique challenges including complex anatomy, variable patient cooperation and provider expertise. Diagnostic errors inevitably occur. We designed a collaborative and stepwise quality improvement (QI) process to address diagnostic errors within our laboratory. We retrospectively reviewed medical records to identify diagnostic TTE errors in 100 consecutive cardiac surgery patients ≤ 5 years old (July 2020-January 2021). We identified 18 diagnostic errors. Most errors had minor impact (14/18), and 13 were preventable or possibly preventable. We presented these results to our sonographers and faculty and requested input on preventing and managing diagnostic errors. Our root cause analysis based on their responses yielded 7 areas for improvement (imaging, reporting, systems, time, environment, people, QI processes). Our faculty and sonographers chose QI processes and imaging as initial areas for intervention. We defined our SMART goal as a 10% reduction in diagnostic errors. We implemented interventions focused on QI processes. On initial follow up in May 2022, we identified 7 errors in 70 patients (44% reduction in error rate). Utilizing a stepwise and team-based approach, we successfully developed QI initiatives in our echocardiography laboratory. This approach can serve as a model for a collaborative QI process in other institutions.

Pediatric Normal Values and Z Score Equations for Left and Right Ventricular Strain by Two-Dimensional Speckle-Tracking Echocardiography Derived from a Large Cohort of Healthy Children

Strain values vary with age in children and are both vendor and platform specific. Philips QLAB 10.8 and TomTec AutoSTRAIN are two widely used strain analysis platforms, and both incorporate recent European Association of Cardiovascular Imaging/American Society of Echocardiography/Industry Task Force to Standardize Deformation Imaging guidelines. The aims of this study were to establish normal strain values and Z scores for both platforms using a large data set of healthy children and to compare values among these two platforms and a previous version, QLAB 10.5, which predated the task force guidelines. Echocardiograms from 1,032 subjects <21years old with structurally and functionally normal hearts were included. Images were obtained on the Philips EPIQ platform. Left ventricular (LV) and right ventricular (RV) strain was analyzed using QLAB 10.8 and AutoSTRAIN, and measurement reliability was assessed. Z score equations were derived as a function of age for QLAB 10.8 (LV longitudinal and circumferential strain) and AutoSTRAIN (LV and RV longitudinal strain). A subset (n=309) was analyzed using QLAB 10.5. Strain values were compared among the three platforms. For both of the newer platforms, strain varied with age, with magnitude reaching a maximum at 4 to 5years. For LV longitudinal strain, the largest differences in value were observed in the youngest patients when using QLAB 10.5; the other two platforms were similar. LV circumferential strain measurements (QLAB 10.5 vs QLAB 10.8) were different for all ages, as were measurements of RV longitudinal strain (QLAB 10.8 vs AutoSTRAIN). Reliability was greater for AutoSTRAIN than for QLAB 10.8 and greater for LV than for RV strain. Normal RV and LV strain values and Z scores were generated from a large cohort of children for two commonly used platforms in pediatric echocardiography laboratories. Following the incorporation of task force guidelines, the greatest improvement in standardization was seen in infants. Small differences persist between modern platforms; however, these results support the cautious consideration of comparing interplatform measurements.

Artificial intelligence in the pediatric echocardiography laboratory: Automation, physiology, and outcomes.

Artificial intelligence (AI) is frequently used in non-medical fields to assist with automation and decision-making. The potential for AI in pediatric cardiology, especially in the echocardiography laboratory, is very high. There are multiple tasks AI is designed to do that could improve the quality, interpretation, and clinical application of echocardiographic data at the level of the sonographer, echocardiographer, and clinician. In this state-of-the-art review, we highlight the pertinent literature on machine learning in echocardiography and discuss its applications in the pediatric echocardiography lab with a focus on automation of the pediatric echocardiogram and the use of echo data to better understand physiology and outcomes in pediatric cardiology. We also discuss next steps in utilizing AI in pediatric echocardiography.

Investigating a Rapid and Safe Outpatient Pediatric Screening Protocol

There is great interest and benefit in optimizing efficiency and productivity in a pediatric echo lab. 1 Mathewson J. Dyar D. Jones F. Sklansky M. Perry J. Michelfelder E. et al. Conversion to digital technology improves efficiency in the pediatric echocardiography laboratory. J Am Soc Echocardiogr. 2002; 15: 1515-1522 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar ,2 Lai W. Srivastava S. Cohen M. Frommelt P. Allada V. Pediatric echocardiography laboratory organization and clinical productivity. J Am Soc Echocardiogr. 2013; 26: 1180-1186 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar We studied the feasibility and impact of a rapid but complete anatomic survey (base echocardiogram protocol; Supplemental Table 1) designed to decrease the time of image acquisition and report generation without sacrificing diagnostic ability in a low-risk pediatric population. We defined a low-risk indication as murmur, abnormal electrocardiogram, syncope, chest pain, family history of congenital heart disease (not myopathy), and palpitations. This protocol assesses all anatomy but does not include detailed quantification and is significantly shorter than our routine clinical echo protocol. It images the heart in all standard planes and utilizes sweeps and side-by-side two-dimensional and color Doppler imaging. The assumption in the use of this protocol is that if findings are normal then the patient will be discharged from pediatric cardiology clinic.

Organization of Pediatric Echocardiography Laboratories: Impact of Sonographers on Clinical, Academic, and Financial Performance

Echocardiography has evolved the first-line imaging for diagnosis and management of pediatric and congenital heart disease all over the world. While it recognized as essential component of pediatric cardiac care delivery, organization of pediatric echocardiography services is very heterogeneous across the world, mainly related to significant differences in material and human resources in heterogeneous health care systems. In this paper, we focus on the role of pediatric sonographers, defined as expert technicians in pediatric echocardiography. While in some services sonographers are an essential part of the organizational structure, other laboratories operate only with physicians trained in echocardiography. The impact of sonographers on clinical, academic and financial performance will be discussed. Two organizational models (with and without sonographers) will be compared, and the advantages and disadvantages of each model will be evaluated. Different models of care provision are possible and decisions on organizational models need to be adjusted to the demands and available resources.

Editorial introductions.

Editorial introductions.

Using Quality Improvement Methodology to Standardize Doppler Acquisition in a Pediatric Cardiology Echocardiography Laboratory.

Introduction:In echocardiography, the Doppler principle allows the measurement of tissue velocities. Using the Bernoulli equation, velocities are translated to estimated pressure differences, which dictate the timing of cardiac interventions. Our echocardiography laboratory demonstrated variability in the Doppler interrogation of heart valves, leading to difficulties in comparison over time and study accuracy. To align with previously published quality metrics in echocardiography, our laboratory used quality improvement methodology to achieve measurable improvement in Doppler acquisition.Methods:We developed a standardized protocol for Doppler acquisition and translated it to a 20-point scoring system. We established a baseline over 4 months via random assessment of 2 first-time, normal studies per day. Interventions included standardizing the process for acquisition, education, visual tracking, and individual feedback.Results:The percentage of studies with a score of 16 or higher preintervention was 17%. The median score was 13.4. In total, we analyzed 407 studies, 173 pre- and 234 postintervention. Over a 4-month intervention period, the median score improved to 18.1, with 85% of studies achieving a score of 16 or higher. Special cause variation occurred after protocol distribution, education, and feedback.Conclusions:Our initiative demonstrated significant improvement in the Doppler interrogation of cardiac structures using a measurable scoring system and a concrete goal of incorporating 20 areas of Doppler assessment in normal studies. Our next step is to spread this assessment to abnormal studies, thus developing consistency in evaluating all studies throughout the laboratory.

Daily management System (DMS) Huddle Process as a Quality Improvement (QI) Tool to Improve Patient and Family Safety in a Pediatric Echocardiography Laboratory.

Daily management System (DMS) Huddle Process as a Quality Improvement (QI) Tool to Improve Patient and Family Safety in a Pediatric Echocardiography Laboratory.

ASE Statement on the Reintroduction of Echocardiographic Services during the COVID-19 Pandemic

• Echocardiography services have been interrupted by the COVID pandemic. • Services are being gradually reintroduced as healthcare facilities reopen. • Operational, workflow and prioritization considerations are suggested.

Practice Variations in Pediatric Echocardiography Laboratories

Quantification guidelines for pediatric echocardiograms were published in 2010 establishing consensus regarding standard measurements. However, a standard protocol for performance and analysis of pediatric echocardiograms was not defined. This study aims to identify practice variations among pediatric laboratories. A survey was sent to 85 North American pediatric laboratory directors. The survey included 29 questions assessing: demographics, methods of image acquisition, parameters routinely evaluated and reported, and methods used to assess chamber sizes, valves, and ventricular function. There were 47/85 (55%) responses; 83% were academic centers and 77% in an urban setting. Wide variations exist in acquisition method (clips versus sweeps) and color scale settings. The most commonly used methods for left ventricular (LV) function are M-mode shortening fraction, qualitative assessment, and Doppler Tissue Imaging. The most commonly used parameter for right ventricular function is qualitative. LV mass is routinely measured by the majority of centers with variations in methods of calculation. Conversely, while a minority measure left atrial volume, there is consensus regarding the preferred method. While multiple techniques exist for assessing valves, qualitative assessment is reported to be the preferred method. Despite quantification guidelines, there is a lack of uniformity in performance and analysis of pediatric echocardiograms. Further studies are needed to determine why variations exist and whether development of consensus guidelines might improve interpretation, consistency and quality of reports, patient care, and provide a standardized system allowing for comparative research among centers.

Determinants of Physician, Sonographer, and Laboratory Productivity: Analysis of the Third Survey from the American Society of Echocardiography Committee on Pediatric Echocardiography Laboratory Productivity

The American Society of Echocardiography Committee on Pediatric Echocardiography Laboratory Productivity was formed in 2011 to study institutional factors that could influence the clinical productivity of physicians and sonographers in academic pediatric echocardiography laboratories. In the previous two surveys, staff clinical productivity remained stable while total echocardiography volumes increased. This third survey was designed to assess how clinical productivity is associated with laboratory infrastructure elements such as training, administrative tasks, quality improvement, research, and use of focused cardiac ultrasound (FCU). Survey questions were sent by e-mail to North American laboratories. The aims were to assess (1) educational and training obligations, (2) academic productivity and research, (3) laboratory medical director satisfaction, (4) quality improvement, (5) laboratory leadership roles, and (6) impact and use of FCU. Survey responses were compared with clinical productivity metrics defined in the first two surveys. There were 38 responses. Academic productivity was higher at institutions with more dedicated imaging personnel, personnel with dedicated protected academic time, and advanced imaging fellows. Academic productivity did not correlate with clinical productivity and was not significantly affected by the presence of dedicated research sonographers. The satisfaction level of laboratory medical directors was related to dedicated administrative time and an administrative stipend. The majority of administrative roles were tasked to the laboratory medical director with support of the technical director. FCU was listed as a hospital privilege at four institutions (13%). Twenty-two (58%) were training FCU providers in one or more subspecialties. FCU was not associated with clinical or academic productivity. This third survey gathered supplemental data to complement the clinical productivity data collected from the first two surveys. Together, the results of these surveys further describe the range of factors that can affect North American academic pediatric echocardiography laboratories.

Improving Wait Time for Patients in a Pediatric Echocardiography Laboratory - a Quality Improvement Project.

Prolonged wait times for echocardiograms in the outpatient pediatric cardiology clinic led to patient and provider dissatisfaction at our institution. The aims of this project were to measure our baseline performance with regard to echocardiogram wait time (EWT), to implement a formal quality improvement (QI) program to improve EWT, and to measure the impact of QI on EWT. A QI team was formed comprising of cardiologists (A.P., T.S.), sonographer (A.W.), and QI mentor (J.M.). EWT was defined as time in minutes from initiation of the order in the electronic medical record to start of the echocardiogram. Goal EWT was set as ≤ 20 minutes for 90% patients. Flowcharts were created after process observation to identify sources of potential delay contributing to EWT. QI methodology such as driver diagrams were utilized to identify interventions, which were then implemented and studied as Plan-Do-Study-Act cycles. Sequential interventions included early start time, huddles involving clinic and echo laboratory staff, patient tracking system, and repurposing of a clinic room for echo. EWT was tracked for 840 patients. Mean EWT was 22.5 ± 17.5 minutes at baseline and decreased to 15.3 ± 7.8 minutes postintervention (P < 0.001). Postintervention, 81% of the patients waited < 20 minutes for their echo, and 98% patients waited < 30 minutes, compared with baseline numbers of 62% and 76%, respectively (P < 0.001). We were able to utilize QI methodology to derive interventions and track changes, resulting in quantifiable improvement in EWT in a busy pediatric echo laboratory.

Three-Dimensional Mitral Valve Morphology and Age-Related Trends in Children and Young Adults with Structurally Normal Hearts Using Transthoracic Echocardiography

The mitral valve has a complex three-dimensional (3D) morphology that is incompletely described by two-dimensional echocardiography (echo). Three-dimensional echo provides a more robust tool to analyze the mitral valve. The shape of the mitral annulus and leaflets, and differences with age, have not been described by 3D echo in normal children. Our objective was to characterize and quantify the 3D mitral valve morphology in children with normal transthoracic echocardiograms over a broad spectrum of age and to identify differences in valve shape with age. Three-dimensional midsystolic mitral valve models were constructed in 100 children and young adults with normal echocardiograms using 3D transthoracic images. Annular and leaflet metrics were quantified and regression equations were prepared. Interuser and intrauser variability was measured. Two hundred fifty patients, from neonate to young adult, were retrospectively reviewed to obtain 100 evaluable patients (40% evaluable). The annular height to commissural width ratio of the mitral valve ("saddle shape") was preserved across age (median 24.3, IQR 21.8-28.1). Three-dimensional mitral valve area, length, and volume parameters were linearly related to body surface area (P<.001). The ratio of anterior to posterior leaflet length and posterior leaflet angle increased with body surface area (P=.0004 and .002, respectively) suggesting posterior movement of the coaptation line. Two-dimensional lateral annular diameter underestimated 3D lateral annular metrics (P<.001, mean difference 20-22%) but was highly correlated (R>0.87, P<.001). Interuser and intrauser variability were acceptable. Assessment of 3D mitral valve morphology in children is possible in a modern clinical pediatric echocardiography laboratory using transthoracic images, although further optimization of imaging is needed. The saddle shape of the mitral annulus was preserved across age and size. Most mitral valve parameters increased linearly with patient size. Further investigation is warranted to explore changes in valve morphology in the pediatric population in health and with disease.

Determinants of Pediatric Echocardiography Laboratory Productivity: Analysis from the Second Survey of the American Society of Echocardiography Committee on Echocardiography Laboratory Productivity

The American Society of Echocardiography Committee on Pediatric Echocardiography Laboratory Productivity aimed to study factors that could influence the clinical productivity of physicians and sonographers and assess longitudinal trends for the same. The first survey results indicated that productivity correlated with the total volume of echocardiograms. Survey questions were designed to assess productivity for (1) physician full-time equivalent (FTE) allocated to echocardiography reading (echocardiograms per physician FTE per day), (2) sonographer FTE (echocardiograms per sonographer FTE per year), and (3) machine utilization (echocardiograms per machine per year). Questions were also posed to assess work flow and workforce. For fiscal year 2013 or academic year 2012-2013, the mean number of total echocardiograms-including outreach, transthoracic, fetal, and transesophageal echocardiograms-per physician FTE per day was 14.3±5.9, the mean number of echocardiograms per sonographer FTE per year was 1,056±441, and the mean number of echocardiograms per machine per year was 778±303. Both physician and sonographer productivity was higher at high-volume surgical centers and with echocardiography slots scheduled concordantly with clinic visits. Having an advanced imaging fellow and outpatient sedation correlated negatively with clinical laboratory productivity. Machine utilization was greater in laboratories with higher sonographer and physician productivity and lower for machines obtained before2009. Measures of pediatric echocardiography laboratory staff productivity and machine utilization were shown to correlate positively with surgical volume, total echocardiography volumes, and concordant echocardiography scheduling; the same measures correlated negatively with having an advanced imaging fellow and outpatient sedation. There has been no significant change in staff productivity noted over two Committee on Pediatric Echocardiography Laboratory Productivity survey cycles, suggesting that hiring practices have matched laboratory volume increases.

Unplanned Repeat Echocardiography with Sedation in Children: Patient Risk Factors.

Patient selection criteria for echocardiography with sedation in children are not well defined. We attempted to identify predictors of unplanned repeat echocardiography with sedation. This was a single-center, case-control study of echocardiograms performed in children aged 1-36months. Cases underwent unplanned repeat examinations with sedation, while controls did not. Patient variables and study indications were compared. Logistic regression identified the most significant predictors. Cases (n=104, median time to repeat echocardiogram 17days, median age 12.9months) were older than controls (n=212, median age 5.0months, P<0.001). Significantly more cases than controls had structural cardiac disease (64 vs. 23%) and anatomic complexity ≥moderate (38 vs. 5%, P<0.001 for both). Cases more often had Kawasaki disease (11 vs. 2%), and controls more often had murmur (56 vs. 11%, P<0.001 for both). Logistic regression identified age 6months to <2years (OR 3.26, 95% CI 1.70-6.28, P<0.001), Kawasaki disease (OR 5.20, 95% CI 1.46-18.50, P=0.01), and known pre-echocardiogram anatomic complexity ≥moderate (OR 3.99, 95% CI 1.64-9.66, P=0.002) as significant risk factors. An indication for murmur was protective (OR 0.32, 95% CI 0.13-0.76, P=0.01). We identified several risk factors for unplanned repeat echocardiography with sedation in children, including age 6months to <2years, higher anatomic complexity, and Kawasaki disease. Murmur was a protective factor. These results may help pediatric echocardiography laboratories establish criteria for sedation.

Fetal echocardiography — A recent four year experience from a single urban center

The purpose of this study was to determine the yield of fetal echocardiography based on indications for referral and to establish the incidence of structural heart disease noted in a diverse urban population.A retrospective review of our Pediatric Echocardiography Laboratory database was undertaken from March 2010 to June 2014. Demographic information, indications for referral and prenatal diagnoses were recorded. The diagnosed cardiac anomalies were classified into structural and rhythm abnormalities and the former was divided into major and minor anomalies. We compared the number of fetal echocardiograms performed during this four-year period to a similar four-year period, a decade earlier. Also, we compared the number of cardiac admissions to the neonatal intensive care unit in these two periods.3623 fetal echocardiograms were performed on 2953 patients between 2010 and 2014. Fetal indications accounted for 70% of referrals. Overall, yield of congenital heart disease was 11.5%; 6.8% from maternal and 13.4% from fetal indications. Abnormal obstetrical fetal ultrasound was associated with congenital heart disease in 13.9% of cases. Of 336 fetuses with congenital heart disease, 119 were major and 47 were critical. 80% of all congenital heart diseases (273 of 336) and 90% of major and critical heart disease were found in those referred for fetal indications. Approximately half (24 of 47, 51%) of the critical congenital heart disease involved defects with varying degrees of left heart hypoplasia. Compared to a previous period, there was an increase in FE and neonatal intensive care unit admissions with cardiac diagnoses. However, critical congenital heart disease detected postnatally fell from 28.8 to 12.8% (P=0.001).Yield of fetal echocardiograms is higher for fetal versus maternal indications. At our center, increase in prenatal detection of critical congenital heart disease may have resulted in reduction in congenital heart disease diagnosed in the neonatal intensive care unit.

Pediatric Echocardiography Laboratory Organization and Clinical Productivity

The American Society of Echocardiography's Committee on Pediatric Echocardiography Laboratory Productivity (C-PELP) was formed to study the organizational and productivity issues particular to academic pediatric echocardiography laboratories. After much deliberation, the committee chose studies per physician full-time equivalent per day --the average number of studies interpreted per day by a full-time echocardiography physician dedicated to the laboratory -as the primary measure of physician productivity. A survey was sent to 74 North American pediatric echocardiography laboratory directors. The aims of the survey were to (1) determine the annual laboratory volume and types of echocardiographic studies performed, (2) define the average number of studies performed by a pediatric cardiac sonographer in a year, (3) assess the productivity of echocardiography physicians, and (4) identify factors (programmatic or laboratory related) that affect clinical productivity. There were 54 responses to the C-PELP 2011 survey. The average number of studies per physician full-time equivalent per day was 15.0 + 4.5 (median, 13.8; range, 6.2 -27.1), and the average number of studies performed per year by a sonographer was 1,297 + 326 (median, 1,279; range 717 -2,475). These figures were not adjusted for case complexity, time requirement for transesophageal echocardiography, level of expertise, or availability of sonographer assistance. Moreover, the issues of study quality and accuracy were not addressed. The C-PELP 2011 survey gathered important information on the current organization and staffing of academic pediatric echocardiography laboratories, but the committee did not attempt to craft guidelines or recommendations on staffing requirements. The results of the survey, however, should provide a framework for additional investigation into the optimal structure and staffing of pediatric echocardiography laboratories.

Digital Imaging, Archiving, and Structured Reporting in Pediatric Echocardiography: Impact on Laboratory Efficiency and Physician Communication

Digital structured reporting (DSR) is an emerging technology in medical information management. In November of 2006, the pediatric echocardiography laboratory at Children's Hospital of Wisconsin transitioned from transcription-based reporting of results to DSR. Transthoracic echocardiograms were reviewed for the study duration and time to report completion for October of 2006 (the last month of phone-based transcription) and January of 2007 (the third month of DSR). For both months, the 5 cardiologists responsible for echocardiography reporting were evaluated for report generation time and the 5 sonographers were evaluated for study duration. Data for physicians and sonographers were analyzed individually, as a group between months, between examination types (brief vs comprehensive), and diagnoses (normal vs abnormal findings). The time to generate a final report to the electronic medical record/auto-fax to the referring physician for all examination types between months decreased significantly from the transcription month to the DSR month (median 23.8 vs 1.2 hours; P =.001). This decrease was consistent among physicians and occurred despite an increase in monthly echocardiography volume of 12% between the study periods. No difference was noted in report generation times between brief and comprehensive transthoracic echocardiography for transcription (P =.220) or DSR (P =.185). Analysis of diagnoses after instituting DSR revealed significantly shorter report generation time for normal examination findings versus abnormal examination findings (0.97 vs 1.5 hours; P =.001). Study duration decreased significantly from the transcription month to the DSR month for all examination types (32 vs 27 minutes; P =.001). For both months, the study duration was longer for abnormal versus normal transthoracic echocardiography findings (transcription: 37 vs 27 minutes; DSR: 32 vs 23 minutes). DSR is a superior technology for pediatric echocardiography reporting and an important next step to increase efficiency and customer satisfaction. Although congenital heart disease increases DSR study report time, the value of digitally scripted, database-compatible, complete segmental analysis of the heart and vascular structures with direct transfer of quantitative data from the ultrasound machine to the report without the need for a transcription interface justifies the time expense. DSR should be a goal for all pediatric echocardiography laboratories to decrease consumer wait time, increase laboratory efficiency, and improve compliance with Intersocietal Commission for the Accreditation of Echocardiography Laboratories standards.